Six item version FPI-6 USER GUIDE AND MANUAL
M
AUGUST 2005 © Anthony Redmond 1998
All rights reserved, May not be copied without permission
www.leeds.ac.uk/medicine/FASTER/FPI/
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Foot Posture Index - User guide and manual
Acknowledgments The FPI was developed with funding from the following agencies
The CMT Association of the USA The Australasian Podiatry Council, Australian Podiatry Education and Research Fund The Podiatry Education and Research Account of the NSW Podiatrists’ Registration Board.
In-kind support was also provided by the Arthritis Research Campaign Sincere thanks are due to the following institutions and individuals for their assistance in the development and testing of the FPI University of Sydney, Australia University of Western Sydney, Australia University of South Australia University of Huddersfield, United Kingdom University of Leeds, United Kingdom Royal Alexandra Hospital for Children, Sydney, Australia
Prof Robert Ouvrier Dr Jack Crosbie Dr Jennifer Peat Dr Joshua Burns Rolf Scharfbillig Angela Evans Alex Copper Anne-Maree Keenan Dr Jim Woodburn Liz Barr
All staff and students at the University of Western Sydney, School of Exercise and Health Sciences. All of the other clinicians in the many disciplines who have contributed with their time, suggestions and expertise in the development of the FPI to date. About the author Dr Anthony Redmond is Arthritis Research Campaign lecturer in the Academic Unit of Musculoskeletal Disease at the University of Leeds. He has worked in clinical podiatry and foot-related research for the majority of his career, mostly in multidisciplinary gait and lower limb clinics. The FPI was conceived as a part answer to the recurring clinical problem of assessing gait and foot posture variables reliably in the clinical setting. Work first started on the various iterations of the FPI in 1996, with a more formal approach to the development of the FPI as part of his PhD candidature in the faculty of medicine at the University of Sydney. Various iterations have appeared in the literature† but only this six-item version has completed all validation studies satisfactorily. We now recommend that the use of any previous versions be discontinued. The validation process is described in full in:
Redmond AC. Foot Posture in Neuromuscular Disease (PhD Thesis) University of Sydney, 2004. Redmond AC., Crosbie J., Ouvrier RA. Development and validation of a novel rating system for scoring foot posture: the Foot Posture Index. Clinical Biomechanics (In Press) FPI manuals and datasheets The FPI concept and data sheets have been released into the public domain. The datasheets may be copied freely for clinical or research purposes although they should not be altered or adapted without the express permission of the copyright holder. All rights are reserved for this manual/user guide and it should not should be copied or redistributed in any form without the author’s express consent. Further information can be found on-line at www.leeds.ac.uk/medicine/FASTER/FPI
A.R. August 2005
†
Redmond A, Burns J, Crosbie J, Ouvrier R, Peat J. An initial appraisal of the validity of a criterion based, observational clinical rating system for foot posture. Journal of Orthopedic and Sports Physical Therapy 2001;31(3):160. Payne C, Oates M, Noakes H. Static stance response to different types of foot orthoses. J Am Pod Med Assoc 2003;93(6):492- 8. Evans AM, Copper AW, Scharfbillig RW, Scutter SD, Williams MT. The reliability of the foot posture index and traditional measures of foot position. J Am Pod Med Assoc 2003;93:203-13. Yates B, White S . The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. Am J Sports Med 2004: 32 (3): 772-780
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Foot Posture Index - User guide and manual
Introduction
The Foot Posture Index (FPI) is a diagnostic clinical tool aimed at quantifying the degree to which a foot can be considered to be in a pronated, supinated or neutral position. It is intended to be a simple method of scoring the various features of foot posture into a single quantifiable result, which in turn gives an indication of the overall foot posture. The foot posture index rates weightbearing posture according to a series of predefined criteria. The FPI started life as an eight-item draft version, which during a thorough validation process was eventually refined to the six-item version detailed in this manual. All observations are made with the subject standing in a relaxed angle and base of gait, double limb support, static stance position. This relaxed double limb support position has been reported to approximate the position about which the foot functions during the gait cycle.
