Idiopathic Toe Walking Research Articles

Use of the normalcy index for the assessment of abnormal gait in the anterior cruciate ligament deficiency combined with meniscus injury

The normalcy index (NI) has been implemented by several studies as a simple index for quantitatively analyzing diffident gait abnormalities, such as children with cerebral palsy and idiopathic toe-walkers. However, whether the NI can be used in anterior cruciate ligament (ACL) deficiency with different types of meniscus injuries or not, has not been reported yet. In this study, 25 patients who combined different types of ACL and meniscus injuries were evaluated by the NI analysis. 12 healthy subjects were used to define the normal range of NI. The result showed that NI values of patients were significantly larger than the control group (P < 0.05). Meanwhile, the tendency of increasing NI values associated with increasing pathology were significant with only 5 subjects in the smallest group (Jonkheere-Terpsta test: P < 0.001). These results indicated that the NI was a concise yet effective tool to evaluate combined ACL and meniscus injury patients. Increasing severity degree of meniscus tears in ACL rupture patients is corresponded to increasing NI values. It also demonstrates that the proposed NI can be applied as a robustness factor to detect the discrepancy between healthy and patient subjects clinically, and has the potential in the quantitative evaluation of pre- or post-surgery and rehabilitation.

Idiopathic toe-walking in childhood

Background. Idiopathic toe walking (ITW) in childhood is a benign age-dependent disorder of the normal walking formula.Objective: neurological, catamnestic and electromyographic analysis of patients with ITW.Materials and methods. The study group consisted of 59 patients aged 1 year 4 months to 15 years (mean age is 6.10 ± 3.54 years) with a predominance of males (76 %) and the onset of violations in the age of 4 years in 83 % of cases, a normal history and the absence of signs of organic neurological deficiency.Results and conclusions. As a result of differential diagnosis cerebral palsy, spastic paraplegia, peripheral neuropathy, myopathy and other diseases as possible causes of ITW were excluded. A high proportion of comorbid disorders of the neurotic spectrum in patients with ITW was determined, so tranquilizing and anxiolytic therapy was indicated in half of the patients. Electromyography doesn’t revealed pathology of peripheral neuromotor apparatus. Follow-up monitoring for 2–6 years, showed complete spontaneous regression of violations of the pattern of the walk at 84.8 % of the patients of 7–8 years of life. The formation of contractures of the ankle joint in 5 patients required operative correction. The issues of therapeutic tactics (gypsuming, orthosis of feet, botulinum toxin therapy, physiotherapy) were discussed. The absence of evidence-based effect of therapeutic measures is confirmed.

Reliability of a New Clinical Gait Assessment Scale for Children with Idiopathic Toe Walking Gait – A Pilot Study

Aims Children with idiopathic toe walking (ITW) gait are increasingly referred to physical therapists. The purpose of this study was to evaluate the intra-rater and inter-rater reliability of the Clinical Gait Assessment Scale (CGAS), a newly developed observational rating scale. Methods Four raters evaluated videos of four children. Foot, arm and head/trunk movement was scored as children walked over four surfaces. Intra-class correlation coefficients (ICC), model (3,k) were calculated to determine intra-rater and inter-rater reliability of each dependent variable. Results The key findings of this study indicate robust intra- and inter-rater reliability, particularly of the foot (Inter-rater reliability, ICC (3,2)=0.9) and head and trunk (Inter-rater reliability, ICC (3,2)=1.0) subsections. Arm movements were more challenging to rate and showed moderate reliability (Inter-rater reliability, ICC (3,2)=0.7). Highest total impairment score; the highest value occurred while walking on the obstacle course (38 ± 29). Conclusions Overall, the CGAS showed adequate/acceptable reliability across different surfaces (linoleum, textured surface, narrow base, obstacle), however the obstacle surface was most challenging surface to the rater.

Exploring health professionals' understanding of evidence-based treatment for idiopathic toe walking.

