Children with hydrocephalus often have developmental delays and hypotonia. A study conducted by Lorch et al1 found that children with benign extra-axial fluid (idiopathic external hydrocephalus) were at a statistically significant higher risk for developing cerebral palsy and having evidence of gross motor delays and hypotonia at adjusted ages of 12 months and 18 to 24 months. Faulty foot biomechanics often accompany hypotonia and can affect the entire kinetic chain. Children without a stable base of support may have difficulty maintaining posture and achieving motor milestones at the expected age.2
Traditionally, foot orthoses have been used to treat many different types of lower extremity musculoskeletal impairments. The benefits of foot orthoses may include reduced frequency of movement-related injury, proper alignment of the skeleton, improved cushioning, enhanced sensory feedback, and overall comfort.3,4 Foot orthoses are sometimes used to provide a more stable base of support for children with sensorimotor impairments, which in turn may lead to improved function. Previous research has suggested that static and dynamic postural stability in both healthy and injured adults improved as a result of foot orthoses.5,6 However, there is limited research on the outcomes of intervention with foot orthoses in children with sensorimotor impairment.
Martin7 examined the effect of supramalleolar orthoses on postural stability in children with Down syndrome. Martin found both immediate and longer-term improvement in postural stability with the use of flexible supramalleolar orthoses. The Gross Motor Function Measure and the Balance subtest of the Bruininks Oseretky Test of Motor Proficiency were used to measure postural stability in her study. Selby-Silverstein et al8 also examined the effect of foot orthoses on posture and gait in children with Down Syndrome. In Selby-Silverstein et al’s study, subjects with foot orthoses demonstrated immediate decreases in external rotation, foot progression angle, and heel eversion in standing, and more consistent foot function during gait.
A few investigators have reported on the effectiveness of orthoses that have incorporated both the ankle and foot.9,10 Harris et al9 found improvements with duration and ease of standing balance and upright posture through the use of inhibitive ankle-foot orthoses in a child with cerebral palsy. In addition, Zachazewski et al10 reported improvements in the gait pattern of an adult with traumatic brain injury when using an inhibitive ankle-foot orthoses.
We found no reports of studies that specifically examined the use of a modified stabilizing foot splint (SFS) in children. Therefore, a case report designed to illustrate the influence of modified SFSs was warranted. The main purpose of this article was to describe the influence of bilateral modified SFSs on the functional status of one child.
Despite little research concerning the use of orthoses as an intervention, previous results show positive effects on standing balance, upright posture, and ambulation. Based on these past findings and our clinical experiences with foot orthoses, we hypothesized that the use of modified SFSs would improve the overall functional mobility of a child with developmental delay. The authors hypothesized that the time required to perform a selected set of activities (ie, rise to stand, standing, lowering, cruising, and stepping forward) would be reduced with the use of modified SFSs. Finally, the authors believed that the time the child could hold a standing position would increase when using the modified SFSs.
The child was a 19-month-old girl with the diagnoses of developmental delay, hydrocephalus, and congenital absence of the corpus callosum. The diagnoses were not determined until 12 months of age. Magnetic resonance imaging and computed tomography studies of the brain revealed mild to moderate hydrocephalus involving the lateral and third ventricles with no intraventricular obstructive lesion.
Hydrocephalus is an excessive accumulation of cerebrospinal fluid in the ventricles of the brain and occurs when there is an imbalance between the amount of cerebrospinal fluid that is produced and absorbed. A build-up of cerebrospinal fluid causes the ventricles to enlarge and the pressure inside the skull to increase.11,12 There are two forms of hydrocephalus, communicating (nonobstructive) and noncommunicating (obstructive). Communicating hydrocephalus occurs when absorption of cerebrospinal fluid is inadequate without obstruction of the ventricular pathways.11 Noncommunicating hydrocephalus is caused by a blockage in the passages in which the cerebrospinal fluid flows. Hydrocephalus can be either congenital or acquired because of multiple factors such as infection, head trauma, and brain tumors.11
Two main treatment procedures exist to treat hydrocephalus. Traditionally, shunting has been the most common method of treatment. This procedure involves placing a flexible tube into the ventricular system that diverts the flow of cerebrospinal fluid into another region of the body where it can be absorbed. Common areas to which the fluid may be diverted include the peritoneal cavity or the right atrium of the heart.12 A relatively new, less-invasive surgical option for treating hydrocephalus is endoscopic third ventriculostomy. This surgery involves making a small hole in the floor of the third ventricle to allow free flow of spinal fluid into the basal cisterns for absorption.12 The child in this report underwent endoscopic third ventriculostomy before the initiation of outpatient physical therapy services.