Derivation of the foot posture index
The FPI was derived from a search of the literature yielding details of clinical assessment in more than 140 papers. From these 140 papers, 36 distinct clinical measures were identified. In identifying indicators potentially appropriate for use in the FPI, emphasis was placed on indicators that met the following criteria: a) b) c) d) e)
Measures must be easy to conduct Measures must be time-efficient to perform Using the measures must not depend on costly technology The results of the measure must be simple to understand Assessment yields quantifiable data (at a minimum of ordinal level)
In addition it was considered essential for the combination of the chosen measures to, between them, measure foot posture in all of the three body planes and to also provide information on rearfoot, midfoot and forefoot segments. Eight measures were incorporated into a working draft of the FPI and this was refined to six items after a series of validation studies. Scoring foot posture
The user attaches a score to a series of observations that are routinely used by experienced practitioners. Features commensurate with an approximately neutral foot posture are graded as zero, while pronated postures are given a positive value, and supinated features a negative value.
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Foot Posture Index - User guide and manual
When the scores are combined, the aggregate value gives an estimate of the overall foot posture. High positive aggregate values indicate a pronated posture, significantly negative aggregate values indicate a supinated overall foot posture, while for a neutral foot the final FPI aggregate score should lie somewhere around zero. While the measures are conducted in double limb support each foot should be scored independently. FPI scoring criteria
The six clinical criteria employed in the FPI-6 are: 1. Talar head palpation 2. Supra and infra lateral malleolar curvature 3. Calcaneal frontal plane position 4. Prominence in the region of the talonavicular joint 5. Congruence of the medial longitudinal arch 6. Abduction/adduction of the forefoot on the rearfoot
Using the specified criteria
Full explanations of each of the FPI constituent parts are detailed subsequently, and the derivation of each is referenced and detailed in Appendix 1. Each of the component tests or observations are simply graded 0 for neutral, with a minimum score of –2 for clear signs of supination, and + 2 for positive signs of pronation. Unless the criteria outlined for each of the features are clearly met then the more conservative score should be awarded. It is also to be emphasised that the gradings need to be awarded on the basis of the criteria outlined below. Variation resulting from observations based on ‘clinical feel’ or past experience alone will result in unacceptable inter-observer error.
Preparing the patient
The patient should stand in their relaxed stance position with double limb support. The patient should be instructed to stand still, with their arms by the side and looking straight ahead. It may be helpful to ask the patient to take several steps, marching on the spot, prior to settling into a comfortable stance position. During the assessment, it is important to ensure that the patient does not swivel to try to see what is happening for themself, as this will significantly affect the foot posture. The patient will need to stand still for approximately two minutes in total, in order for the assessment to be conducted. The assessor needs to be able to move around the patient during the assessment and to have uninterrupted access to the posterior aspect of the leg and foot.
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Foot Posture Index - User guide and manual
1. Talar Head Palpation (Palpation for talo-navicular congruence)
This is the only scoring criterion that relies on palpation rather than observation. The head of the talus is palpated on the medial and lateral side of the anterior aspect of the ankle, according to the standard method described variously by Root, Elveru and many others. Scores are awarded for the observation of the position as follows. Diagram showing the position of the fingers when palpating of the head of the talus. The circles indicate the precise point of palpation on the medial and lateral side.
Clinical note: This is not an attempt to determine the so-called subtalar neutral position. For the FPI measure the subtalar joint is not manipulated into the position where the head of the talus is in maximal congruence with the navicular. For the FPI measure the head of the talus is simply palpated in the relaxed stance position and the talar head orientation reported. It may however be useful in some cases to move the foot into inversion and eversion while palpating for the talar head as this can aid in determining wether the head is still palpable in individuals on the border between 1 &2 or –1&-2.
