January-June 2018 Int. J Rehabil. Sci.

Volume 07, Issue 01

Original Article
TRENDS OF SMOKING AMONG THE PARENTS OF CONGENITAL
TALIPES EQUINOVARUS PATIENTS
Junaid Akram1, Suhail Karim1, Amir shahzad2, Liaqar Ali Malik2
Abstract
Background: Congenital Talipes Equino-Varus is one of the deformities of the lower limb that is most prevalent among males. Many
epidemiological studies are in progress/going on to know the exact cause, even though it is suggested that genetic and environmental factors
(smoking) play central role in causing the disorder.
Objectives: To evaluate the trends of smoking, economic status, educational and ethnic background in parents of patients with Congenital Talipes
Equino-Varus
Methodology: The study was a descriptive cross section survey carried out at PIPOS Rehabilitation Services Program (PRSP), Peshawar from
April 2014 to May 2014. A self-structured questionnaire was used to collect data from participants. Only the patients with clubfoot were included
in the study. The data was analyzed by using SPSS V20.
Results: Number of the participants included in the study were n=107 and Mean age was 8.22± 6.10 years. 70 (65 %) participants were having
bilateral clubfeet and 37 (35%) were unilateral clubfeet. There was not even a single participant whose mother did smoke but there were 47 (44%)
participants whose father used to smoke during pregnancy. 4 (4%) of participants were having household smoking and 56 (52%) participants’
parents were not smoker. Data revealed that 69 (64%) of mothers were illiterate, 48 (48%) families of the participants were having average
economic income, 81 (76%) of respondents were from rural area and 83 (78%) of respondent parents married within the family while 24 (22%) of
respondent parents married outside the family.
Conclusion: This study clearly showed the trends of smoking among the family members of the clubfeet participants. Passive mother smoking,
average income families, illiterate mothers and family marriages were common among clubfoot patients.
Key words: Club Foot; Maternal Smoking; foot deformities
Received on: 12-12-2017, Revised on 06-04-2018, Accepted on 06-04-2018
Introduction
Various studies showed that one child out of every 1. Shifa Tameer-e-Millat University, Islamabad
thousand is born with club foot. (1,2) Congenital 2. Pakistan Institute of Prosthetic and Orthotic Sciences,
Peshawar
Talipes Equino Varus or clubfoot is a birth defect Correspondence
attributed to atrophy of the calf muscles of leg, Department of Physical Therapy. Shifa Tameer-e-Millat
equinus of the ankle, varus of the hind foot, cavus of University, Islamabad
midfoot or adductus of the forefoot (3). It can be due E-mail: drjunaidmalik2@gmail.com
to imbalance of planter flexors and dorsiflexors with
both, the triceps surae and tibialis posterior being household smoking habits during the duration of
mostly affected. As a result of muscle belly pregnancy (13,14). Thereafter, many epidemiological
shortening, their tendons are relatively longer than studies carried out for the firm cause that maternal
normal (4). smoking habit during pregnancy greatly affects to
Initially, in prospect of epidemiology in 400 BC, cause the club foot in child (15,16).
Hippocrates identified the first clubfoot and they A study was in need to confirm the aforementioned
believed that the pressure from uterine molding on factors in the Pakistan. Owning to outcomes of earlier
the developing foot caused the deformity (5). After epidemiological studies; it will be first ever study on
that, two factors were stated by researchers that were club feet to know the causes, particularly role of
genetic and environment (6). Many studies stated, maternal smoking to cause club foot in Peshawar,
multiple births, reduced amniotic fluid volume, Khyber Pakhtunkhwa. This study was carried out to
prolonged gestation, and increased birth weight have explore the causes and role of maternal smoking to
also been suggested to cause decreased fetal cause Congenital telipus equanovrus.
