Re: Paris

[Guest guest]

,

Thank you for keeping us updated on your trip and for your

perspective on what you have seen. We all wish that we could be

there with you.

From what you have learned in Paris, does Bensahel's French

Physiotherapy outcomes seem to be similar to what they had reported

in their 10 year outcomes paper at the May 2000 POSNA Convention. In

that study of 350 children, they reported 63% non-surgical success

for those treated by " well trained physiotherapists " and 30% non-

surgical success for those who were " less specialized

physiotherpists " .

I would agree that Bensahels French method seems to be much better at

non-surgical success than the traditional methods of treatment in the

US. Has the non-surgical success rate in their more recent treatment

of children within the past 5 years or so been much different from

their POSNA 10 year outcomes report?

The following is the abstract of Bensahels paper at the May 2000

POSNA convention.

THE EARLY PHYSIOTHERAPIC TREATMENT IN CLUBFOOT : RESULTS AT 10 YEARS

FOLLOW UP.

H Bensahel, Ph Souchet, K Mazda, Y Desgrippes, C Thémar-Noel, GF

Penneçot

Saint Mandé, Paris, France

Purpose : To evaluate the efficiency of a specific technique of

physiotherapy during the first year of age in the treatment of

clubfoot with peculiar attention to the standards of specialization

of the physical therapists.

Introduction : In order to reduce the deformities and to decrease the

imbalance of the muscles, this peculiar conservative treatment using

a specific physiotherapic method must start at birth ..

Methods : Since 1972, we use a conservative treatment based on a

specific physiotherapy . It consists in gentle manipulations. It

tends to reduce progressively the different deformities of the foot.

These manipulations are the masterpiece of the treatment. They

respect the physiology of the movements in neonates. Then are done

active stimulations of the muscle and finally a light, short and

flexible splint is used to maintain the correction.

The end results were classified according to Bensahel's

classification.

Patients: 350 cases were evaluated. The average follow up was 10

years (range : 7 to 14 years). These cases were compared to a

previously published population of 338 feet followed untill end of

growth.

Results: Out of these 350 feet, a significant difference was found

depending on the degree of training of the physiotherapist who was in

charge of the patient : 63% of the feet treated by a well trained

physical therapist were classified as good results (i.e. avoided

surgery) when a good result was obtained in only 30 % of the feet

treated by a less specialied physical therapist.

Regarding the classification of the foot at birth, we noticed that

our conservative treatment decreased the deformities in the four

groups : 50% of the group B became group A in the hands of

specialized physiotherapists (33% for the others); 100% group C

became group B (89% for the other s) . As for the group D, all the

feet were improved in both groups of physiotherapists ( and , more,

few cases have been improved from group D to B in the hands of the

trained physical therapist).

Comparing this outcome to the one found in our previous series of 338

feet, we emphasize the usefullness of considering not only the rate

of the different kinds of results, but also the outcome related to

the birth classification.

Conclusion : 63% of the babies treated since birth with this

physiotherapic method by a trained physical therapist won't need

surgery at a mean follow up of 10 years. In the remaining cases,

physiotherapy always decreased the deformities of the feet, leading

to an easier and more limited surgery with a better result.

http://www.posna.org/meetings/vancouver/abstracts3.htm#FT_Physio

Please keep us informed about the what you learn both in Paris as

well as in Montpelier.

and (3-17-99)

> Hello all,

>

> I'm writing this from Paris after spending the day at Hopital

> Debre with Dr. Henri Bensahel and his colleagues. Dr. Bensahel,

now

> retired from clincal practice has been using his physio based

> treatment of clubfeet for 29 years and Kristy Brundage (who is the

> therapist in my clinic) and I spent a fascinating day.

>

> I have to admit that I arrived a bit sceptical as what I have heard

> is that this method does not allow for as good as correction as

> plaster based methods. However, after watching Jean-Simon (who is

a

> physio working exclusively with clubfeet) work I was truly

> impressed. There is much to learn here.

>

> Dr. Bensahel believes, like Dr. Ponseti, that one must understand

the

> pathoanatomy of clubfoot in order to undo the deformity with a

> precise sequence of manipulation. He also believes that surgery

and

> poor manipulation/casting causes increased fibrosis and scarring

and

> leads to poorer functional results. Their philosphy is " ne pas

> lutter avec le bebe " or don't fight with the baby and this has

> resulted in very gentle handling and manipulation.

>

> Kristy tells me that what we say yesterday is much akin to

MacKenzie

> (?spelling) manipulative/mobilization techniques taught in physio

> schools across the world. I was very ijmpressed that they are able

> to mobilize the subtalar and ankle joints as well as the skin and

> soft tissues of the back of the foot. The feet, which are taped or

> splinted with plastic material, not casted, look healthier than

those

> that are casted. The soft tissues look and feel better.

>

> There has been a lot of debate in this group about pain during

> treatment. Every baby I saw yesterday slept though their treatment

> or interacted happily with their parent or with an assistant. The

> only time they cried was when I touched the feet - I was being

gentle

> but obviously do not at this stage have " the touch " of these

> therapists. Pretty incredible.

>

> I'm not sure how to translate what I've seen into my practice yet.

I

> can't imagine parents who would be able to come 5 days a week for 5

> or 6 months, even if my center could provide the physio resources.

> However I am convinced that there is a lot to learn from this

> technique and am really glad that I came. This morning I'm going

> back to attend a followup clinic and will be interested in what I

see.

>

>

> son

>

> PS. Short, if you read this email me as I've lost your

> address. There was a British family here yesterday looking for a

> nonsurgical alternative. Do you know of anyone using this

technique

> in Britain??

[Guest guest]

,

Thank you for keeping us updated on your trip and for your

perspective on what you have seen. We all wish that we could be

there with you.

From what you have learned in Paris, does Bensahel's French

Physiotherapy outcomes seem to be similar to what they had reported

in their 10 year outcomes paper at the May 2000 POSNA Convention. In

that study of 350 children, they reported 63% non-surgical success

for those treated by " well trained physiotherapists " and 30% non-

surgical success for those who were " less specialized

physiotherpists " .

I would agree that Bensahels French method seems to be much better at

non-surgical success than the traditional methods of treatment in the

US. Has the non-surgical success rate in their more recent treatment

of children within the past 5 years or so been much different from

their POSNA 10 year outcomes report?

The following is the abstract of Bensahels paper at the May 2000

POSNA convention.

THE EARLY PHYSIOTHERAPIC TREATMENT IN CLUBFOOT : RESULTS AT 10 YEARS

FOLLOW UP.

H Bensahel, Ph Souchet, K Mazda, Y Desgrippes, C Thémar-Noel, GF

Penneçot

Saint Mandé, Paris, France

Purpose : To evaluate the efficiency of a specific technique of

physiotherapy during the first year of age in the treatment of

clubfoot with peculiar attention to the standards of specialization

of the physical therapists.

Introduction : In order to reduce the deformities and to decrease the

imbalance of the muscles, this peculiar conservative treatment using

a specific physiotherapic method must start at birth ..

Methods : Since 1972, we use a conservative treatment based on a

specific physiotherapy . It consists in gentle manipulations. It

tends to reduce progressively the different deformities of the foot.

These manipulations are the masterpiece of the treatment. They

respect the physiology of the movements in neonates. Then are done

active stimulations of the muscle and finally a light, short and

flexible splint is used to maintain the correction.

The end results were classified according to Bensahel's

classification.

Patients: 350 cases were evaluated. The average follow up was 10

years (range : 7 to 14 years). These cases were compared to a

previously published population of 338 feet followed untill end of

growth.

Results: Out of these 350 feet, a significant difference was found

depending on the degree of training of the physiotherapist who was in

charge of the patient : 63% of the feet treated by a well trained

physical therapist were classified as good results (i.e. avoided

surgery) when a good result was obtained in only 30 % of the feet

treated by a less specialied physical therapist.

Regarding the classification of the foot at birth, we noticed that

our conservative treatment decreased the deformities in the four

groups : 50% of the group B became group A in the hands of

specialized physiotherapists (33% for the others); 100% group C

became group B (89% for the other s) . As for the group D, all the

feet were improved in both groups of physiotherapists ( and , more,

few cases have been improved from group D to B in the hands of the

trained physical therapist).

Comparing this outcome to the one found in our previous series of 338

feet, we emphasize the usefullness of considering not only the rate

of the different kinds of results, but also the outcome related to

the birth classification.

Conclusion : 63% of the babies treated since birth with this

physiotherapic method by a trained physical therapist won't need

surgery at a mean follow up of 10 years. In the remaining cases,

physiotherapy always decreased the deformities of the feet, leading

to an easier and more limited surgery with a better result.

http://www.posna.org/meetings/vancouver/abstracts3.htm#FT_Physio

Please keep us informed about the what you learn both in Paris as

well as in Montpelier.

and (3-17-99)

> Hello all,

>

> I'm writing this from Paris after spending the day at Hopital

> Debre with Dr. Henri Bensahel and his colleagues. Dr. Bensahel,

now

> retired from clincal practice has been using his physio based

> treatment of clubfeet for 29 years and Kristy Brundage (who is the

> therapist in my clinic) and I spent a fascinating day.