Score
-2
-1
0
1
2
Talar head palpable on lateral side/but not on medial side
Talar head palpable on lateral side/slightly palpable on medial side
Talar head equally palpable on lateral and medial side
Talar head slightly palpable on lateral side/ palpable on medial side
Talar head not palpable on lateral side/ but palpable on medial side
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Foot Posture Index - User guide and manual
2. Supra and
infra lateral malleolar curvature (Observation and comparison of the curves above and below the lateral ankle malleoli)
In the neutral foot it has been suggested that the curves should be approximately equal. In the pronated foot the curve BELOW the malleolus will be more acute than the curve above due to the abduction of the foot, and eversion of the calcaneus. The opposite is true in the supinated foot.
Supinated (-2)
Score Clinical note 1: For estimating malleolar curvature, it may be helpful to use a straight edge for reference. This can be a set square, ruler or even a pen according to availability.
Neutral (0)
Pronated (+2)
-2
-1
0
1
2
Curve below the malleolus either straight or convex
Curve below the malleolus concave, but flatter/ more shallow than the curve above the malleolus
Both infra and supra malleolar curves roughly equal
Curve below malleolus more concave than curve above malleolus
Curve below malleolus
markedly
more concave than curve above malleolus
Clinical note 2: Where oedema or obesity obscures the curvature this measures should be either scored at zero or removed from the assessment and indicated as such. 6
Foot Posture Index - User guide and manual
3. Calcaneal frontal plane position (Inversion / eversion of the calcaneus)
This is an observational equivalent of the measurements often employed in quantifying the relaxed and neutral calcaneal stance positions. With the patient standing in the relaxed stance position, the posterior aspect of the calcaneus is visualised with the observer in line with the long axis of the foot. Angular measurements are not required for the FPI, the foot is graded according to visual appraisal of the frontal plane position. Supinated (-2)
Score
-2 More than an estimated 5° inverted (varus)
Neutral (0)
-1 Between vertical and an estimated 5° inverted (varus)
0 Vertical
Pronated (+2)
1 Between vertical and an estimated 5° everted (valgus)
2 More than an estimated 5° everted (valgus)
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Foot Posture Index - User guide and manual
4. Bulging in the region of the talonavicular joint (TNJ)
In the neutral foot the area of skin immediately superficial to the TNJ will be flat. The TNJ becomes more prominent if the head of the talus is adducted in rearfoot pronation. Bulging in this area is thus associated with a pronating foot. In the supinated foot this area may be indented. Supinated (-2)
Score
Clinical note: Bulging of the TNJ area is a common finding in pronated feet. However, true convexity of the area is usually only seen with highly supinated postures. Unless there is a definite indentation, assigning negative scores to this observation should be undertaken judiciously.
Neutral (0)
Pronated (+2)
-2
-1
0
1
2
Area of TNJ markedly concave
Area of TNJ slightly, but definitely concave
Area of TNJ flat
Area of TNJ bulging slightly
Area of TNJ bulging markedly
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Foot Posture Index - User guide and manual
5. Height and congruence of the medial longitudinal arch
While arch height is a strong indicator of foot function, the shape of the arch can also be equally important. In a neutral foot the curvature of the arch should be relatively uniform, similar to a segment of the circumference of a circle. When a foot is supinated the curve of the MLA becomes more acute at the posterior end of the arch. In the excessively pronated foot the MLA becomes flattened in the centre as the midtarsal and Lisfranc’s joints open up. Neutral (0)
This observation should be made taking both the arch height and the arch congruence into consideration.
Supinated foot (-2)
Clinical note: While simple arch height will usually be the more readily apparent of the two components of this measure, arch congruence is probably more subtle and informative. Careful observation of the arch congruence should be the main element of this measure with arch height factored in secondarily.