Otherwise, the child had no other significant medical history and was not taking any medications. She had normal passive range of motion of all extremities. She was able to control isolated movements in all extremities. However, there was hypotonia involving both lower extremities. She could stand with bilateral upper extremity support for periods of one to two minutes. In the standing position, she demonstrated significant foot pronation and knee hyperextension bilaterally.
At 13 months, outpatient physical therapy was initiated, one to two times per week for 45-minute sessions. Intervention consisted of activities to promote strength, upright balance, proprioceptive feedback, core stability, and functional mobility. At 19 months of age she began receiving additional physical therapy services through the local early intervention program. It was at this time that a referral for orthoses was made.
The child was fitted bilaterally with custom-modified SFSs using a three-point support system (Fig. 1). Casts were first created with each foot held in a subtalar neutral position. Support areas were created for the medial arch, transverse arch, and laterally above the cuboid notch. Aquaplast-T was used to create the modified SFSs from the casts. Fabrication guidelines were those expressed by Cusick.4 The modified SFSs were designed to stabilize the calcaneus and promote subtalar neutral posturing of the foot in weight- bearing. No posting or other revisions to the modified SFSs were needed.
Before collecting data on the effects of the modified SFSs, we obtained the Institutional Review Board’s approvals from the supervising health care organization and educational facility, as well as informed consent from the child’s parents. When data collection began, the child had been wearing the modified SFSs for 22 days. At this time, she was starting to pull to stand, sidestep along furniture, lower herself to sit, and take steps consistently with two-handed support. These same activities were difficult to accomplish without the modified SFSs.
The primary instrument used to examine outcomes in this report was the Peabody Developmental Motor Scales, 2nd edition (PDMS II).13 The PDMS II is a widely used developmental tool that is composed of six subtests concerning the motor skills of children from birth to six years. The locomotion subtest consists of 89 items involving mobility from one location to another. It has been standardized on a sample of 2003 subjects and has been found to have good reliability and validity.13 The test-retest reliability was found to be high for the subset locomotion (r = 0.93).13
Five items from the locomotion subtest of the PDMS II were tracked over a period of three weeks. The five items were rising to stand (skill 23), cruising (skill 26), lowering (skill 27), static standing (skill 30), and stepping forward (skill 32).
Each item was scored as a 2, 1, or 0.13 A score of 2 was recorded for performance that was completely mastered. A score of 1 was recorded for performance that resembled the criteria, but was not mastered. A score of 0 was recorded for performance that demonstrated no ability or attempt to accomplish the skill.
The order of each attempted skill was as follows: rising to stand (skill 23), static standing (skill 30), cruising (skill 26), stepping forward (skill 32), and lowering (skill 27). Each individual item has a more specific explanation within the guide booklet, which the examiner followed.13
The child’s performance was scored on the same day of the week and same time period, but under three different conditions: with shoes and modified SFSs, with shoes only, and barefoot. During the first week, we employed the following sequence of data gathering: shoes and SFSs, barefoot, and shoes only. In the second week, the sequence was barefoot, shoes only, and shoes and SFSs, and in the third week, shoes only, shoes and SFSs, and barefoot. This testing technique was used to control for possible order and practice effects.
In addition, the amount of time it took for the child to accomplish each skill was timed in seconds, using a stopwatch. The same experienced rater timed the skill and recorded the rating on the PDMS II for all three weeks. The maximum amount of time that was allowed to accomplish the skill was one minute. This limitation was designed to reduce frustration with attempts of each successive skill.
Descriptive statistics (frequencies) using SPSS, version 13 (SPSS Inc., Chicago, Ill) were compiled for the selected skills that were attempted each week. In addition, differences of the speed of completion of skills between the first and third weeks were calculated.
Measurements of functional skills using the PDMS II showed improvements in both performance and time required to complete activities when using both shoes and modified SFSs (Table 1). For week 1, the child was able to score a 2 on all five items when the child used shoes and modified SFSs; one of five items with shoes only; and three of five items when barefoot. At week 2, the child was able to score a 2 with four of five items when the child used shoes and modified SFSs bilaterally; and three of five items with shoes only; and two of five items when barefoot. At week 3, the child was able to score a 2 with four of five items when the child used shoes and the modified SFSs; three of five items with shoes only; and three of five items when barefoot. Week 3 was unusual in that the child began preschool on the day of testing and seemed to fatigue more easily than usual. The shoes and modified SFSs seemed to enable the accomplishment of walking forward with one hand held. She was able to take four steps forward week 1 and week 3; she took one step forward week 2.