>

> I have to admit that I arrived a bit sceptical as what I have heard

> is that this method does not allow for as good as correction as

> plaster based methods. However, after watching Jean-Simon (who is

a

> physio working exclusively with clubfeet) work I was truly

> impressed. There is much to learn here.

>

> Dr. Bensahel believes, like Dr. Ponseti, that one must understand

the

> pathoanatomy of clubfoot in order to undo the deformity with a

> precise sequence of manipulation. He also believes that surgery

and

> poor manipulation/casting causes increased fibrosis and scarring

and

> leads to poorer functional results. Their philosphy is " ne pas

> lutter avec le bebe " or don't fight with the baby and this has

> resulted in very gentle handling and manipulation.

>

> Kristy tells me that what we say yesterday is much akin to

MacKenzie

> (?spelling) manipulative/mobilization techniques taught in physio

> schools across the world. I was very ijmpressed that they are able

> to mobilize the subtalar and ankle joints as well as the skin and

> soft tissues of the back of the foot. The feet, which are taped or

> splinted with plastic material, not casted, look healthier than

those

> that are casted. The soft tissues look and feel better.

>

> There has been a lot of debate in this group about pain during

> treatment. Every baby I saw yesterday slept though their treatment

> or interacted happily with their parent or with an assistant. The

> only time they cried was when I touched the feet - I was being

gentle

> but obviously do not at this stage have " the touch " of these

> therapists. Pretty incredible.

>

> I'm not sure how to translate what I've seen into my practice yet.

I

> can't imagine parents who would be able to come 5 days a week for 5

> or 6 months, even if my center could provide the physio resources.

> However I am convinced that there is a lot to learn from this

> technique and am really glad that I came. This morning I'm going

> back to attend a followup clinic and will be interested in what I

see.

>

>

> son

>

> PS. Short, if you read this email me as I've lost your

> address. There was a British family here yesterday looking for a

> nonsurgical alternative. Do you know of anyone using this

technique

> in Britain??

[Guest guest]

Hi ,

So glad you have the chance to experience this technique, as we know

very well text books are not the best teaching guides alone. I would

love to get any written material you might find usefull (if it is in

english) linked us to his papers from AAOS and I really

appreciated this.

The babies I care for here seem to have no real skin problems as

each time I remove the cast I wash them and massage then manipulate

with a gentle babyoil lotion. The problem comes after the tenotomy and

3 weeks in a cast. They just grow so much at this young age and most

of them come out looking a bit puffy and discolored especially at the

dorsum of the foot. Some of this I belive is from the extra

dorsiflexion at the ankle for maximum correction after the tenotomy.

Have some fun while you are there, I hear Paris is wonderfull in the

spring...OOH LA LA

Beth~~The Cast Lady

[Guest guest]

Hello again,

End of day 2 in Paris. Today I was able to spend time in Dr.

Souchet's clubfoot follow-up clinic (if I've spelt that wrong I'm

blaming jetlag). I was a bit surprised to see a lot of patients who

have had surgery of some sort and 2 who had significant talar

deformity ( " flat topped talus " ) which may be due to excessive

manipulative attempts to get the heel down. One of these patients

was treated by a " less experienced " therapist and I think that this

may have contributed to the result, however I am really just

speculating. , I cannot give you any updated figures on

outcomes although it seems that the patients are being tracked

reasonably well with graded examination and xrays.

I think that therapist experience is key here. In a sense it reminds

me of ultrasound examination of the hips, also largely pioneered in

Europe. This is now a very well accepted and useful technique,

however it hinges on operator expertise (ie. the USS technician). In

my center, I rely on the USS scans from one of the 2 hospitals as the

techs at the other hospital do not have a consistent volume and

experience of children's hips. It makes a HUGE difference.

The two therapists that I had the chance to observe were true

artists, I cannot put it any other way. But I think that quality

control may be a problem with any widespread attempt at

introduction.

I'm not sure that this is a perfect method, but there is something

here. I don't know that I believe that the whole hindfoot correction

can be made this way in severe clubfeet, however I think that it may

be helpful to allow some motion of the ankle and talus during

treatment (maybe cast half the week and tape/splint/exercise the

other half - this I think sounds like what is being done in NY,

correct me if I'm wrong). I don't know, it's just all rummaging

around in my head right now. I think that I need to try some longer,

gentler manipulations and perhaps some taping to see how the feet

respond....

Cast Lady, my comments about the state of casted feet did not relate

to skin problems but rather to the " woody " feeling that you get after

casting (eg. after 6 weeks in cast for a broken ankle). While my

Ponseti feet are not nearly as bad as my pre-Ponseti patients (3

months in casts), the physio feet are definitely suppler (is that a

word? I've been thinking in French for 2 days).

Off to Montpellier tomorrow to learn more. Thanks to everyone for

their comments and interest. It's nice to be able to share this

and " think out loud " a bit.

son

[Guest guest]

,

Can you describe for us what the Bensahel method entails:

How long does a typical physiotherapy session take? How is the

taping and splinting different than the casting most of us have

seen? What is the range of time frames in months for which daily

visits might be needed? Then does it go to every other day, every

third day? Does any of Bensahels method use parents learning the

manipulation and or splinting? Are casts ever used? Once the foot

is initially corrected, do they use DBB's, AFO's, something else or

just ongoing occasional physiotherapy? If the method didn't work,

typically how old is the child when they can tell that surgery would

be needed? If they have relapses, how is that dealt with? With the

Bensahel method, if surgery is needed, is it performed like in the

traditional US methods that they would start with posterior release

and then if needed progress from medial to lateral to plantar

releases or is the surgery done differently in any significant way?

Do they ever use a tenotomy to deal with the equinus? Is Dr.

Bensahel aware of anyone in Canada or the US currently use his method?

With the population of France at about 60 million, statistically they

should have about 1,000 children born with clubfoot per year. I

would also guess that there are somewhere between 100-200 pediatric

orthopedists or doctors that treat children with orthopedic

problems. Can you find out or estimate what percent of doctors in

France would use Bensahel's method, what percent Dimeglio's or other

physiotherapy methods as well as Traditional North American type

treatment and/or other methods?

Also, what is the difference between " well trained " and " less

experienced " physiotherpists at the same hospital where I would

assume that there would be the ability to train them all? Is the

" less experienced " just that they have been trained but may have only

treated children for a few years versus 10 years plus for someone

" well trained " or is it something else?

Also, Bensahel's outcome study at POSNA was for patients from 7 to 14

with an average age of 10 years. Since the method has been in effect

for 29 years, have there been other studies of the patients over 14

years of age where other outcome results were evaluated other than

just whether surgery occurred or not? For example, degrees of

flexibility, existance of pain or not, or other objective or

subjective means of evaluating long-long term outcomes?

Also, while you are at the EPOS meeting, there are other ped orthos

in Europe that use the Ponseti method. Dr. Ponseti has some doctors

listed from France, Spain, Belgium, Sweden and Italy. If you run

into them, can you get their perspectives from practicing in Europe?

Thanks for your information and perspective.

and (3-17-99)

> Hello again,

>

> End of day 2 in Paris. Today I was able to spend time in Dr.

> Souchet's clubfoot follow-up clinic (if I've spelt that wrong I'm

> blaming jetlag). I was a bit surprised to see a lot of patients

who

> have had surgery of some sort and 2 who had significant talar

> deformity ( " flat topped talus " ) which may be due to excessive

> manipulative attempts to get the heel down. One of these patients

> was treated by a " less experienced " therapist and I think that this

> may have contributed to the result, however I am really just

> speculating. , I cannot give you any updated figures on

> outcomes although it seems that the patients are being tracked

> reasonably well with graded examination and xrays.

>

> I think that therapist experience is key here. In a sense it

reminds

> me of ultrasound examination of the hips, also largely pioneered in

> Europe. This is now a very well accepted and useful technique,

> however it hinges on operator expertise (ie. the USS technician).

In

> my center, I rely on the USS scans from one of the 2 hospitals as

the

> techs at the other hospital do not have a consistent volume and

> experience of children's hips. It makes a HUGE difference.

>

> The two therapists that I had the chance to observe were true

> artists, I cannot put it any other way. But I think that quality

> control may be a problem with any widespread attempt at

> introduction.

>

> I'm not sure that this is a perfect method, but there is something

> here. I don't know that I believe that the whole hindfoot

correction

> can be made this way in severe clubfeet, however I think that it

may

> be helpful to allow some motion of the ankle and talus during

> treatment (maybe cast half the week and tape/splint/exercise the

> other half - this I think sounds like what is being done in NY,

> correct me if I'm wrong). I don't know, it's just all rummaging

> around in my head right now. I think that I need to try some

longer,

> gentler manipulations and perhaps some taping to see how the feet

> respond....

>

> Cast Lady, my comments about the state of casted feet did not

relate

> to skin problems but rather to the " woody " feeling that you get

after

> casting (eg. after 6 weeks in cast for a broken ankle). While my

> Ponseti feet are not nearly as bad as my pre-Ponseti patients (3

> months in casts), the physio feet are definitely suppler (is that a

> word? I've been thinking in French for 2 days).