Score
-2 Arch high and acutely angled towards the posterior end of the medial arch
Pronated foot (+2)
-1 Arch moderately high and slightly acute posteriorly
0 Arch height normal and concentric ally curved
1 Arch lowered with some flattening in the central portion
2 Arch very low with severe flattening in the central portion – arch making ground contact
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Foot Posture Index - User guide and manual
6. Abduction/ adduction of the forefoot on the rearfoot. (Too many toes sign)
When viewed from directly behind, and in-line with the long axis of the heel (not the long axis of the whole foot), the neutral foot will allow the observer to see the forefoot equally on the medial and lateral sides. In the supinated foot the forefoot will adduct on the rearfoot resulting more of the forefoot being visible on the medial side. Conversely pronation of the foot causes the forefoot to abduct resulting in more of the forefoot being visible on the lateral side. Supinated (-2)
Clinical note: This measure should be treated with caution where there is a fixed adduction deformity of the forefoot on the rearfoot in the nonweightbearing state. Normally it is possible to see the toes by the observer raising their angle of view slightly. If the toes are obscured by other structures the mtp joints or more proximal structures can be used as a guide.
Score
-2 No lateral toes visible. Medial toes clearly visible
Neutral(0)
-1 Medial toes clearly more visible than lateral
0 Medial and lateral toes equally visible
Pronated (+2)
1 Lateral toes clearly more visible than medial
2 No medial toes visible. Lateral toes clearly visible
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Foot Posture Index - User guide and manual
FPI total score
The final FPI score will be a whole number between –12 and +12. In most cases there will be a consistent pattern of scores and the clinical picture will be immediately clear. However in some patients there will be a dominance of motion occurring in one of the three body planes or a difference between the function of the forefoot and rearfoot. The foot segments and the body plane measured by each of the observations are indicated on the FPI data sheet. This allows the FPI to provide substantially more information than existing single segment/single plane assessment techniques. While the information needs careful clinical interpretation based on the clinician’s knowledge of anatomy and function, the information yielded by the FPI assessment allows such interpretation to be better informed by data.
Examples Example 1. Abnormal frontal plane observations predominate in a patient, with transverse and sagittal plane measures reading near neutral.
Talar head palpation +1 Malleolar curves +1 Inv/eversion calcaneus +1 TNJ prominence 0 Congruence of MLA 0 Abd/adduction of FF +1 _______________________ TOTAL +4
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Foot Posture Index - User guide and manual
Example 2. The rearfoot factors may be near less marked in a patient while the midfoot/forefoot observations indicate substantial instability in the midfoot.
Talar head palpation +1 Malleolar curves +1 Inv/eversion calcaneus +1 TNJ prominence +2 Congruence of MLA +2 Abd/adduction of FF +1 ______________________ TOTAL +8
In both of these cases the clinician interprets the results to put the foot posture into its clinically relevant context. The clinician may decide to use the FPI as a general overview of the foot function (just using the total score) or conversely he or she may prefer to keep the planar or segmental information disaggregated in order to retain the differentiation of the individual components of the score. Either way the clinician has more information available, upon which to base a decision. Getting to know the FPI
The FPI is designed to be simple to use and for the set criteria to limit variability in scoring. Nevertheless, it is worth developing some exercise with using the measure before applying the scores in earnest. We recommend that the novice user rates approximately 30 individuals with as broad a range of foot types as possible before using the FPI formally in clinic.
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Foot Posture Index - User guide and manual
Validation of the FPI
The validation of the FPI was conducted in several stages.
Item validity
FPI scores were compared initially to concurrently derived Valgus Index (VI) scores. Ratings of the eight components making up the draft FPI were undertaken for each of 131 subjects (91 male and 40 female aged 18-65 (Mean=33.7 years) while they stood on a ‘pedograph’, ink and paper mat. In ordinal regression modelling the FPI-8 total scores predicted 59% of the variance in VI values (Cox and Snell R2=0.590, B=0.551, P0.65 for six of the eight FPI components. The components measuring Helbing’s sign (0.36) and the congruence of the lateral border (0.20) of the foot showed poor inter-item reliability. Principal components analysis yielded two separate factors. The first included seven of the initial eight FPI items. A second factor, explaining 12% of the variance, was mainly a function of the congruence of the lateral border of the foot suggesting that a separate subgroup with variation in foot position independent of the lateral foot contour might be evident. A Fastrak™ electromagnetic tracking (EMT) system was then used to reconstruct a three-dimensional lower limb model for the right leg of 20 healthy volunteers in each of three positions (pronated, neutral, supinated). The FPI scoring criteria (again except lateral border shape) predicted between 63% and 80% of the variance in their EMT derived equivalents.