Idiopathic toe walking (ITW) is an exclusionary diagnosis resulting in a child walking on the balls of their feet. Preferred treatment options may be due to the severity of the toe or the health professional preference There are limited guidelines supporting consistent treatment recommendations for this condition. This research aimed to understand agreement between health professionals' knowledge of evidence for common treatment strategies for ITW and if health professionals supported these strategies being used in clinical practice. An international online survey was opened to registered health professionals who treat children with ITW between July 2017 and March 2018. The survey had two components: (a) demographic variables and variables relating to knowledge of evidence about ITW treatments and (b) support for common treatment strategies. Additional data on strategy use, referrals, and preference were collected. Kappa statistics described intra-rater agreement between evidence knowledge and support. Multivariable regression analyses identified factors associated with the 10 most commonly preferred treatments. There were 908 international responses. Kappa agreement for paired correct responses determined a fair agreement for evidence support knowledge for four strategies including watch and wait (Kappa = 0.24), stretching (Kappa = 0.30), sensory integration strategies (Kappa = 0.40), and motor control strategies (Kappa = 0.24) and moderate responses for 13 others. No strategies had greater than moderate agreement between correct knowledge of evidence and strategy support. Profession, location, number of children seen in practice, and not correctly identifying the evidence factored into many of the most commonly used strategies for ITW (p < .05). The results from this study, which confirm a variety of interventions, are utilized in the management of ITW around the world. Furthermore, there remains a disconnection between paediatric health professionals' understanding of the evidence of common treatment strategies of ITW and a consensus for the treatment of this condition.

Commentary on "Differentiating Between Idiopathic Toe Walking and Cerebral Palsy: A Systematic Review".

“How should I apply this information?” This valuable systematic review reminds therapists of subtle, but distinct differences between idiopathic toe walking and cerebral palsy. The authors report these differences observed through the application of a number of assessment methods. Standard assessments described by this review include joint range of motion, muscle length and flexibility, and classification of any spasticity (Modified Ashworth Scale). If these are not standard practices, therapists should consider these as assessments which are easily learned and perfected in any practice setting. Nonstandard clinical methods included the use of electromyography or 3-D gait analysis. These improved the clinical picture enabling greater differentiation between the conditions. However, these assessments may be less accessible to therapists, potentially costly, and setting dependent. “What should I be mindful about when applying this information?” Although there is limited discussion of validity or reliability of the assessments, this should not dissuade therapists from applying these measures in practice where possible. This review did not consider of birth complications or developmental history of the child. These additional factors from the history could influence a therapist's referral for nonstandard assessments. These additional nonstandard assessments may place additional cost or time pressure on families, and the results may or may not change treatment course. This review highlights the lack of consensus of measures for differentiating between conditions. It highlights the poorly defined diagnostic criteria for idiopathic toe walking. These differences may impact communication about these conditions between health care providers. It may also impact health care providers to communicate either diagnosis or long-term treatment plan. These inconsistencies may create challenges for parents, particularly if they observe their child being assessed in different ways by each of their health care providers. This warrants consideration for the development of standardized assessment practice for toe-walking gait. Cylie Williams, PhD Antoni Caserta, BPod Department of Physiotherapy, Monash University Frankston, Australia Melissa Chee Parent of a child with idiopathic toe walking

Differentiating Between Idiopathic Toe Walking and Cerebral Palsy: A Systematic Review

The purpose of this systematic review is to identify evidence-based examination components that enable a clinician to distinguish between participants with idiopathic toe walking (ITW) and cerebral palsy (CP) to accurately categorize them into their respective movement system diagnosis. Five articles were used that compared key clinical findings, walking characteristics, and muscle firing patterns of participants with CP and ITW. Differences in these components allow participants with CP and ITW to be classified into different movement system diagnoses to better target plan of care. The authors recommend that clinicians perform specific evidence-based tests and measures in accordance with the International Classification of Functioning, Disability and Health model.

Evaluation of Postural Control in Children With Idiopathic Toe Walking

Evaluation of Postural Control in Children With Idiopathic Toe Walking

Interventions for idiopathic toe walking.

Interventions for idiopathic toe walking.

Effect of Plantar Flexor Muscle Strengthening on the Gait of Children With Idiopathic Toe Walking: A Study Protocol.