movement, thus reduction in fetal movement causes
the club foot (7,8,9). Furthermore, Wynne-Davies Methodology
found concordance for clubfoot was the same This study used quantitative methods doing a cross-
between dizygotic twins and single births, providing sectional survey. The study was conducted on
evidence against decreased limb movement as a Clubfeet patients at PRSP from 11th April 2014 to
cause for clubfoot (10). Similarly, it was also 30th May, 2014. Inclusion criteria were clubfeet from
concluded that the defect could be associated with the general population and Telipus equanovrus
neuromuscular disorders (11). Males are affected patient were excluded. Study population was the
more often than females, thus females require more Congenital telipus equanovrus patients equal or less
susceptibility loci than males (5,12). With the than 24 months. There were 107 patients.
passage of time, findings also confirmed the previous Data was collected directly from the parents via using
studies that reported the associations with young a questionnaire. A self-developed questionnaire was
maternal age, maternal education, young paternal and used after seeking consent from the participants. A
maternal (parents) age, parental smoking habits, and list of questions was generated through reviewing

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 January-June 2018 Int. J Rehabil. Sci.
literature and sample questionnaires from relevant
articles. The questionnaire consisted of different
variables including demographics i.e. age, sex, level
of parents’ education, diagnosis and causes like ages
of the parents, family or cousins marriage, smoking
which were extracted from the literature. All the
information was collected by parents who were the
respondents of study. The data were analyzed by
using SPSS V 20.
Results
Sample size of study was consisted of 107
participants, among them 90 (84%) were male and
17(16%) females. The statistics showed that 69
(64%) of mothers were illiterate, moreover, there
were 27 (25 %) mothers who had school level of
education, 6 (6%) had college level of education and
5 (5 %) had university level of education. The study
reflected that majority of respondents to a family
with an average economic state i.e. average economic
status was 48 (48%) then, 2nd majority of respondents
were from a poor family i-e, poor family status was
32 (30%). Furthermore, 14 (13%) of respondents
were from family with below average, 9 (8%) of
respondents were from family with above average
economic status and 1 (1%) of respondents from
wealthy family. Respondent were mostly from the
rural area of KPK i-e 81 (76%) of respondents were
from rural area and 26 (24%) of participants were
from urban area of KPK. Results of our study
reflected that n=70 (65 %) participants were having
bilateral clubfeet and n=37 (35%) were having
unilateral clubfeet. And 27 (73%) of all the unilateral
respondents were left sided. The result showed that
majority of respondents was affected with left side.
Minimum fathers’ age was 18 years and maximum
father’s age was 53 years. Mean fathers’ age was
30.48 (±5.60). By further classification of father age
into limit, i-e between the age of: 18 to 27years were
36 (34%), 28 to 37years were 62 (58%), 38 to 47 Father
years were 7 (7%) and 48 to 57 years were 2 (2%). Mother
The result clearly showed that majority of father’s Household smoking
age of participants lied in 28 to 37 years. Minimum
No smoking
mother’s age was 18 years and maximum age was 48
Total
years. Mean age was 26.41 (±5.20). By further
classification of father age into limit, i-e between the
age of: 18 to 27years were 63 (59%), 28 to 37years
were 40 (37%), 38 to 47 years were 3 (3%), 48 to 57
years were 1 (1%). The result clearly showed that
majority of father’s age of respondents lied in 18 to
27 years. Figure 1 reflects that there were majority of
participants whose parents were married within the
family, i-e 83 (78%) of respondent married within the
family while 24 (22%) of respondents married
outside the family.
Volume 07, Issue 01
There were no participants in the study whose parents
were having club feet at their birth. From the sample
size of 107, there were 71 (66%) participants who
had sibling and 36 (34%) participants were the first
child of their parents.
100
80
60
40
20
0
Marriages within Family Marriages outside
Family
Figure 1. Parents’ Marriage
From the 71 participants who were having siblings,
18 (25%) participants were having effected siblings
in which at least 1 and utmost 2 siblings were
present. 53 (75%) were having normal siblings. There
were 2 twins baby birth, both were monozygotic
twin, one was male and other was female. One baby
of twins was normal and another was affected with
CTEV. Results showed that study contained no
clubfeet whose mother did smoking during
pregnancy. There were 47(44 %) participants whose
fathers were smoker. There were only 4 participants
whose family members use to smoke during
pregnancy.(table 2) There were only five participants
who had neuromuscular disorder, counting to that, 3
were Arthrogryposis, 1 was Spina Bifida, and 1 was
Dystrophic Dwarfism.