>

> Off to Montpellier tomorrow to learn more. Thanks to everyone for

> their comments and interest. It's nice to be able to share this

> and " think out loud " a bit.

>

> son

[Guest guest]

,

Can you describe for us what the Bensahel method entails:

How long does a typical physiotherapy session take? How is the

taping and splinting different than the casting most of us have

seen? What is the range of time frames in months for which daily

visits might be needed? Then does it go to every other day, every

third day? Does any of Bensahels method use parents learning the

manipulation and or splinting? Are casts ever used? Once the foot

is initially corrected, do they use DBB's, AFO's, something else or

just ongoing occasional physiotherapy? If the method didn't work,

typically how old is the child when they can tell that surgery would

be needed? If they have relapses, how is that dealt with? With the

Bensahel method, if surgery is needed, is it performed like in the

traditional US methods that they would start with posterior release

and then if needed progress from medial to lateral to plantar

releases or is the surgery done differently in any significant way?

Do they ever use a tenotomy to deal with the equinus? Is Dr.

Bensahel aware of anyone in Canada or the US currently use his method?

With the population of France at about 60 million, statistically they

should have about 1,000 children born with clubfoot per year. I

would also guess that there are somewhere between 100-200 pediatric

orthopedists or doctors that treat children with orthopedic

problems. Can you find out or estimate what percent of doctors in

France would use Bensahel's method, what percent Dimeglio's or other

physiotherapy methods as well as Traditional North American type

treatment and/or other methods?

Also, what is the difference between " well trained " and " less

experienced " physiotherpists at the same hospital where I would

assume that there would be the ability to train them all? Is the

" less experienced " just that they have been trained but may have only

treated children for a few years versus 10 years plus for someone

" well trained " or is it something else?

Also, Bensahel's outcome study at POSNA was for patients from 7 to 14

with an average age of 10 years. Since the method has been in effect

for 29 years, have there been other studies of the patients over 14

years of age where other outcome results were evaluated other than

just whether surgery occurred or not? For example, degrees of

flexibility, existance of pain or not, or other objective or

subjective means of evaluating long-long term outcomes?

Also, while you are at the EPOS meeting, there are other ped orthos

in Europe that use the Ponseti method. Dr. Ponseti has some doctors

listed from France, Spain, Belgium, Sweden and Italy. If you run

into them, can you get their perspectives from practicing in Europe?

Thanks for your information and perspective.

and (3-17-99)

> Hello again,

>

> End of day 2 in Paris. Today I was able to spend time in Dr.

> Souchet's clubfoot follow-up clinic (if I've spelt that wrong I'm

> blaming jetlag). I was a bit surprised to see a lot of patients

who

> have had surgery of some sort and 2 who had significant talar

> deformity ( " flat topped talus " ) which may be due to excessive

> manipulative attempts to get the heel down. One of these patients

> was treated by a " less experienced " therapist and I think that this

> may have contributed to the result, however I am really just

> speculating. , I cannot give you any updated figures on

> outcomes although it seems that the patients are being tracked

> reasonably well with graded examination and xrays.

>

> I think that therapist experience is key here. In a sense it

reminds

> me of ultrasound examination of the hips, also largely pioneered in

> Europe. This is now a very well accepted and useful technique,

> however it hinges on operator expertise (ie. the USS technician).

In

> my center, I rely on the USS scans from one of the 2 hospitals as

the

> techs at the other hospital do not have a consistent volume and

> experience of children's hips. It makes a HUGE difference.

>

> The two therapists that I had the chance to observe were true

> artists, I cannot put it any other way. But I think that quality

> control may be a problem with any widespread attempt at

> introduction.

>

> I'm not sure that this is a perfect method, but there is something

> here. I don't know that I believe that the whole hindfoot

correction

> can be made this way in severe clubfeet, however I think that it

may

> be helpful to allow some motion of the ankle and talus during

> treatment (maybe cast half the week and tape/splint/exercise the

> other half - this I think sounds like what is being done in NY,

> correct me if I'm wrong). I don't know, it's just all rummaging

> around in my head right now. I think that I need to try some

longer,

> gentler manipulations and perhaps some taping to see how the feet

> respond....

>

> Cast Lady, my comments about the state of casted feet did not

relate

> to skin problems but rather to the " woody " feeling that you get

after

> casting (eg. after 6 weeks in cast for a broken ankle). While my

> Ponseti feet are not nearly as bad as my pre-Ponseti patients (3

> months in casts), the physio feet are definitely suppler (is that a

> word? I've been thinking in French for 2 days).

>

> Off to Montpellier tomorrow to learn more. Thanks to everyone for

> their comments and interest. It's nice to be able to share this

> and " think out loud " a bit.

>

> son

[Guest guest]

Hi and everyone

Lots of good questions. I may have to wait until I get home to do

them justice as I am having trouble connecting to the internet from

my hotel and am at a smoky internet cafe with a French (not French

method) keyboard that is driving me crazy as the letters are in

different places.

Dr Bensahel tells us that he is about to publish his latest results.

I'll try to find out where and when. The Bensahel method involves 20-

30 mns manip per foot then very cool looking taping with elastoplast

over a thin material to protect the skin. The parents come 5-7 days

a wk for up to a year. The therapists do not teach the family the

treatment. Some pts are splinted with sandsplint plastic at the

therapists discretion. The therapist directs the treatment. It

seems that physio is widely used in Europe - some favour the

continuous motion machine and physio technique used in Montpellier by

Dimeglio and his wife. Not much talk of the Ponseti technique.

Haven't managed to corner Dr Dimeglio or probably more importantly

Mme Dimeglio yet but still trying.

More later

son

[Guest guest]

,

Thanks for your reports. Do you know if Dr. Bensahel or his hospital

group has a web site of information?

Also, here is some of the information that I am aware of on a few of

the Ponseti method doctors in Europe.

One of the doctors in France that uses the Ponseti method is a doctor

named Professor J. Berrard from Lyon. I had posted a message in

January 2000 about a conversation I had with Dr. Ponseti. From that

posting...

" When I had asked Dr. Ponseti about physiotherapy methods last summer

(Aug 1999) (after my original ped ortho had mentioned the French

physiotherapy method presented at the POSNA meeting , Dr. Ponseti

showed me a letter he had received in July 1999 from a Professor J.

Berrard at the Hospital DeBrousse in Lyon France. "

" In that letter Professor Berrard indicaed " Since we have met, we

have completely abandonned our technique to perform yours (Ponseti's)

instead. We have already treated nine feet and our first results

following thoroughly your technique seem extremely interesting,

actually better than those obtained with the treatment we used during

the two first months of life which was made of physiotherapy, bandage

and plaster. The next very interesting period will be walking

acquisition. In autumn (1999) we will assess the first cases treated

your way. By that time I might write you again in the case we

encounter problems we cannot solve. " Of course, this is only

information from one French Hospital's experience and there are

probably 100-200 pediatric orthopedists in France at a lot of other

hospitals. "

http://boards2.parentsplace.com/messages/get/ppclubfoot21/7/2.html

In April 2000, when we were at the Children's Hospital of LA for a

checkup when Dr. Ponseti went there to present his method, he told us

a bit about his Feb 2000 trip to France and Spain. The following are

some of the excerpts from what we had posted then concerning his trip.

Dr. Ponseti indicated that Dr. Ey, in Barcelona, Spain, has now

treated 112 feet in the first two years since learning the Ponseti

method. Dr. Ponseti saw some of them at the Hospital de Sant Joan de

Deu (the Children's Hospital in Barcelona), and said that they all

looked good. Dr. Ey is going to present her work in a few months

(this would have been in 2000) at the Orthopaedic European Meeting in

Milano, Italy.

Dr. Ponseti was also in Lyon, France. There in the past year (from

early 1999 to early 2000), Professour Berard has treated 25 clubfeet

with the Ponseti method. He has two very good assistants, and several

French and Swiss orthopaedic surgeons attended. A few of the

visiting doctors had his book and clubfoot models and are set to

start using the Ponseti method in their own hospitals.

http://groups.yahoo.com/group/nosurgery4clubfoot/message/1171

In addition, Dr. Herzenberg presented a joint study at the AAOS

Convention with a Dr. Christof Radler, Vienna AUSTRIA and

Noam Bor, MD, Afula ISRAEL

http://www.aaos.org/wordhtml/anmt2001/poster/pe132.htm

and

> Hi and everyone

>

> Lots of good questions. I may have to wait until I get home to do

> them justice as I am having trouble connecting to the internet from

> my hotel and am at a smoky internet cafe with a French (not French

> method) keyboard that is driving me crazy as the letters are in

> different places.

>

> Dr Bensahel tells us that he is about to publish his latest

results.

> I'll try to find out where and when. The Bensahel method involves

20-

> 30 mns manip per foot then very cool looking taping with

elastoplast

> over a thin material to protect the skin. The parents come 5-7

days

> a wk for up to a year. The therapists do not teach the family the

> treatment. Some pts are splinted with sandsplint plastic at the

> therapists discretion. The therapist directs the treatment. It

> seems that physio is widely used in Europe - some favour the

> continuous motion machine and physio technique used in Montpellier

by

> Dimeglio and his wife. Not much talk of the Ponseti technique.