To evaluate the effect of plantar flexor strengthening associated with conventional physical therapy treatment in participants with idiopathic toe walking. Thirty participants, of both sexes diagnosed with idiopathic toe walking, aged 5 and 11 years, will be recruited and randomized into 2 groups: the control group, who will undergo gait training, triceps surae muscle stretching, anterior tibial muscle strengthening, and motor sensory training, and the intervention group, who will undergo the same training as the control group and, additionally, triceps surae muscle strengthening. The intervention will be performed twice a week for 8 weeks. The participants will undergo a 3-dimensional gait kinematic analysis, passive amplitude of dorsiflexion movement, isometric dynamometry of the anterior tibial and triceps surae muscles, motor coordination, quality of life, and perception of the parents regarding the equinus gait at baseline and at the end of treatment. Quality of life will be reevaluated during a 24-week follow-up.

Serial ankle casts for patients with idiopathic toe walking: effects on functional gait parameters.

PurposeThe aim of the present study was to investigate the functional effects on gait parameters of serial ankle casts for patients with idiopathic toe walking (ITW), in comparison with an unremarkable control group.MethodsA prospective trial with a pre-test–post-test control group design included ten patients with ITW and ten healthy matched children. Children with ITW underwent serial casting to stretch the plantar flexors, with two 14-day periods with walking plaster casts set at the maximum available ankle dorsiflexion. Both groups were assessed clinically and using a functional gait analysis before and after serial casting, as well as at a six-month follow-up visit.ResultsThe normalized plantar heel force increased from 5% pre-interventionally to 79% at the follow-up. The upper ankle-joint angle and the base angle also demonstrated significant changes. Normalized compound action potentials of the medial heads of the gastrocnemius were reduced by 70%. None of these parameters demonstrated any significant differences at the follow-up examination in comparison with the healthy control group. Variations in the displacement of the knee joint on the sagittal plane and of the center of gravity in the transverse plane did not show any significant differences in comparison with the control group.ConclusionThe reduction of muscle tone and lengthening of the ankle plantar flexors led to persistent increased active ankle dorsiflexion with significant long-term improvement of functional kinematic parameters. No significant difference in the gait analysis was found between the ITW group and healthy children six months after treatment.Level of EvidenceLevel II - Therapeutic

The Dynamic Baropodometric Profile of Children with Idiopathic Toe-Walking A Cross-Sectional Study.

Idiopathic toe-walking (ITW) gait may present in children older than 3 years and in the absence of a medical condition known to cause or be associated with toe-walking gait. It is unknown how this gait type changes pressure distribution in the growing foot. We sought to determine whether children with ITW gait exhibit different plantar pressures and temporal gait features than typically developing children. Children aged 3 to 6 years were recruited who had either a typical heel-toe gait pattern or a diagnosis of ITW. The ITW diagnosis was reported by the parent/caregiver and confirmed through history and physical examination. Temporal gait measures, peak pressures, and impulse percentages were measured. A minimum of ten unshod footprints were collected. Data were compared with unpaired t tests. The study included 40 children with typical gait and 56 with ITW gait. The ITW group displayed lower peak pressures at the hallux, midfoot, and hindfoot ( P < .05) and higher and lower pressure impulse percentages at the forefoot ( P < .001) and hindfoot ( P < .001), respectively. The ITW group spent a higher percentage of contact time at all areas of the forefoot and less at the midfoot and rearfoot ( P < .05). There were no significant differences in total step duration and foot progression angle between groups ( P > .05). There were differences in pressure distributions between groups. Understanding these differences may help us better understand the compensations or potential long-term impact that ITW gait may have on a young child's foot. Podiatric physicians may also consider the use of this equipment in the clinical setting to measure outcomes after treatment for ITW.