Item reduction
The items Lateral border congruence and Helbing’s sign had not demonstrated adequate validity and were removed to produce the final six-item instrument.
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Foot Posture Index - User guide and manual
Validation of the FPI
FPI-6 Instrument validity
Once the FPI had been reduced to its final six-item form the validity was evaluated further. Six item FPI scores were compared with contemporaneous EMT data obtained during quiet standing and during normal walking. The FPI-6 scores predicted 64% of the variation in the static ankle/subtalar position during quiet double limb standing (adjusted R2=0.64, F=73.529, P
Jan 18, 2011 It is not uncommon for a person's foot posture and/or mobility to be assessed during a clinical examination. The exact relationship, however, between static posture and mobility is not known. The purpose of this study was to determine the degree of association between static foot posture and mobility. The static foot posture and foot mobility of 203 healthy individuals was assessed and then. Page 1 IVAFTSPA Thank you for purchasing the Ivation Foot Spa Multifunction Heated Massager. This User Guide is intended to provide you with guidelines to ensure that operation of this product is safe and does not pose risk to the user. Any use that does not conform to the guidelines described in this User Guide may void the limited warranty. Dec 12, 2017 A foot that is considered “normal” will have a value of 0 to +5. What do I do with the results of the Foot Posture Index? The results of the Foot Posture Index help determine the appropriate interventions you may want to use with your patient, including strengthening, stretching, manual therapy. Foot Posture Index - User guide and manual. The Foot Posture Index (FPI) is a diagnostic clinical tool aimed at quantifying the degree to which a foot can be considered to be in a pronated, supinated or neutral position. The Foot Posture Index (FPI-6) is a reliable (experienced examiners) assessment tool used in clinical practice to classify foot posture. No work has been completed to determine the reliability of the FPI-6 between novice examiners.
Abstract
Background
Reliability is an integral component of clinical assessment and necessary for establishing baseline data, monitoring treatment outcomes and providing robust research findings. In the podiatric literature traditional measures of foot assessment have been shown to be largely unreliable. The Foot Posture Index (FPI-6) is a clinical tool used in the assessment of foot and to date, there is limited research published which evaluates the reliability of this tool in children and adolescents.
Method
Thirty participants aged 5 - 16 years were recruited for the research. Two raters independently recorded the FPI-6 score for each participant.
Results
Almost perfect agreement between the two raters was identified following weighted kappa analysis (Kw = 0.86).
Conclusion
The FPI-6 is a quick, simple and reliable clinical tool which has demonstrated excellent inter-rater reliability when used in the assessment of the paediatric foot.
Background
The clinician has become increasingly aware of the need to have valid and reliable measures of assessing foot position for establishing baseline data, monitoring treatment outcomes and providing robust research findings. Most of the common measures of foot posture have been scrutinised for validity and reliability in the adult foot [-] but very little attention has been given to establishing the usefulness of similar measures in the assessment of the paediatric foot. While it is a broad assumption, clinicians often believe that the outcomes of validity and reliability studies of measures of foot position in adults are directly transferable to paediatric populations. This may not be the case and the extrapolation of such findings would be erroneous.
In an extensive study on the reliability of foot position in children (4-6 years), adolescents (8 - 15 years) and adults (20 - 50 years), it was reported that the reliability of measures of foot position in children were reduced when compared to adults, with raters commenting that children remained less still between repeated measures []. The reduced reliability of measures of foot position in children was also identified in a later study looking at the intra-rater reliability of measuring anthropometric characteristics of children's feet [6]. Since clinicians rarely need to take repeated measures at each assessment session but are more interested in the comparability of a measurement on a subsequent visit, future reliability studies may need to consider asking all participants to move about between repeated measures. It may be that children are generally less consistent in the placement of their feet compared to adults, thus reducing measurement reliability.