> Haven't managed to corner Dr Dimeglio or probably more importantly

> Mme Dimeglio yet but still trying.

>

> More later

>

> son

[Guest guest]

How exciting!!! Thank you for that information, Dr. son! Enjoy

your time with the Dimeglios. They are such wonderful people. The

French Technique is so awesome! Our ped. ortho will be in France as

well. If you get a chance, look him up. His name is Dr. Kaye

Wilkins and he is a wonderful man!

We went to Quinns 6 week check up with Dr. Wilkins on Monday. We

have such wonderful news. On radiograph, his navicular is in correct

position, as is his calcaneous. His angles are above what they

should be, and his foot moves wonderfully. HE IS RADIOGRAPHICALLY

CORRECTED AND HIS PHYSICAL EXAMINATION REVEALS A WONDERFULLY FLEXIBLE

CORRECTED FOOT!!!!!!!!!!!!!!!!!!!! I actually was told these words

which was music to my ears; " No surgery. His foot looks great and

it will not be necessary. Lets just maintain now " . Radiographic

correction AND functional correction. Praise God for the Dimeglios.

We will go to therapy once every other week for a new splint, and to

the ortho once every three months. Traveling is over, but I gotta

tell you, it was sooooooooooooo worth it. I would have traveled to

hell and back for this therapy.

Quinn stands really well now, and his foot has a beautiful arch and

he everts his foot wonderfully.

Needless to say, we are well pleased.

Jody

> Hello all,

>

> I'm writing this from Paris after spending the day at Hopital

> Debre with Dr. Henri Bensahel and his colleagues. Dr. Bensahel,

now

> retired from clincal practice has been using his physio based

> treatment of clubfeet for 29 years and Kristy Brundage (who is the

> therapist in my clinic) and I spent a fascinating day.

>

> I have to admit that I arrived a bit sceptical as what I have heard

> is that this method does not allow for as good as correction as

> plaster based methods. However, after watching Jean-Simon (who is

a

> physio working exclusively with clubfeet) work I was truly

> impressed. There is much to learn here.

>

> Dr. Bensahel believes, like Dr. Ponseti, that one must understand

the

> pathoanatomy of clubfoot in order to undo the deformity with a

> precise sequence of manipulation. He also believes that surgery

and

> poor manipulation/casting causes increased fibrosis and scarring

and

> leads to poorer functional results. Their philosphy is " ne pas

> lutter avec le bebe " or don't fight with the baby and this has

> resulted in very gentle handling and manipulation.

>

> Kristy tells me that what we say yesterday is much akin to

MacKenzie

> (?spelling) manipulative/mobilization techniques taught in physio

> schools across the world. I was very ijmpressed that they are able

> to mobilize the subtalar and ankle joints as well as the skin and

> soft tissues of the back of the foot. The feet, which are taped or

> splinted with plastic material, not casted, look healthier than

those

> that are casted. The soft tissues look and feel better.

>

> There has been a lot of debate in this group about pain during

> treatment. Every baby I saw yesterday slept though their treatment

> or interacted happily with their parent or with an assistant. The

> only time they cried was when I touched the feet - I was being

gentle

> but obviously do not at this stage have " the touch " of these

> therapists. Pretty incredible.

>

> I'm not sure how to translate what I've seen into my practice yet.

I

> can't imagine parents who would be able to come 5 days a week for 5

> or 6 months, even if my center could provide the physio resources.

> However I am convinced that there is a lot to learn from this

> technique and am really glad that I came. This morning I'm going

> back to attend a followup clinic and will be interested in what I

see.

>

>

> son

>

> PS. Short, if you read this email me as I've lost your

> address. There was a British family here yesterday looking for a

> nonsurgical alternative. Do you know of anyone using this

technique

> in Britain??

[Guest guest]

Hello Jody and everyone else,

Congratulations on Quinn's foot. That's great news! I hadn't

realized that Kaye Wilkins was your surgeon, I actually spent some

time talking to him today and he is very pleased with the results

that his therapists are getting with patients. Kristy and I had a

LONG talk with Frederique Dimeglio today. She described her method -

basically a very orderly, gentle lengthy daily manipulation, foot

initially taped daily with the addition of a continuous passive

motion machine for the first 3 months of life. Did you use CPM with

Quinn? It doesn't sound like CPM is obligatory - I sense that the

key is the manipulation and (like Ponseti and Bensahel) the

understanding of the pathoanatomy of the foot and the " undoing " of

the deformity.

Now, we didn't have the opportunity to see anything clinical so bear

that in mind, but from our conversation it seems that they are

following their feet objectively, documenting progress with photos

and video and only operating on 10% with quite limited procedures.

There is obviously a quiet rivalry between Paris and Montpellier on

this issue and so one must read between the lines a bit, however I

think that in Paris, there are more and more extensive operations.

The differences in the techniques are how the feet are taped, whether

metal footplates are added into the taping (yes, in Paris, sometimes;

not in Montpellier) and whether so-called " softcast " splints are used

(basically a flexible type of fiberglass roll applied like a cast and

then immediately removed and converted to a splint - Mme. Dimeglio

does this after 3 months).

A lot of people think that clubfoot is caused by a relative

neurologic imbalance in the lower limb muscles, perhaps because of a

deficit of anterior horn cells in the spine (these are the cells that

power the muscles, they are damaged in polio and some other

disorders). The theoretical advantage to all the physio methods are

as follows: motion is maintained therefore the muscles if anything

have the opportunity to train and get stronger rather than weaker in

a cast, the joints are gradually mobilized and kept moving and

therefore the stiffness is gradually reduced. The disadvantages that

I can see are a danger of damage to the talar head with unskilled or

too aggressive manipulation (this can also happen with any manip/cast

technique or with surgery) and " breaking the midfoot " or manipulating

through the wrong joints.

I think that I am going to try and come back here for a week sometime

in the fall - I haven't told my husband this news yet, I'll have to

break it to him gently as he's at home running the ship! - and get

some hands on in Frederique Dimeglio's physio room. Unfortunately my

therapist won't be able to come as she'll be busy with baby #4 due in

August. I'm also cooking up a plot to see if my center and the folks

in Montreal could bring Dr. Dimeglio over as a visiting prof

sometime. May not pan out, but I'll propose it to my colleagues when

I return.

Does anyone remember who is seeing Gail Chorney in NY? I think that

she's the nearest to me practicing this method in the US.

Anyway, must go. We're " stuck " here tonight in order to get our

Saturday night stay before we fly out Sunday. Not much happening at

the conference tomorrow (business meetings for EPOS members and the

like) and so I think we'll check out the beach at Palavas. I hear

that the snow is gone in Ontario and so it'll be good to get home.

[Guest guest]

Jody,

What great news! You must be thrilled.. it sounds like the treatment

worked wonderfully. So glad Quinn has such a good prognosis. I've

been reading Dr. son's thoughts on the French method with

interest.. Congratulations!

A.

[Guest guest]

Dr. son,

Thank you for your reports from Paris. It's been interesting to

follow. Do you think, then, that you'll try to incorporate some of

this method in your practice? I am curious about the advantages you

spoke of.. less muscle weakness and stiffness. Do you mean that you

think with plaster casting the muscles and ligaments are made

permanently weaker and stiffer, or temporarily? You're not talking

about calf size, correct? Am I right that the calf size is going to

be smaller no matter what the treatment?

Thanks for the information, and enjoy the rest of your trip.

A.

> Hello Jody and everyone else,

>

> Congratulations on Quinn's foot. That's great news! I hadn't

> realized that Kaye Wilkins was your surgeon, I actually spent some

> time talking to him today and he is very pleased with the results

> that his therapists are getting with patients. Kristy and I had a

> LONG talk with Frederique Dimeglio today. She described her

method -

> basically a very orderly, gentle lengthy daily manipulation, foot

> initially taped daily with the addition of a continuous passive

> motion machine for the first 3 months of life. Did you use CPM

with

> Quinn? It doesn't sound like CPM is obligatory - I sense that the

> key is the manipulation and (like Ponseti and Bensahel) the

> understanding of the pathoanatomy of the foot and the " undoing " of

> the deformity.

>

> Now, we didn't have the opportunity to see anything clinical so

bear

> that in mind, but from our conversation it seems that they are

> following their feet objectively, documenting progress with photos

> and video and only operating on 10% with quite limited procedures.

> There is obviously a quiet rivalry between Paris and Montpellier on

> this issue and so one must read between the lines a bit, however I

> think that in Paris, there are more and more extensive operations.

> The differences in the techniques are how the feet are taped,

whether

> metal footplates are added into the taping (yes, in Paris,

sometimes;

> not in Montpellier) and whether so-called " softcast " splints are

used

> (basically a flexible type of fiberglass roll applied like a cast

and

> then immediately removed and converted to a splint - Mme. Dimeglio

> does this after 3 months).