Translation and transcultural adaptation of the Toe Walking Tool: screening tool of toe walking patients

The Toe Walking Tool (TWT) is a clinical screening instrument which helps in the differentiation of children with normal development, idiopathic toe-walking or toe-walking due to a medical cause. To carry out the translation and cross-cultural adaptation of the TWT for the Spanish pediatric population and to evaluate its content validity. This paper was carried out following an inverted method of translation and back-translation. Once the pre-final Spanish version was obtained, its analysis was conducted through the Delphi method by a panel of experts. The content validity of the tool explores its clarity, viability, applicability and usefulness. An expert panel composed by 15 professionals determine the content validity of the Spanish version of the TWT. The questionnaire translated and adapted transculturally into Spanish presented an excellent global content validity index (0.94) and the expert committee considered that the scale was easily understandable, viable, simple to apply and useful in the pediatric setting. The Spanish version of the TWT presents an excellent content validity and is an understandable, viable, simple and useful assessment tool. It is necessary to carry out future studies to analyze its psychometric properties with a Spanish pediatric population.

Are Baby Walker Warnings Coming Too Late?: Recommendations and Rationale for Anticipatory Guidance at Earlier Well-Child Visits.

Baby walkers, traditionally marketed to parents as products that can help babies learn how to walk, are devices composed of a suspended seat surrounded by a rigid frame that is connected to wheels. This design positions infants to sit in a balanced standing position with their toes touching the floor, thereby allowing them to move independently without parental support. For many parents, baby walkers are viewed as an ideal way to encourage their children to begin walking, while keeping them entertained, quiet, and safe.1,2 Research has suggested that, despite their name, baby walkers can potentially hinder a child’s ability to walk. Studies have reported lower locomotive development test scores for babies who used baby walkers than those who did not.1,3,4 In addition, baby walkers may detrimentally affect the development of normal gait patterns and posture in early childhood and may even lead to idiopathic toe walking gait pattern development.5,6 In addition to gait concerns, baby walkers are associated with a high risk of injury. Alarmingly, statistics reveal that approximately 12% to 50% of children who use baby walkers become injured.7 Between 2004 and 2008, there were approximately 3000 children aged 15 months and younger who required treatment in US emergency rooms due to injuries from baby walker usage.8 However, this report did not include cases treated in urgent care centers or pediatric clinics/offices, and therefore, incidence may be higher. Baby walker injuries may be caused by falling down stairs, burns from electrical outlets, or drowning from walking into a pool or accessing the toilet.1 Since babies can independently move in baby walkers, they may be able to reach items on higher surfaces and are therefore at higher risks for reaching hazards, such as pulling hot liquids from counters.8 While the American Academy of Pediatrics (AAP) clearly states that baby walkers do not promote independent walking and stress that baby walkers can delay normal development and motor control, this warning does not appear until the published 8- to 12-month anticipatory guidance period.1,9 With baby walker usage remaining high in the United States, the question arises as to whether this guidance is coming too late. This study examines the age, gait patterns, and risks for injury of babies using baby walkers in video clips posted publicly on YouTube in order to evaluate whether additional anticipatory guidance is needed at earlier well-child visits.

Idiopathic toe walking—A follow-up survey of gait analysis assessment

BackgroundToe-walking is a normal variant in children up to 3 years of age but beyond this a diagnosis of idiopathic toe-walking (ITW) must be considered. ITW is an umbrella term that covers all cases of toe-walking without any diagnosed underlying medical condition and before assigning these diagnosis potential differential diagnoses such as cerebral palsy, peripheral neuropathy, spinal dysraphism and myopathy must be ruled out. Gait laboratory assessment (GLA) is thought to be useful in the evaluation of ITW, and kinematic, kinetic and electromyography features associated with ITW have been described. However, the longer term robustness of a diagnosis based on GLA has not been investigated. The primary aim of this study was to examine if a diagnosis of ITW based on GLA features persisted. MethodsAll patients referred to a national gait laboratory service over a ten year period with queried ITW were sent a postal survey to establish if a diagnosis of ITW which had been offered following GLA persisted over time. The gait and clinical parameters differentiating those reported as typical ITW and not-typical-ITW following GLA were examined in the survey respondents. ResultsOf 102 referrals to the laboratory with queried ITW, a response rate of 40.2% (n = 41) was achieved. Of the respondents, 78% (n = 32) were found to be typical of ITW following GLA and this diagnosis persisted in the entire group at an average of 7 years post GLA. The other nine subjects were reported as not typical of ITW following GLA and 44.4% (n = 4) received a subsequent differential diagnosis. The clinical examination and gait analysis features differentiating these groups were consistent with previous literature. ConclusionGLA appears to be a useful objective tool in the assessment of ITW and a diagnosis based on described features persists in the long-term.