The Foot Posture Index (FPI-6) is an assessment tool that is thought to reduce many of the reliability concerns surrounding more traditional measures of the foot. The FPI-6 has been refined from an eight point scale to a six point scale and permits assessment across the three planes of the foot []. The FPI-6 yields a score based upon six individual criteria which are summated to provide a total score which is then used to determine foot posture. This total score is often used in the form of continuous data, however this assumes that each individual item of the index and the divisions within that item have equal weighting. This is not based upon any evidence and it is believed that this has been formed for convenience.
The reliability of the FPI-6 has been tested in adults with excellent intra-rater results (ICC 0.92 - 0.93) but moderate inter-rater results (0.52 - 0.65) []. Two studies investigating the reliability of the index in a paediatric population have been identified, one of which evaluated the reliability of the older version of the index (FPI-8) []. This study looked at a number of measures of foot position in addition to the FPI-8 and following reliability analysis, ICC values of 0.80 for children and 0.91 for adolescents were presented. More recently, Cain et al [] investigated the intra-rater and inter-rater reliability of the refined FPI-6 on ten adolescents. Findings from this study reported excellent intra-rater reliability (ICC values ranged from 0.81 - 0.92) and good inter-rater reliability (ICC 0.69). However, consideration of the nature of the data generated by the FPI-6 would suggest that analysis using ICCs would be incorrect for the present study unless logit transformed scores are used. This is the process of changing raw FPI-6 scores into a data form suitable for parametric analysis but for this, large data sets are required []. Without transformation the index produces categorical data and therefore raw scores should be analysed using Kappa scores, particularly when the data is not normally distributed [].
In clinical practice it is common that patient care is shared amongst a team of clinicians and therefore, it is vital that any tool used in the assessment of the child is repeatable between clinicians. There is limited evidence looking at the reliability of traditional measures of foot posture in children, however initial research suggests that the FPI-6 is a reliable tool when used in the assessment of the child's foot. This study aims to investigate the inter-rater reliability of the FPI-6 when used by two experienced observers in the assessment of the paediatric foot.
Methods
User Guide Ipad
Participants
A convenience sample of 30 participants aged 5 to 16 years of age was recruited for the study from paediatric clinics at the Clinical Education Centre for Podiatric Medicine at the University of East London, UK. Prior to data collection ethical approval was granted from the University of East London. Details of the research were sent to parents/guardians with the appointment information and on attendance, parents/guardians gave informed consent form for participation. The children also assented to participate in the study.
All children referred to the paediatric clinic were considered for inclusion. Children were excluded if they presented with a foot position that would be associated with abnormal structural features or would obscure visualisation of normal foot architecture (for example, congenital foot deformity such as talipes, history of surgery, Juvenile Idiopathic Arthritis).
Procedure
Inter-rater reliability was determined for two podiatrists with postgraduate experience of working in paediatrics (in excess of five years). Both raters participated in a training session on the FPI-6 and had equal exposure to the index prior to start of the study. The training session was undertaken on two participants (not included in the study) for familiarisation with the assessment tool and to allow open discussion about the index criteria.
On the day of attendance for podiatric assessment, consent and assent was determined prior to starting data collection. Each participant was asked to stand, take a few steps forward and march on the spot for six-eight steps and then to stand still, with arms by their side and looking forward. Both observers performed an independent bilateral foot assessment of each child using the six criteria of the FPI-6:
▫ talar head palpation
▫ curvature at the lateral malleoli
▫ inversion/eversion of the calcaneus
▫ talonavicular bulging
▫ congruence of the medial longitudinal arch
▫ abduction/adduction of the forefoot on the rearfoot
Since bias may be increased when measuring consecutively between the left and right feet, the first foot measured was always randomly chosen. The child remained in the same position whilst the second observer assessed foot posture. Each observer was blinded to the other observer's results.