>

> A lot of people think that clubfoot is caused by a relative

> neurologic imbalance in the lower limb muscles, perhaps because of

a

> deficit of anterior horn cells in the spine (these are the cells

that

> power the muscles, they are damaged in polio and some other

> disorders). The theoretical advantage to all the physio methods

are

> as follows: motion is maintained therefore the muscles if anything

> have the opportunity to train and get stronger rather than weaker

in

> a cast, the joints are gradually mobilized and kept moving and

> therefore the stiffness is gradually reduced. The disadvantages

that

> I can see are a danger of damage to the talar head with unskilled

or

> too aggressive manipulation (this can also happen with any

manip/cast

> technique or with surgery) and " breaking the midfoot " or

manipulating

> through the wrong joints.

>

> I think that I am going to try and come back here for a week

sometime

> in the fall - I haven't told my husband this news yet, I'll have to

> break it to him gently as he's at home running the ship! - and get

> some hands on in Frederique Dimeglio's physio room. Unfortunately

my

> therapist won't be able to come as she'll be busy with baby #4 due

in

> August. I'm also cooking up a plot to see if my center and the

folks

> in Montreal could bring Dr. Dimeglio over as a visiting prof

> sometime. May not pan out, but I'll propose it to my colleagues

when

> I return.

>

> Does anyone remember who is seeing Gail Chorney in NY? I think

that

> she's the nearest to me practicing this method in the US.

>

> Anyway, must go. We're " stuck " here tonight in order to get our

> Saturday night stay before we fly out Sunday. Not much happening

at

> the conference tomorrow (business meetings for EPOS members and the

> like) and so I think we'll check out the beach at Palavas. I hear

> that the snow is gone in Ontario and so it'll be good to get home.

>

>

[Guest guest]

Glad you met Dr. Wilkins. We really like him. He is wonderful with

the kiddos, and with the worried moms, too! I think our appointment

with him on Monday was as exciting for him as for me! It must be very

rewarding for him to see a very stiff, severe clubfoot unfold and

become a beautiful, functioning foot.

We tried the CPM. It just didn't work out for Quinn and I. We co-

sleep, and Quinn is a side sleeper, so he always woke up about 15

minutes after I hooked him up. I would try and try, but he always

woke when trying to move to his side. The infant must be asleep

while on it. I have 2 friends who used it, and their children

tolerated it wonderfully. It is used on a case by case basis in San

.

I have met a PT out of Dallas, and she and I are hiring a guy to do a

professional webpage for us about the French Technique. There will

possibly be video, audio and a chat, plus many links etc about FP. If

you would like some more info, feel free to e-mail me about it at;

jody2ms@...

I hope you are able to go back to France in the Fall. Maybe next

year your PT can go. I am excited and very happy to see your

enthusiasm! It is a wonderfully gentle approach to clubfoot

correction.

Enjoy the rest of your stay in France!!

Jody

> Hello Jody and everyone else,

>

> Congratulations on Quinn's foot. That's great news! I hadn't

> realized that Kaye Wilkins was your surgeon, I actually spent some

> time talking to him today and he is very pleased with the results

> that his therapists are getting with patients. Kristy and I had a

> LONG talk with Frederique Dimeglio today. She described her

method -

> basically a very orderly, gentle lengthy daily manipulation, foot

> initially taped daily with the addition of a continuous passive

> motion machine for the first 3 months of life. Did you use CPM

with

> Quinn? It doesn't sound like CPM is obligatory - I sense that the

> key is the manipulation and (like Ponseti and Bensahel) the

> understanding of the pathoanatomy of the foot and the " undoing " of

> the deformity.

>

> Now, we didn't have the opportunity to see anything clinical so

bear

> that in mind, but from our conversation it seems that they are

> following their feet objectively, documenting progress with photos

> and video and only operating on 10% with quite limited procedures.

> There is obviously a quiet rivalry between Paris and Montpellier on

> this issue and so one must read between the lines a bit, however I

> think that in Paris, there are more and more extensive operations.

> The differences in the techniques are how the feet are taped,

whether

> metal footplates are added into the taping (yes, in Paris,

sometimes;

> not in Montpellier) and whether so-called " softcast " splints are

used

> (basically a flexible type of fiberglass roll applied like a cast

and

> then immediately removed and converted to a splint - Mme. Dimeglio

> does this after 3 months).

>

> A lot of people think that clubfoot is caused by a relative

> neurologic imbalance in the lower limb muscles, perhaps because of

a

> deficit of anterior horn cells in the spine (these are the cells

that

> power the muscles, they are damaged in polio and some other

> disorders). The theoretical advantage to all the physio methods

are

> as follows: motion is maintained therefore the muscles if anything

> have the opportunity to train and get stronger rather than weaker

in

> a cast, the joints are gradually mobilized and kept moving and

> therefore the stiffness is gradually reduced. The disadvantages

that

> I can see are a danger of damage to the talar head with unskilled

or

> too aggressive manipulation (this can also happen with any

manip/cast

> technique or with surgery) and " breaking the midfoot " or

manipulating

> through the wrong joints.

>

> I think that I am going to try and come back here for a week

sometime

> in the fall - I haven't told my husband this news yet, I'll have to

> break it to him gently as he's at home running the ship! - and get

> some hands on in Frederique Dimeglio's physio room. Unfortunately

my

> therapist won't be able to come as she'll be busy with baby #4 due

in

> August. I'm also cooking up a plot to see if my center and the

folks

> in Montreal could bring Dr. Dimeglio over as a visiting prof

> sometime. May not pan out, but I'll propose it to my colleagues

when

> I return.

>

> Does anyone remember who is seeing Gail Chorney in NY? I think

that

> she's the nearest to me practicing this method in the US.

>

> Anyway, must go. We're " stuck " here tonight in order to get our

> Saturday night stay before we fly out Sunday. Not much happening

at

> the conference tomorrow (business meetings for EPOS members and the

> like) and so I think we'll check out the beach at Palavas. I hear

> that the snow is gone in Ontario and so it'll be good to get home.

>

>

[Guest guest]

Dr. son,

We, too, see Dr. Wilkins. He is wonderful. Caleb did use the CPM machine.

He was a good sleeper during those first few months, so he averaged 8-10

hours a night on the machine. It enabled our PT to get a better manipulation

as his foot was already loose when we went for our appointment.

Our PT is incredible and has very gifted hands. She always stressed with me

to make sure my hands were properly placed so as to work in the correct plane

of the foot. She would observe me doing them to make sure they were done

correctly.

Caleb has been walking for two months now and does very well. His foot looks

so incredible. I couldn't be more please with the French method.

Thanks for filling us in on what you've experienced!

Traci

davidsol@... wrote:

> Hello Jody and everyone else,

>

> Congratulations on Quinn's foot. That's great news! I hadn't

> realized that Kaye Wilkins was your surgeon, I actually spent some

> time talking to him today and he is very pleased with the results

> that his therapists are getting with patients. Kristy and I had a

> LONG talk with Frederique Dimeglio today. She described her method -

> basically a very orderly, gentle lengthy daily manipulation, foot

> initially taped daily with the addition of a continuous passive

> motion machine for the first 3 months of life. Did you use CPM with

> Quinn? It doesn't sound like CPM is obligatory - I sense that the

> key is the manipulation and (like Ponseti and Bensahel) the

> understanding of the pathoanatomy of the foot and the " undoing " of

> the deformity.

>

> Now, we didn't have the opportunity to see anything clinical so bear

> that in mind, but from our conversation it seems that they are

> following their feet objectively, documenting progress with photos

> and video and only operating on 10% with quite limited procedures.

> There is obviously a quiet rivalry between Paris and Montpellier on

> this issue and so one must read between the lines a bit, however I

> think that in Paris, there are more and more extensive operations.

> The differences in the techniques are how the feet are taped, whether

> metal footplates are added into the taping (yes, in Paris, sometimes;

> not in Montpellier) and whether so-called " softcast " splints are used

> (basically a flexible type of fiberglass roll applied like a cast and

> then immediately removed and converted to a splint - Mme. Dimeglio

> does this after 3 months).

>

> A lot of people think that clubfoot is caused by a relative

> neurologic imbalance in the lower limb muscles, perhaps because of a

> deficit of anterior horn cells in the spine (these are the cells that

> power the muscles, they are damaged in polio and some other

> disorders). The theoretical advantage to all the physio methods are

> as follows: motion is maintained therefore the muscles if anything

> have the opportunity to train and get stronger rather than weaker in

> a cast, the joints are gradually mobilized and kept moving and

> therefore the stiffness is gradually reduced. The disadvantages that

> I can see are a danger of damage to the talar head with unskilled or

> too aggressive manipulation (this can also happen with any manip/cast

> technique or with surgery) and " breaking the midfoot " or manipulating

> through the wrong joints.

>

> I think that I am going to try and come back here for a week sometime

> in the fall - I haven't told my husband this news yet, I'll have to

> break it to him gently as he's at home running the ship! - and get

> some hands on in Frederique Dimeglio's physio room. Unfortunately my

> therapist won't be able to come as she'll be busy with baby #4 due in

> August. I'm also cooking up a plot to see if my center and the folks

> in Montreal could bring Dr. Dimeglio over as a visiting prof

> sometime. May not pan out, but I'll propose it to my colleagues when

> I return.