Full length foot orthoses have an immediate treatment effect and modify gait of children with idiopathic toe walking

BackgroundThere remains a substantial lack of evidence to support the use of foot orthoses as a conservative treatment option for idiopathic toe walking (ITW). Encouraging heel contact during gait is one of the primary goals of most interventions in paediatric ITW. Research QuestionDoes the combined treatment of high-top boots and orthoses increase the number of heel contacts during gait and change spatio-temporal gait parameters? MethodsThis within subject designed randomised controlled trial recruited fifteen children diagnosed with ITW (n = 10 males). They were fitted with bilateral custom made rigid contoured carbon fibre foot orthoses placed inside high-top boots. To analyze the effect of this treatment, heel contacts and spatio-temporal parameters measured by an 8.3 m Gaitrite® mat were compared to barefoot walking and shod walking. ResultsAn immediate increase in heel contact (p = 0.021) was observed in the combined treatment only. Gait changes included a large increase in stride time in the combined treatment condition compared to barefoot walking (p = 0.006). This was associated with a decrease in the percentage of swing phase in the gait cycle (p < 0.010), an increase in stance phase (p < 0.010) and an increase in double support time (p < 0.001). SignificanceThese results suggest the hardness and thickness of the shoe and stiffness of the orthosis midsole may lead to improved local dynamic stability and foot position awareness with increased sensory feedback provided through the entire length of the foot. Further research is indicated to validate this treatment option on long term outcomes in this population group.

Quantifying Sensory Function Associated With Idiopathic Toe Walking in Children

Abstract Date Presented 4/20/2018 This ongoing study is examining sensory functions in children with idiopathic toe walking (ITW) to establish a framework to detect sensory differences that underlie ITW. Identifying sensory functions that underpin toe walking is a valuable contribution to the development of targeted treatments for ITW. Primary Author and Speaker: Virginia Chu

Idiopathic Toe Walking and Postural Instability: The Next Step

Abstract Date Presented 4/19/2018 This study investigated differences in postural control and sensory processing between toe walkers and non–toe-walking peers. Significant differences were found. The study contributes to the body of knowledge related to idiopathic toe walkers with an emphasis on proprioceptive needs. Primary Author and Speaker: Jessica McHugh Contributing Authors: Mary F. Baxter, Pei-Fen Chang, Katy Mitchell

Impact of Using Heel Wedges to Reduce Idiopathic Toe Walking in a Child With Autism

Abstract Date Presented 4/20/2018 The purpose of this study was to investigate the impact of using heel wedge inserts to decrease toe walking in a child with autism with insidious toe walking in a school setting. The use of gel heel wedges significantly reduced the instances of toe walking in this child with autism. Primary Author and Speaker: Kristen Sidman Additional Authors and Speakers: Robert Silva

Magnetic resonance imaging of the spine in idiopathic toe walking ‐ is there a role?

Magnetic resonance imaging of the spine in idiopathic toe walking ‐ is there a role?

McArdle’s disease: A differential diagnosis of idiopathic toe walking

Idiopathic toe walking (ITW) is a pathological gait pattern in which children walk on their tip toes with no orthopedic or neurological reason. Physiological characteristics of the gastrocnemius muscles, the Achilles tendon, and the foot of toe walkers differ from subjects with a plantigrade walking pattern. McArdle’s disease is characterized by the inability to break down muscle glycogen. It is an autosomal-recessive condition, characterized by low exercise tolerance, muscular atrophy at the shoulder girdle, episodes of myoglobinuria after vigorous physical activities and the occurrence of the second wind phenomenon. The aim of this review is to present the case studies of two subjects who were originally diagnosed as idiopathic toe walkers, but were then found to have McArdle’s disease. This review will describe some physical characteristics that distinguish McArdle´s disease from Idiopathic toe walkers.