Data Analysis
Data were entered and analyses were performed using SPSS Software Package version 15.0 and MedCalc statistical software. Before conducting analysis, the data were tested for normality using the Kolmogorov-Smirnov test. The data were not normally distributed and were positively skewed. The FPI-6 values for the left and right foot for each rater were compared using a Wilcoxon matched paired signed ranks test. There was no significant difference between the left and right foot for rater one (z = -0.49, p = 0.62) or rater two (z = -0.22, p = 0.83). Therefore for further analysis, the left foot only was considered.
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Results
Thirty participants were recruited into the research and further information on gender and age-range is presented in Table Table1.1. Scores of foot posture are presented in Table Table2.2. These scores are presented for each participant and from both raters.
Table 1
Gender and age banding for participants recruited into the research (n = number of participants in age band)
| Age band (years) | n | Male | Female |
| 5-6 | 5 | 3 | 2 |
| 7-8 | 4 | 4 | 0 |
| 9-10 | 10 | 4 | 6 |
| 11-12 | 0 | 0 | 0 |
| 13-14 | 8 | 3 | 5 |
| 15-16 | 3 | 0 | 3 |
| Total | 30 | 14 | 16 |
Table 2
Raw FPI-6 scores for individual participants involved in the study from both raters.
| FPI-6 Scores | ||
| Participant | Rater 1 | Rater 2 |
| 1 | 11 | 8 |
| 2 | 11 | 12 |
| 3 | 8 | 8 |
| 4 | 11 | 12 |
| 5 | 10 | 10 |
| 6 | 5 | 3 |
| 7 | 6 | 6 |
| 8 | 11 | 11 |
| 9 | 8 | 7 |
| 10 | 11 | 11 |
| 11 | 12 | 12 |
| 12 | 10 | 10 |
| 13 | 5 | 5 |
| 14 | 12 | 12 |
| 15 | 9 | 10 |
| 16 | 7 | 8 |
| 17 | 11 | 11 |
| 18 | 10 | 10 |
| 19 | 10 | 10 |
| 20 | 7 | 7 |
| 21 | 1 | 2 |
| 22 | 5 | 4 |
| 23 | 9 | 10 |
| 24 | -1 | -1 |
| 25 | 12 | 12 |
| 26 | 11 | 11 |
| 27 | 7 | 6 |
| 28 | 5 | 5 |
| 29 | 9 | 9 |
| 30 | 11 | 11 |
The FPI-6 score was assigned to a predetermined category (highly pronated (FPI-6 score 10 to 12), pronated (FPI-6 score 6 to 9), neutral (FPI-6 score 0 to 5), supinated (FPI-6 score -1 to -4) and highly supinated (FPI-6 score -5 to -12) as recommended by Redmond [11]. Table Table33 shows the observed agreement between the two raters for each foot type category. A weighted kappa score was applied to the actual scores and a Kappa coefficient (Kw) of 0.86 was determined. The result has been described as almost perfect agreement [12,]. Agreement between raters for this categorical data into foot type categories was also tested using a weighted kappa test. The inter-rater reliability showed almost perfect agreement (Kw = 0.88).
Table 3
Foot Posture Index User Guide And Manual Download
Level of agreement in determining foot posture between the two raters
| Observer A | |||||
| Observer B | HP | P | N | S | Total |
| HP | 14 | 2 | 0 | 0 | 16 |
| P | 1 | 7 | 0 | 0 | 8 |
| N | 0 | 0 | 5 | 0 | 5 |
| S | 0 | 0 | 0 | 1 | 1 |
| Total | 15 | 9 | 5 | 1 | 30 |
| Weighted Kappa | 0.88 |
HP = Highly Pronated (10 - 12)
P = Pronated (6 -9)
N = Neutral (0 - 5)
S = Supinated (-1 - -4)
Discussion
The aim of this study was to determine the inter-rater reliability of the FPI-6 in the assessment of the paediatric foot. The inter-rater agreement when the actual score was compared and when the score was categorised showed almost perfect agreement []. One previous study looking at the reliability of the FPI-6 in adolescents also determined good level of inter-rater reliability (ICC = 0.69) []. This study looked at intra and inter-rater reliability across three raters, however direct comparison of results is difficult because in this study the inter-rater reliability was measured using an Interclass Correlation Coefficient (ICC).