>

> Does anyone remember who is seeing Gail Chorney in NY? I think that

> she's the nearest to me practicing this method in the US.

>

> Anyway, must go. We're " stuck " here tonight in order to get our

> Saturday night stay before we fly out Sunday. Not much happening at

> the conference tomorrow (business meetings for EPOS members and the

> like) and so I think we'll check out the beach at Palavas. I hear

> that the snow is gone in Ontario and so it'll be good to get home.

>

>

>

>

[Guest guest]

Hello Theresa,

We are planning to try and incorporate more manipulation and taping

into our treatment protocol when we return. I think that we'll start

with the next new patient we have and sit down with the family to

discuss different options and go from there.

Regarding muscle strength and joint motion, I really think that we

have to see what happens when we let the feet be a bit more mobile

during treatment. I suspect that you cannot build up the leg to be

normal in terms of muscle bulk, but you may be able to prevent

further atrophy during treatment. Even if kids to atrophy a bit

during casting, I'm not really to worried as I suspect that that

comes back with walking. It's more the stiffness that I don't want

to worsen by completely and continuously immobilizing the foot.

We're certainly not abandoning the Ponseti technique as I think that

it is great, but this experience has certainly made me think. I'm

probably going to spend longer manipulating my feet and try a bit

harder with the hindfoot.

Anyway, home Sunday and back to work,

son

PS. Jody, I am interested in your website. I took some digital

video of Jean-Pierre (not Jean-Simon as I posted previously)

manipulating a baby's foot in Paris. It's a big file but you may be

interested. -- In nosurgery4clubfoot@y..., " Audilet "

<audilet@b...> wrote:

> Dr. son,

>

> Thank you for your reports from Paris. It's been interesting to

> follow. Do you think, then, that you'll try to incorporate some of

> this method in your practice? I am curious about the advantages you

> spoke of.. less muscle weakness and stiffness. Do you mean that you

> think with plaster casting the muscles and ligaments are made

> permanently weaker and stiffer, or temporarily? You're not talking

> about calf size, correct? Am I right that the calf size is going to

> be smaller no matter what the treatment?

> Thanks for the information, and enjoy the rest of your trip.

>

> A.

>

>

>

> > Hello Jody and everyone else,

> >

> > Congratulations on Quinn's foot. That's great news! I hadn't

> > realized that Kaye Wilkins was your surgeon, I actually spent

some

> > time talking to him today and he is very pleased with the results

> > that his therapists are getting with patients. Kristy and I had

a

> > LONG talk with Frederique Dimeglio today. She described her

> method -

> > basically a very orderly, gentle lengthy daily manipulation, foot

> > initially taped daily with the addition of a continuous passive

> > motion machine for the first 3 months of life. Did you use CPM

> with

> > Quinn? It doesn't sound like CPM is obligatory - I sense that

the

> > key is the manipulation and (like Ponseti and Bensahel) the

> > understanding of the pathoanatomy of the foot and the " undoing "

of

> > the deformity.

> >

> > Now, we didn't have the opportunity to see anything clinical so

> bear

> > that in mind, but from our conversation it seems that they are

> > following their feet objectively, documenting progress with

photos

> > and video and only operating on 10% with quite limited

procedures.

> > There is obviously a quiet rivalry between Paris and Montpellier

on

> > this issue and so one must read between the lines a bit, however

I

> > think that in Paris, there are more and more extensive

operations.

> > The differences in the techniques are how the feet are taped,

> whether

> > metal footplates are added into the taping (yes, in Paris,

> sometimes;

> > not in Montpellier) and whether so-called " softcast " splints are

> used

> > (basically a flexible type of fiberglass roll applied like a cast

> and

> > then immediately removed and converted to a splint - Mme.

Dimeglio

> > does this after 3 months).

> >

> > A lot of people think that clubfoot is caused by a relative

> > neurologic imbalance in the lower limb muscles, perhaps because

of

> a

> > deficit of anterior horn cells in the spine (these are the cells

> that

> > power the muscles, they are damaged in polio and some other

> > disorders). The theoretical advantage to all the physio methods

> are

> > as follows: motion is maintained therefore the muscles if

anything

> > have the opportunity to train and get stronger rather than weaker

> in

> > a cast, the joints are gradually mobilized and kept moving and

> > therefore the stiffness is gradually reduced. The disadvantages

> that

> > I can see are a danger of damage to the talar head with unskilled

> or

> > too aggressive manipulation (this can also happen with any

> manip/cast

> > technique or with surgery) and " breaking the midfoot " or

> manipulating

> > through the wrong joints.

> >

> > I think that I am going to try and come back here for a week

> sometime

> > in the fall - I haven't told my husband this news yet, I'll have

to

> > break it to him gently as he's at home running the ship! - and

get

> > some hands on in Frederique Dimeglio's physio room.

Unfortunately

> my

> > therapist won't be able to come as she'll be busy with baby #4

due

> in

> > August. I'm also cooking up a plot to see if my center and the

> folks

> > in Montreal could bring Dr. Dimeglio over as a visiting prof

> > sometime. May not pan out, but I'll propose it to my colleagues

> when

> > I return.

> >

> > Does anyone remember who is seeing Gail Chorney in NY? I think

> that

> > she's the nearest to me practicing this method in the US.

> >

> > Anyway, must go. We're " stuck " here tonight in order to get our

> > Saturday night stay before we fly out Sunday. Not much happening

> at

> > the conference tomorrow (business meetings for EPOS members and

the

> > like) and so I think we'll check out the beach at Palavas. I

hear

> > that the snow is gone in Ontario and so it'll be good to get home.

> >

> >

[Guest guest]

,

I am glad that you will be able to offer a number of different

treatment alternatives to parents so that they can have a choice of

methods based on what is important to them. I assume that is to some

degree what NYU has been able to do in their having available to

offer to parents the French (w and w/o the passive motion machine),

Kite, Ponseti, English, Turco, McKay-, Bensahel, Illizarov

methods, etc.

From what you have learned about the Bensahel and Dimeglio methods,

how are they similar and how are they different? I had heard that

Dimeglio's is a modification of Bensahel's method, but in what ways

other than the possible addition of the passive motion machine and

some limited casting? Also, how does either method deal with relapse

risks? Do either of them use AFO's or DBB's or do they use

physiotherapy to deal with potential relapses. Also, other than in

Paris or Montpelier, what do the other ped orthos at the EPOS seem to

be doing?

Thanks for you sharing your trip with all of us.

and (3-17-99)

> > > Hello Jody and everyone else,

> > >

> > > Congratulations on Quinn's foot. That's great news! I hadn't

> > > realized that Kaye Wilkins was your surgeon, I actually spent

> some

> > > time talking to him today and he is very pleased with the

results

> > > that his therapists are getting with patients. Kristy and I

had

> a

> > > LONG talk with Frederique Dimeglio today. She described her

> > method -

> > > basically a very orderly, gentle lengthy daily manipulation,

foot

> > > initially taped daily with the addition of a continuous passive

> > > motion machine for the first 3 months of life. Did you use CPM

> > with

> > > Quinn? It doesn't sound like CPM is obligatory - I sense that

> the

> > > key is the manipulation and (like Ponseti and Bensahel) the

> > > understanding of the pathoanatomy of the foot and the " undoing "

> of

> > > the deformity.

> > >

> > > Now, we didn't have the opportunity to see anything clinical so

> > bear

> > > that in mind, but from our conversation it seems that they are

> > > following their feet objectively, documenting progress with

> photos

> > > and video and only operating on 10% with quite limited

> procedures.

> > > There is obviously a quiet rivalry between Paris and

Montpellier

> on

> > > this issue and so one must read between the lines a bit,

however

> I

> > > think that in Paris, there are more and more extensive

> operations.

> > > The differences in the techniques are how the feet are taped,

> > whether

> > > metal footplates are added into the taping (yes, in Paris,

> > sometimes;

> > > not in Montpellier) and whether so-called " softcast " splints

are

> > used

> > > (basically a flexible type of fiberglass roll applied like a

cast

> > and

> > > then immediately removed and converted to a splint - Mme.

> Dimeglio

> > > does this after 3 months).

> > >

> > > A lot of people think that clubfoot is caused by a relative

> > > neurologic imbalance in the lower limb muscles, perhaps because

> of

> > a

> > > deficit of anterior horn cells in the spine (these are the

cells

> > that

> > > power the muscles, they are damaged in polio and some other

> > > disorders). The theoretical advantage to all the physio

methods

> > are

> > > as follows: motion is maintained therefore the muscles if

> anything

> > > have the opportunity to train and get stronger rather than

weaker

> > in

> > > a cast, the joints are gradually mobilized and kept moving and

> > > therefore the stiffness is gradually reduced. The

disadvantages

> > that

> > > I can see are a danger of damage to the talar head with

unskilled

> > or

> > > too aggressive manipulation (this can also happen with any

> > manip/cast

> > > technique or with surgery) and " breaking the midfoot " or

> > manipulating

> > > through the wrong joints.

> > >

> > > I think that I am going to try and come back here for a week

> > sometime

> > > in the fall - I haven't told my husband this news yet, I'll

have

> to

> > > break it to him gently as he's at home running the ship! - and

> get

> > > some hands on in Frederique Dimeglio's physio room.