Improvements were also noted with the time required to complete activities when using both shoes and modified SFSs (Table 2). The least amount of time required to pull to stand was with shoes and modified SFSs for weeks 1 and 2. A reduction of 14.72 seconds was found in the time required to perform this task. At week 3 the child did not accomplish this task.
The greatest amount of time to hold a standing position was observed in each of the three weeks when the child was wearing shoes and modified SFSs. However, the change from week 1 to week 3 was negligible.
The least amount of time required to cruise (four steps) was with the shoes and modified SFSs in each of the three weeks. There was a reduction in amount of time required from week 1 to week 3 of 4.6 seconds.
The least amount of time required to walk forward with one hand held was with the shoes and modified SFSs in all three weeks. There was a reduction in amount of time required from week 1 to week 3 of 35.92 seconds.
Finally, the least amount of time required to lower to sit was found when the child was barefoot in week 1 and 3; the least amount of time required to lower to sit for week 2 was with shoes and modified SFSs. The greatest difference in time (25.95 seconds), however, was with shoes and modified SFSs from week 1 to week 3.
DISCUSSION AND CONCLUSIONS
This case report illustrates the influence of modified SFSs and shoes on the functional abilities of a child with developmental delay due to hydrocephalus and congenital absence of the corpus callosum. The overall ability to perform five functional tasks was improved when wearing both the shoes and modified SFSs compared with wearing shoes alone or when barefoot. The biggest difference observed was in performance of the skill of walking forward for four steps. The improvement was readily seen with initial application of the modified SFSs and shoes. The outcomes were consistent with the past research on foot orthoses that indicated improved static and dynamic postural stability in both healthy and injured adults.5,6
The outcomes were also consistent with the two studies of children with Down syndrome.7,8 Martin7 found both immediate and longer-term improvement in walking, running, and jumping with the application of supramalleolar orthoses. Selby-Silverstein et al8 also described the improved foot function during gait with orthoses. Their results suggested that a longer time may be required for improvements to be seen in more complex skills. Possibly, greater improvements could have been found had data been collected over a greater length of time.
It should be noted that the child’s behavior was unusual because of the initiation of a preschool program during the third week in performing the lower to sit task. Her fatigue level may have affected her performance. The improvements may have been greater if the measures had not been taken at the time she started her preschool program.
As was conjectured, there were improvements in the time required to complete selected tasks. The least amount of time required to complete the pull to stand, cruise, and walk forward tasks was found when the child was wearing the modified SFSs and shoes. However, the greatest difference in time from week 1 to week 3 was found when the child was wearing the modified SFSs and shoes. It could be that the shoes with the modified SFSs had restricted the ease of accomplishing this particular task.
Finally, it was predicted that the amount of time to hold a standing position would be increased from the first to the third week with the modified SFSs and shoes. The amount of time to hold a standing position actually decreased; however, we considered the change to be clinically insignificant. The decrease could have been due to the child’s increase in fatigue because of the initiation of the preschool program during this final week of the data collection.
A limitation of this report was that the exposure to the orthoses varied throughout the course of the day. When the child worked on standing and cruising, she used her shoes and modified SFSs. If the child was sleeping or playing on the floor, no shoes or orthoses were used. The caregiver also admitted that there were occasions in which other footwear such as sandals were used. Each day was different with respect to the amount of time spent wearing the orthoses; however, the child did use the shoes and SFSs on a daily basis. Perhaps a log kept by the caregiver would give a clearer picture of the times when the orthoses were worn.
Another limitation was that the tasks were performed only three times, under each condition, and over a period of three weeks. A greater length of time spent analyzing the intervention would have been especially helpful because of the confounding variable of initiation of preschool during the third week.
Finally, there was a limitation of time allowed (ie, one minute) to complete each task. This limitation was designed to reduce the child’s frustration and increase compliance to the activities as a whole. Increased time allotment could have made a difference in accomplishing the tasks.
However, the overall positive results indicated that the future study of the modified SFSs as an intervention is warranted. A single subject design with careful recording of interventions through the use of a log could be used to document the effectiveness of the orthoses with functional skills. Future investigators could also examine larger samples of children of different ages and diagnoses and extend the study over a greater time period.