Using the FPI-6 in adults, Cornwall et al reported moderate reliability between observers []. The study had a substantial sample size (n = 46) and also used three raters (of varying clinical experience) to determine inter-rater reliability, left and right foot data was pooled and an ICC applied. The study reported moderate agreement between observers (ICC = 0.57) for actual FPI-6 scores and between 65-74% agreement when the FPI-6 scores were categorised. The findings reported must be interpreted with caution following the pooling of data as this is a procedure that has been considered to give false results [14].
It is likely that the sample size of the present study and the experience of the raters using the index accounts for the high level of inter-rater agreement. Cornwall et al reported that a learning effect was seen whereby the ICC improved for the second half of the measurements compared to the first []. In the present study, both raters had similar experience with using the FPI-6 which is important because otherwise, varying levels of expertise would render the kappa an inappropriate tool for analysis []. As the raters both had experience in the paediatric field of podiatry they were able to develop a good rapport and allow the children to relax whilst data collection occurred. Care was taken to ensure that the children remained still between repeated observations, a problem noted in one of the earlier studies [].
An improvement in inter-rater reliability would be expected to be seen when using the categorical ratings as recommended in the user manual as this introduces a smoothing effect of the differences between observers. This is due to each category covering a range of two to four points which will be within the disagreement margin for the actual values between raters. The categorical ratings have recently been updated [] but the new groupings do not allow for differences between the potentially abnormal and pathological scores (previously called pronated and highly pronated) and therefore were not used in this study.
A further consideration for the differing results between the studies is the foot type assessed. The adult FPI-6 study [] included the greatest range of foot types with FPI-6 scores within the categories of 'supinated' through to 'pronated' and included one 'highly pronated' case. The authors commented that all raters had difficultly distinguishing in the mid-range of the index - between normal/pronated feet and normal/supinated feet - which was where the majority of their participant group were placed. The FPI-8 study in children [] had values ranging from -1 to +14 thus including only 'normal' feet through to 'highly pronated' feet and so had less need to differentiate in the mid-range of the index. The present study, because of its selection of a convenience sample of children attending for podiatric treatment, was only able to assess the reliability in the end range of the scale, including no children with highly supinated feet. Having only participants in this small range may have increased the inter-rater reliability and it is recognised that the reliability does need to be tested across the full range of the index. However, in this study the score was tested for the typical group seen for treatment and research purposes.
A limitation to this study was the sample size. A sample size of 30 cases with two raters is an acceptable minimum sample size for when a moderate level or higher kappa coefficient is expected [], and to show that kappa is different from a value of zero. To confirm the inter-reliability of the FPI-6 in children, further data should be collected, using a larger range of foot types and also testing in specific groups in which treatment or research is occurring such as in cerebral palsy or hypermobility syndromes. Intra-rater reliability must also be considered.
Conclusion
The findings of this study show the FPI-6 has almost perfect inter-rater reliability (Kw = 0.86) between two experienced practitioners when used on the paediatric foot. This suggests that the FPI-6 may be of value in clinical practice and for use in podiatric research. Good inter-rater reliability provides confidence in this assessment tool; however reliability isn't solely a measure of the instrument. One must take into consideration the instrument, the practitioner, the situation and the participant. To ensure good inter-rater reliability for paediatric participants, all raters must receive similar training and have experience in treating the paediatric patient so the recording of outcome measurements is optimised.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
SM and JF were responsible for the conception and design the project. They have collected the data, conducted the statistical analysis and written the manuscript. Both authors have read and approved the final manuscript.
Acknowledgements
The authors would like to thank Dr Paul W Armstrong for statistical guidance.
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