> Unfortunately

> > my

> > > therapist won't be able to come as she'll be busy with baby #4

> due

> > in

> > > August. I'm also cooking up a plot to see if my center and the

> > folks

> > > in Montreal could bring Dr. Dimeglio over as a visiting prof

> > > sometime. May not pan out, but I'll propose it to my

colleagues

> > when

> > > I return.

> > >

> > > Does anyone remember who is seeing Gail Chorney in NY? I think

> > that

> > > she's the nearest to me practicing this method in the US.

> > >

> > > Anyway, must go. We're " stuck " here tonight in order to get

our

> > > Saturday night stay before we fly out Sunday. Not much

happening

> > at

> > > the conference tomorrow (business meetings for EPOS members and

> the

> > > like) and so I think we'll check out the beach at Palavas. I

> hear

> > > that the snow is gone in Ontario and so it'll be good to get

home.

> > >

> > >

[Guest guest]

" PS. Jody, I am interested in your website. I took some digital

video of Jean-Pierre (not Jean-Simon as I posted previously)

manipulating a baby's foot in Paris. It's a big file but you may be

interested. "

Oh, absolutley!! That would be great. I'll let you know as soon as

things get rolling.

I think it is wonderful that you are going to include taping and more

manipulation. The more the foot is worked, the better. Quinn's foot

is manipulated for an hour each day. We do it at bedtime, after he

has fallen asleep. The taping is wonderful, and I can just slip a

sock over his splint and no one is aware of it. Plus, he can bend

his knee and kick his legs, which strengthens his muscles and is of

developmental importance. It also helps with the DBB. I do not have

to worry about his heel coming up, and he has never had a blister,

raw area, or even a red mark from it.

We are at a really interesting point in Quinn's therapy. We are

keeping him out of his tapes more, which allows me to have more

spontaneous therapy time with him. Plus he gets lots of " tummy time "

which encourages eversion and strengthening. He has been sitting up

unassisted since 5 months and 5 days of age, so his developement has

not been hindered at all.

It is really wonderful to see that word is getting out in the ortho

community about the French method. I believe a truly wonderful

doctor is one that continues to absorb new information and utilize it

in their practice. I applaud your enthusiasm!

Jody

> > > Hello Jody and everyone else,

> > >

> > > Congratulations on Quinn's foot. That's great news! I hadn't

> > > realized that Kaye Wilkins was your surgeon, I actually spent

> some

> > > time talking to him today and he is very pleased with the

results

> > > that his therapists are getting with patients. Kristy and I

had

> a

> > > LONG talk with Frederique Dimeglio today. She described her

> > method -

> > > basically a very orderly, gentle lengthy daily manipulation,

foot

> > > initially taped daily with the addition of a continuous passive

> > > motion machine for the first 3 months of life. Did you use CPM

> > with

> > > Quinn? It doesn't sound like CPM is obligatory - I sense that

> the

> > > key is the manipulation and (like Ponseti and Bensahel) the

> > > understanding of the pathoanatomy of the foot and the " undoing "

> of

> > > the deformity.

> > >

> > > Now, we didn't have the opportunity to see anything clinical so

> > bear

> > > that in mind, but from our conversation it seems that they are

> > > following their feet objectively, documenting progress with

> photos

> > > and video and only operating on 10% with quite limited

> procedures.

> > > There is obviously a quiet rivalry between Paris and

Montpellier

> on

> > > this issue and so one must read between the lines a bit,

however

> I

> > > think that in Paris, there are more and more extensive

> operations.

> > > The differences in the techniques are how the feet are taped,

> > whether

> > > metal footplates are added into the taping (yes, in Paris,

> > sometimes;

> > > not in Montpellier) and whether so-called " softcast " splints

are

> > used

> > > (basically a flexible type of fiberglass roll applied like a

cast

> > and

> > > then immediately removed and converted to a splint - Mme.

> Dimeglio

> > > does this after 3 months).

> > >

> > > A lot of people think that clubfoot is caused by a relative

> > > neurologic imbalance in the lower limb muscles, perhaps because

> of

> > a

> > > deficit of anterior horn cells in the spine (these are the

cells

> > that

> > > power the muscles, they are damaged in polio and some other

> > > disorders). The theoretical advantage to all the physio

methods

> > are

> > > as follows: motion is maintained therefore the muscles if

> anything

> > > have the opportunity to train and get stronger rather than

weaker

> > in

> > > a cast, the joints are gradually mobilized and kept moving and

> > > therefore the stiffness is gradually reduced. The

disadvantages

> > that

> > > I can see are a danger of damage to the talar head with

unskilled

> > or

> > > too aggressive manipulation (this can also happen with any

> > manip/cast

> > > technique or with surgery) and " breaking the midfoot " or

> > manipulating

> > > through the wrong joints.

> > >

> > > I think that I am going to try and come back here for a week

> > sometime

> > > in the fall - I haven't told my husband this news yet, I'll

have

> to

> > > break it to him gently as he's at home running the ship! - and

> get

> > > some hands on in Frederique Dimeglio's physio room.

> Unfortunately

> > my

> > > therapist won't be able to come as she'll be busy with baby #4

> due

> > in

> > > August. I'm also cooking up a plot to see if my center and the

> > folks

> > > in Montreal could bring Dr. Dimeglio over as a visiting prof

> > > sometime. May not pan out, but I'll propose it to my

colleagues

> > when

> > > I return.

> > >

> > > Does anyone remember who is seeing Gail Chorney in NY? I think

> > that

> > > she's the nearest to me practicing this method in the US.

> > >

> > > Anyway, must go. We're " stuck " here tonight in order to get

our

> > > Saturday night stay before we fly out Sunday. Not much

happening

> > at

> > > the conference tomorrow (business meetings for EPOS members and

> the

> > > like) and so I think we'll check out the beach at Palavas. I

> hear

> > > that the snow is gone in Ontario and so it'll be good to get

home.

> > >

> > >

[Guest guest]

" From what you have learned about the Bensahel and Dimeglio methods,

> how are they similar and how are they different? I had heard that

> Dimeglio's is a modification of Bensahel's method, "

I think that that is correct,

" but in what ways other than the possible addition of the passive

motion machine and

> some limited casting? "

They tape diffently. In Paris they sometimes incorporate a little

footplate into the taping. They use softroll cast material to make

their splints in Montpellier, not really casting. In Paris they make

plastic type splints that may not fit as well. I didn't actually see

the Montpellier results. It doesn't sound like that there was a lot

of major differences but this technique seems very " operator

dependent " so there may be finesses in the manipulation that are

different.

" Also, how does either method deal with relapse

risks? "

They both use surgery for feet that have not completely responded. I

am reluctant to say what percentage until I see publications from

both centers. In both methods the physio continues long term

although I saw some older feet in Paris that didn't seem to be

getting much out of it. However, I can't really judge after one

morning.

" Do either of them use AFO's or DBB's "

No, I don't think so.

Hope that this helps.

[Guest guest]

,

We as parents have only been able to look at the abstracts of the

papers that Bensahel and Dimeglio sent to the May 2000 POSNA

Convention.

http://www.posna.org/meetings/vancouver/abstracts3.htm#FT_Physio

http://www.posna.org/meetings/vancouver/abstracts3.htm#FT_Motion

I assume that since you are a member of POSNA that they should be

willing to provide you with the full papers with all of the details

of the reports on both methods.

In Montpelier, in the EPOS program, I had not seen any scheduled

presentations on the Bensahel, Dimeglio or other non-surgical

methods. Were there any presentations on the Dimeglio methods while

you were there?

Even at the upcoming POSNA meeting in Cancun, there does not seem to

be any discussion being planned about non-surgical methods of

treatment even though they have a half day course dedicated to

complex foot problems including clubfoot.

http://www.posna.org/NextAnnualMeeting/Forms/OneDayCourse.pdf

It does seem a bit unexpected that with all of the recent interest in

non-surgical methods that they do not seem to be getting into the

convention programs of the worlds 2 major pediatric orthopedic

organizations.

and (3-17-99)

> " From what you have learned about the Bensahel and Dimeglio

methods,

> > how are they similar and how are they different? I had heard

that

> > Dimeglio's is a modification of Bensahel's method, "

>

> I think that that is correct,

>

> " but in what ways other than the possible addition of the passive

> motion machine and

> > some limited casting? "

>

> They tape diffently. In Paris they sometimes incorporate a little

> footplate into the taping. They use softroll cast material to make

> their splints in Montpellier, not really casting. In Paris they

make

> plastic type splints that may not fit as well. I didn't actually

see

> the Montpellier results. It doesn't sound like that there was a

lot

> of major differences but this technique seems very " operator

> dependent " so there may be finesses in the manipulation that are

> different.

>

> " Also, how does either method deal with relapse

> risks? "

>

> They both use surgery for feet that have not completely responded.

I

> am reluctant to say what percentage until I see publications from

> both centers. In both methods the physio continues long term

> although I saw some older feet in Paris that didn't seem to be

> getting much out of it. However, I can't really judge after one

> morning.