Table 1: Smoking during pregnancy
Smoking during Pregnancy
Number Percentage
47 44%
0 0%
4 4%
56 52%
107 100%
Discussion
The first variable was gender; this study consists of
107 participants, males were 84% and females were
16%. In contrast to present study of USA, there were
only 72 participants, in which male were 61% and
female were 39% (5). A study of Vietnam, Sample
size =99, male was 63 and female were 33 % (4).
In this study, mothers level of education was low.
Comparatively to the previous studies the mothers
were educated. (10) Factors for illiteracy of mothers
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 January-June 2018 Int. J Rehabil. Sci.
is: Pakistan has low literacy rate, which is 49% and
mostly respondents were belonged to rural areas of
KPK.
Mean of Paternal age in the study was 30.48 and
mean of maternal age was 26.41, results of this study
are similar to a case control study in America (10).
Literature showed that young age of parents can
cause CTEV in child. The result of the current study
is not in accordance with the previous studies.
The involvement of bilateral clubfoot was greater
than the unilateral in the current study. But according
to a study conducted in America the number of the
unilateral involvement was greater than the bilateral.
(10) Furthermore, participants with left sided
involvement were 53% and right sided were 47%. As
similar to study of Vietnam, 52 % bilateral and 45
were unilateral and right sided proportion was higher
then left sided (17).
In the present study analyzed that 18 out of 107 had
the family history. As compared to study on family
history, 25 out of 346 had the family history of club
foot (18).
The important variable of this study is the role of
maternal smoking during pregnancy. In contrast to
present study, case control study done in UK in 2007
showed that there was strong association of clubfeet
with smoking and frequency was greater in female
than male children (male OR 1.16 [95% CI 0.53–
2.55]; female OR 2.28 [95% CI 0.68–7.66]), the risk
estimates were not statistically significant, nor was a
formal test of interaction between sex and maternal
smoking significant (p = 0.41). Fewer case than
control mothers reported drinking alcohol during the
index pregnancy (35% cases, 43% controls), but the
differences were not significant (19).
The epidemiological study of USA, stated that 47%
of parents of clubfoot patients reported presence of
any smoking in the household during the child’s
pregnancy compared to 17% of control parents
corresponding with a p value of 0.00001192 (5).
Honein et al (2000) demonstrated an interaction
between maternal smoking and family history of
CTEV, with an odds ratio of 20.30 (7.90–51.17) for
the combination of maternal smoking and family
history (18). The epidemiological studies of UK and
USA indicate that there is high risk of maternal
smoking as compared to paternal smoking but the
result are similar regarding paternal smoking. All are
contrary to results of this study. Factors which are
seem in contradictions are i-e in Pakistan, women are
very uncommon to do smoking in the society
particularly women of KPK.
Conclusion
Many epidemiological studies being held to know the
cause, even though it had been concluded that genetic
Volume 07, Issue 01
and environmental factors play central role to cause
the disorder but exact cause is remains unknown. The
few participants had the family history. There was
not a single mother in the current study who did
smoking during the time of pregnancy. But, there
were few children whose father did smoking during
pregnancy. This study concluded by exploring that
marriages within the family and paternal smoking
may cause the CTEV. On the other hand, mothers
were also involved in doing passive smoking, so
there can be the possibility than CTEV can also be
due to this smoking. No association had been
determined between CTEV and maternal smokings
so this can be better understand by calculating the
association with greater number of participants.
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Volume 07, Issue 01
Authors’ contributions:
Junaid Akram: Revising article critically for important
intellectual content for final approval. Responsible for data
integrity.
Suhail Karim Conception and design of the work and
revising it critically for final approval. Responsible for data
integrity.
Amir Shahzad: Conception and design of the work, the
acquisition, analysis, interpretation of data, drafting the
work and revising it for final approval. Responsible for data
integrity.
Liaqat Ali Malik: Revising article critically for important
intellectual content for final approval. Responsible for data
integrity.
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