Foot Orthotics in Children with Juvenile Idiopathic Arthritis

Archives of Disease in Childhood published randomized controlled trial research on the use of foot orthoses in children with juvenile idiopathic arthritis (JIA).   Sixty children randomly received  either ‘fitted’ foot orthotics with customized chair-side corrections or ‘control’ foot orthotics made without corrections.  Changes in pain and quality of life for the children with JIA was assessed at baseline, 3 months and 6 months.

The following results were recorded:

1.  a statistically significant greater difference in pain reduction (baseline—6 months) was seen for the group with fitted foot orthotics

2.  the reduction in pain in the fitted foot orthotics group was clinically important (8 mm).

3.  significant differences in quality of life was seen in the fitted foot orthotic group as measured by the children and independently by their parents/carers.

The researchers concluded that fitted foot orthotics may reduce pain and improve quality of life in selected children with JIA.

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Reference:  Andrea Coda, Peter W Fowlie, Joyce E Davidson, Jo Walsh, Tom Carline, Derek Santos. Foot orthoses in children with juvenile idiopathic arthritis: a randomised controlled trial. Arch Dis Child archdischild-2013-305166Published Online First: 17 March 2014 doi:10.1136/archdischild-2013-305166

Orthotics and Children with Hypotonia

Pediatric Physical Therapy published a systemic review on the efficacy and evidence of using orthoses for children with hypotonia. Ten articles met the inclusion criteria although none were Level I evidence (evidence from properly designed randomized controlled trials).   

The results found that data was reported for body structure and activity components, but not participation outcomes.  Overall, the current evidence suggests that foot orthoses and supramalleolar orthoses may benefit children with hypotonia  but the evidence is low level. 

The researchers concluded that many unanswered questions remain regarding orthotic use for children with hypotonia such as: when is the optimal time to introduce orthoses? Are foot orthoses or supramalleolar orthoses more efficacious? Should orthoses be combined with physical therapy?

What has your experience been regarding the use of orthotics and children with hypotonia?  Based on my experience, the orthotics helped with biomechanical alignment but not necessarily function.  At times, the orthotics have hindered function in order to maintain proper alignment.  

Reference:  Weber, Anna PT, DHS; Martin, Kathy PT, DHS. Efficacy of Orthoses for Children With Hypotonia: A Systematic Review. Pediatric Physical Therapy: Spring 2014 - Volume 26 - Issue 1 - p 38-47. doi: 10.1097/PEP.0000000000000011

Orthotic Use and Down Syndrome

A single subject, alternating treatment design was used to analyze the effectiveness of two different supramalleolar orthotics.  Two children with Down syndrome each participated in three phases: without orthotics, SureStep orthotic and the DAFO #4 orthotic.  Using the Gross Motor Function Measure, results indicated improvements in both children with the SureStep orthotic and child #1 also showed improvements with the DAFO #4.  After the study was completed, both families continued with the SureStep.

The researchers concluded that additional research needs to be conducted to determine the most effective orthotics and what age should the orthotics be introduced.

Reference: Tamminga, Janna S.; Martin, Kathy S.; Miller, Ellen W. Single-Subject Design Study of 2 Types of Supramalleolar Orthoses for Young Children With Down Syndrome. Pediatric Physical Therapy. 24(3):278-284, Fall 2012. doi: 10.1097/PEP.0b013e31825c8257

Heel Lift Effects on Children

Gait and Posture published research comparing heel lifts (10, 20 and 30mm) heights in 32 children with cerebral palsy, arthrogryposis and a control group. The cerebral palsy and arthrogryposis groups showed significant changes in the ankle, knee and pelvis whereas the control group only showed significant changes at the ankle. The higher the heel height resulted in a decrease in anterior pelvic tilt but increased knee flexion except in the control group. The researchers recommend an individualized approach to determine the proper heel height for each child.

Reference:Bartonek A, Lidbeck CM, Pettersson R, Weidenhielm EB, Eriksson M, Gutierrez-Farewik E. Influence of heel lifts during standing in children with motor disorders. Gait Posture. 2011 Jul 19. [Epub ahead of print]

Orthotics Affect on Upper Extremity Use

The Spring 2011 issue of Pediatric Physical Therapy published an interesting study on the use of supramalleolar orthoses and how they affect upper extremity use. Seventeen children with Down Syndrome were divided into two groups of treadmill training - one group of children wore supramalleolar orthoses and the other group did not. Both groups of children were followed every other month to video tape the use of the upper extremities during table top play. The children were followed from when they could pull to stand until independent walking. The results indicated that wearing supramalleolar orthoses did not affect hand support while standing.

Reference: Looper, Julia PT, PhD; Ulrich, Dale PhD Does Orthotic Use Affect Upper Extremity Support During Upright Play in Infants With Down Syndrome? Pediatric Physical Therapy: Spring 2011 - Volume 23 - Issue 1 - p 70–77 doi: 10.1097/PEP.0b013e318208cdea

Treadmill Training, SMO's and Down Syndrome

Physical Therapy published research on the use of supramalleolar orthosis (SMO) and treadmill training in infants with Down Syndrome. Seventeen infants were assigned to treadmill training with SMO's or treadmill training without SMO's. The infants received 3 minutes of treadmill training until the infant was able to take 3 steps independently. One month following the motor skill acquisition of independently taking 3 steps the Gross Motor Function Measure was administered. The infants who did the treadmill training without the SMO's had higher scores on the Gross Motor Function Measure in standing, walking, running and jumping. The researchers concluded that the use of orthosis may have a "detrimental effect of overall gross motor development".

Reference: Looper, Julia, Ulrich, Dale A. Effect of Treadmill Training and Supramalleolar Orthosis Use on Motor Skill Development in Infants With Down Syndrome
PHYS THER 2010 0: ptj.20090021

AFO's in Children with CP

The Journal of Bone and Joint Surgery published research on the use of a floor reaction ankle foot orthoses (AFO's) on children with cerebral palsy (CP). Using gait analysis, the researchers determined that the AFO's restricted sagittal plane motion (left to right motion)which results in improvements in knee extension. The best results were seen in children who had knee and hip flexion contractures of more than or equal to 10 degrees. The efficacy of the orthotic was limited if knee and hip flexion contractures were greater than or equal to 15 degrees. The researchers concluded that this type of orthotic should not be prescribed if knee and hip flexion contractures are great than or equal to 15 degrees.

Reference: Rogozinski, Benjamin M., Davids, Jon R., Davis, Roy B., III, Jameson, Gene G., Blackhurst, Dawn W. The Efficacy of the Floor-Reaction Ankle-Foot Orthosis in Children with Cerebral Palsy J Bone Joint Surg Am 2009 91: 2440-2447

Flat Feet and Motor Skills

Pediatrics reports on research indicating that flat feet in children ages 11-15 did not have a significant effect on 17 motor skills or athletic ability. The researchers do not recommend treating flexible flat feet for athletic performance.
That is a swift blow for all orthotists. This study was done on 11-15 year old children. I would love to see similar research in younger children.

Reference: Tudor, Anton, Ruzic, Lana, Sestan, Branko, Sirola, Luka, Prpic, Tomislav
Flat-Footedness Is Not a Disadvantage for Athletic Performance in Children Aged 11 to 15 Years Pediatrics 2009 123: e386-e392