>

> " Do either of them use AFO's or DBB's "

>

> No, I don't think so.

>

> Hope that this helps.

>

>

[Guest guest]

Maybe this can shed some light. I am relatively sure why there are

no new abstracts. I have presented a few papers at the American

Society for Microbiology and they like to have new papers submitted

at each convention, so things will not be repeated from the last one.

Getting a grant, setting up protocol, and conducting a study takes

more than one year(especially with a human protocol). So, there may

not be anything novel since the last meeting.

I can't tell you why there are no workshops on non-surgical methods.

I agree that there should be. Maybe the people that would put the

workshops on will not be at this meeting in Cancun.

Next year or the year after may bring some wonderful non-surgical

papers. I know that our neuro doc has a Botox/clubfoot study on the

stove. I would think that Quinn would make a wonderful case study

for a Botox/clubfoot paper. But these things take time. ish

Rite has several studies going that they will be presenting at future

meetings. These things take time. It took me almost 9 months just

to get a grant and protocol approval for one of the studies I was

trying to do....and that was with with rabbits. Human studies are

way more involved.

There are a growing number of respected doctors who are going with

non-surgical methods, so I expect to see more at future meetings.

Jody

> > " From what you have learned about the Bensahel and Dimeglio

> methods,

> > > how are they similar and how are they different? I had heard

> that

> > > Dimeglio's is a modification of Bensahel's method, "

> >

> > I think that that is correct,

> >

> > " but in what ways other than the possible addition of the

passive

> > motion machine and

> > > some limited casting? "

> >

> > They tape diffently. In Paris they sometimes incorporate a

little

> > footplate into the taping. They use softroll cast material to

make

> > their splints in Montpellier, not really casting. In Paris they

> make

> > plastic type splints that may not fit as well. I didn't actually

> see

> > the Montpellier results. It doesn't sound like that there was a

> lot

> > of major differences but this technique seems very " operator

> > dependent " so there may be finesses in the manipulation that are

> > different.

> >

> > " Also, how does either method deal with relapse

> > risks? "

> >

> > They both use surgery for feet that have not completely

responded.

> I

> > am reluctant to say what percentage until I see publications from

> > both centers. In both methods the physio continues long term

> > although I saw some older feet in Paris that didn't seem to be

> > getting much out of it. However, I can't really judge after one

> > morning.

> >

> > " Do either of them use AFO's or DBB's "

> >

> > No, I don't think so.

> >

> > Hope that this helps.

> >

> >

[Guest guest]

At the upcoming POSNA Cancun Convention, there will probably also be

scientific papers submitted (for which they may post the abstracts

like was done for the 2000 convention) as well as posters on a lot of

different subjects. Probably some of those will be on non-surgical

methods.

It's just seems suprising that the specific 1/2 day course

on " Complex Foot Deformities in Children, Surgical Management and

Decision Making " doesn't appear to address non-surgical methods,

although it is possible that they will be mentioned in the

introductions.

and (3-17-99)

> > > " From what you have learned about the Bensahel and Dimeglio

> > methods,

> > > > how are they similar and how are they different? I had heard

> > that

> > > > Dimeglio's is a modification of Bensahel's method, "

> > >

> > > I think that that is correct,

> > >

> > > " but in what ways other than the possible addition of the

> passive

> > > motion machine and

> > > > some limited casting? "

> > >

> > > They tape diffently. In Paris they sometimes incorporate a

> little

> > > footplate into the taping. They use softroll cast material to

> make

> > > their splints in Montpellier, not really casting. In Paris

they

> > make

> > > plastic type splints that may not fit as well. I didn't

actually

> > see

> > > the Montpellier results. It doesn't sound like that there was

a

> > lot

> > > of major differences but this technique seems very " operator

> > > dependent " so there may be finesses in the manipulation that

are

> > > different.

> > >

> > > " Also, how does either method deal with relapse

> > > risks? "

> > >

> > > They both use surgery for feet that have not completely

> responded.

> > I

> > > am reluctant to say what percentage until I see publications

from

> > > both centers. In both methods the physio continues long term

> > > although I saw some older feet in Paris that didn't seem to be

> > > getting much out of it. However, I can't really judge after

one

> > > morning.

> > >

> > > " Do either of them use AFO's or DBB's "

> > >

> > > No, I don't think so.

> > >

> > > Hope that this helps.

> > >

> > >

[Guest guest]

" At the upcoming POSNA Cancun Convention, there will probably also be

> scientific papers submitted (for which they may post the abstracts

> like was done for the 2000 convention) as well as posters on a lot

of

> different subjects. "

Of course. But Ponseti, Dimeglio, and others like them may not have

anything new to add since last year.

" > It's just seems suprising that the specific 1/2 day course

> on " Complex Foot Deformities in Children, Surgical Management and

> Decision Making " doesn't appear to address non-surgical methods, "

Well, if the name of the workshop does not mislead me, it seems to be

directed at the surgical approach. There is still a great need for

that, being that the majority of children are treated with casting

and surgery. I wish it were not so, but the fact remains that some

kiddos still require surgery. I would like for my doc to know the

most up to date surgical methods if Quinn were to have required that

type of intervention.

I think that in the next few years, treatment of clubfoot in the

ortho community will be pleasing to us. The fire is just getting

started. All it takes are a few docs that are well known in their

ortho communities, and the ball will begin to roll. I used to work

for and remain friends with Chief of Orthopedics at a very large

teaching hospital, and I have talked with him on the phone recently

about the French Method. He is going to talk with the Chief of Ped.

ortho and give him the info. He also knows Quinns ortho doc quite

well, and they are in touch. With any luck, I see things taking off

there in the near future. There is also a PT school there. Imagine

the French technique being taught to PTs as part of a pediatric

rotation. Hmmm!!!!

In Him,

Jody

Jody

> > > > " From what you have learned about the Bensahel and Dimeglio

> > > methods,

> > > > > how are they similar and how are they different? I had

heard

> > > that

> > > > > Dimeglio's is a modification of Bensahel's method, "

> > > >

> > > > I think that that is correct,

> > > >

> > > > " but in what ways other than the possible addition of the

> > passive

> > > > motion machine and

> > > > > some limited casting? "

> > > >

> > > > They tape diffently. In Paris they sometimes incorporate a

> > little

> > > > footplate into the taping. They use softroll cast material

to

> > make

> > > > their splints in Montpellier, not really casting. In Paris

> they

> > > make

> > > > plastic type splints that may not fit as well. I didn't

> actually

> > > see

> > > > the Montpellier results. It doesn't sound like that there

was

> a

> > > lot

> > > > of major differences but this technique seems very " operator

> > > > dependent " so there may be finesses in the manipulation that

> are

> > > > different.

> > > >

> > > > " Also, how does either method deal with relapse

> > > > risks? "

> > > >

> > > > They both use surgery for feet that have not completely

> > responded.

> > > I

> > > > am reluctant to say what percentage until I see publications

> from

> > > > both centers. In both methods the physio continues long term

> > > > although I saw some older feet in Paris that didn't seem to

be

> > > > getting much out of it. However, I can't really judge after

> one

> > > > morning.

> > > >

> > > > " Do either of them use AFO's or DBB's "

> > > >

> > > > No, I don't think so.

> > > >

> > > > Hope that this helps.

> > > >

> > > >

[Guest guest]

Jody,

I think that you are correct. These things take time. Reputable

investigators do not report results until they have at least a few

years of follow-up. Take Henri Bensahel, he seems to publish every

10 years. It takes the tenacity of a Ponseti to follow through a

single technique over 30 or 40 years and report results to slowly

make a difference. You can't expect, and it would not be

appropriate, for everyone to change their practice overnight.

What needs to happen now is a new generation of surgeons need to

apply these techniques and report several years of wider experience.

If truly nonsurgical approaches are better, they will be adopted over

time.

> > > " From what you have learned about the Bensahel and Dimeglio

> > methods,

> > > > how are they similar and how are they different? I had heard

> > that

> > > > Dimeglio's is a modification of Bensahel's method, "

> > >

> > > I think that that is correct,

> > >

> > > " but in what ways other than the possible addition of the

> passive

> > > motion machine and

> > > > some limited casting? "

> > >

> > > They tape diffently. In Paris they sometimes incorporate a

> little

> > > footplate into the taping. They use softroll cast material to

> make

> > > their splints in Montpellier, not really casting. In Paris

they

> > make

> > > plastic type splints that may not fit as well. I didn't

actually

> > see

> > > the Montpellier results. It doesn't sound like that there was

a

> > lot

> > > of major differences but this technique seems very " operator

> > > dependent " so there may be finesses in the manipulation that

are

> > > different.

> > >

> > > " Also, how does either method deal with relapse

> > > risks? "

> > >

> > > They both use surgery for feet that have not completely

> responded.

> > I

> > > am reluctant to say what percentage until I see publications

from

> > > both centers. In both methods the physio continues long term

> > > although I saw some older feet in Paris that didn't seem to be

> > > getting much out of it. However, I can't really judge after

one

> > > morning.

> > >

> > > " Do either of them use AFO's or DBB's "

> > >

> > > No, I don't think so.

> > >

> > > Hope that this helps.

> > >

> > >