title: The Ponseti method of treatment for clubfoot in Brazil: barriers to bracing compliance.
abstract: BACKGROUND
  Clubfoot is the most common extremity birth defect. It causes the feet of affected individuals to point inward and downward, preventing them from walking normally. Neglected clubfoot causes disabilities that result in a lack of social integration, creating a psychological and financial burden for the family and community. Clubfoot has been effectively treated through the Ponseti method, a treatment utilizing serial casts to correct the deformity followed by use of an abduction brace for approximately 2-4 years. sustained use of the brace is necessary to prevent relapse and ensure a successful outcome. Brace compliance in the setting of limited resources in the developing world can be challenging. The purpose of this study was to identify the barriers to bracing compliance in southeastern Brazil. In addition to socioeconomic and cultural barriers, this study also looked at improper prescribing practices by physicians as a potential cause of noncompliance. The study sought to identify the role of physician education in the use of the Ponseti method and physicians' knowledge of the bracing process.
  
  
  OBJECTIVE
  Identify the barriers to bracing adherence that could negatively impact the treatment of children with clubfoot.
  
  
  METHODS
  Forty-five orthopedists from several centers in southeastern Brazil were interviewed. Physicians were asked about their training in the Ponseti method, their protocol when prescribing the brace, their evaluation of its importance, and a series of open-ended questions designed to identify the positive and negative qualities of local braces. They were also asked what they perceived to be the biggest challenges to sustained brace use.
  
  
  RESULTS
  sixteen of the physicians interviewed were orthopedic residents, and 29 had completed their residencies. Of these two groups, only 25% and 65%, respectively, appropriately prescribe the abduction brace for patients, with the majority recommending use of the brace for an inadequate period of time. The high costs and delays in acquisition of the brace and a lack of orthopedic stores able to adequately construct the orthotic, also present considerable barriers to sustained brace use.
  
  
  CONCLUSIONS
  Many of the causes of noncompliance with bracing protocol stem from systemic inequities and challenges, rather than a lack of collaboration from the families themselves. Furthermore, insufficient prescription of the brace by physicians may represent a major barrier to bracing compliance in southeastern Brazil. This research indicates a need to evaluate physician training and continuing medical education in order to ensure that physicians are adequately utilizing the brace.
authors.affiliation: Hospital do Servidor Publico Estadual, Sao Paulo, Brazil; Associafao de Assistencia a Crianfa Deficiente , Sao Paulo , Brazil.
authors.forename: Monica Paschoal
authors.initials: MP
authors.lastname: Nogueira
authors.forename: Mark
authors.initials: M
authors.lastname: Fox
authors.forename: Kathleen
authors.initials: K
authors.lastname: Miller
authors.forename: Jose
authors.initials: J
authors.lastname: Morcuende
mesh_terms: D001915:Braces; D001938:Brazil; D002370:Casts, Surgical; D003025:Clubfoot / Q000601:surgery / Q000628:therapy*; D006801:Humans; D008349:Manipulation, Orthopedic / Q000379:methods*; D019637:Orthopedic Procedures / Q000193:education*; D010349:Patient Compliance; D055502:Secondary Prevention; D012720:Severity of Illness Index; D016896:Treatment Outcome
references.citation: Pediatrics. 2004 Feb;113(2):376-80
references.pmid: 14754952
references.citation: J Am Acad Orthop Surg. 2003 Nov-Dec;11(6):392-402
references.pmid: 14686824
references.citation: South Med J. 1976 Aug;69(8):1037-8
references.pmid: 959868
references.citation: Disabil Rehabil. 2007 Jun 15-30;29(11-12):845-55
references.pmid: 17577719
references.citation: J Bone Joint Surg Am. 2006 May;88(5):986-96
references.pmid: 16651573
references.citation: J Bone Joint Surg Am. 2009 Mar 1;91(3):530-40
references.pmid: 19255212
references.citation: Pediatr Ann. 2006 Feb;35(2):128-30, 132-6
references.pmid: 16493919
references.citation: Arch Orthop Trauma Surg. 2006 Jan;126(1):15-21
references.pmid: 16283342
references.citation: J Pediatr Orthop. 1990 Jan-Feb;10(1):109-19
references.pmid: 2137134
references.citation: J Am Acad Orthop Surg. 2010 Aug;18(8):486-93
references.pmid: 20675641
references.citation: Isr Med Assoc J. 2005 May;7(5):307-10
references.pmid: 15909463
references.citation: Clin Orthop Relat Res. 1972 May;84:93-6
references.pmid: 5032853
references.citation: Clin Orthop Relat Res. 2009 May;467(5):1146-53
references.pmid: 19224303
references.citation: Clin Orthop Relat Res. 2009 May;467(5):1154-63
references.pmid: 19308648
references.citation: J Bone Joint Surg Am. 1995 Oct;77(10):1477-89
references.pmid: 7593056
references.citation: Iowa Orthop J. 2011;31:30-5
references.pmid: 22096416
references.citation: J Pediatr Orthop. 2002 Jul-Aug;22(4):517-21
references.pmid: 12131451