Toe Walking Research Articles

Gut Microbiome Dysbiosis as a Potential Risk Factor for Idiopathic Toe-Walking in Children: A Review.

Idiopathic toe walking (ITW) occurs in about 5% of children. Orthopedic treatment of ITW is complicated by the lack of a known etiology. Only half of the conservative and surgical methods of treatment give a stable positive result of normalizing gait. Available data indicate that the disease is heterogeneous and multifactorial. Recently, some children with ITW have been found to have genetic variants of mutations that can lead to the development of toe walking. At the same time, some children show sensorimotor impairment, but these studies are very limited. Sensorimotor dysfunction could potentially arise from an imbalanced production of neurotransmitters that play a crucial role in motor control. Using the data obtained in the studies of several pathologies manifested by the association of sensory-motor dysfunction and intestinal dysbiosis, we attempt to substantiate the notion that malfunction of neurotransmitter production is caused by the imbalance of gut microbiota metabolites as a result of dysbiosis. This review delves into the exciting possibility of a connection between variations in the microbiome and ITW. The purpose of this review is to establish a strong theoretical foundation and highlight the benefits of further exploring the possible connection between alterations in the microbiome and TW for further studies of ITW etiology.

A Pilot Study of Idiopathic Toe Walking: Measures and Outcomes

This pilot study sought to determine the feasibility of quantifying sensory processing, postural control, motor skill development and participation in daily life in children with idiopathic toe walking (ITW) compared to children without ITW. A nonrandomized, prospective case-control design was employed. Twenty participants were recruited. Computerized weight bearing and postural control data was successfully collected. Differences were found in forefoot/rearfoot weight bearing, balance, sensory-motor abilities and parent reported participation challenges. Sensory processing results were inconclusive. Findings can inform standardized assessment and treatment of ITW.

Effect of Sensorimotor Exercises in Reducing Toe Walking in Autistic Spectrum Disorder

Effect of Sensorimotor Exercises in Reducing Toe Walking in Autistic Spectrum Disorder

Triceps surae muscle forces during dynamic exercises in patients with Achilles tendinopathy: A cross-sectional study.

The aim of this study was to investigate the individual triceps surae muscle forces during the execution of six different functional movements and rehabilitation exercises in patients with Achilles tendinopathy compared to a control group. Triceps surae muscle forces of 15 participants with Achilles tendinopathy (AT) and 15 healthy controls were estimated through a combination of experimental data and musculo-skeletal modeling. Three-dimensional motion capture and force plates were used to collect the ankle and knee joint angles and moments during three functional movements (walking, heel walking, and toe walking) and three rehabilitation exercises (bilateral heel drop, unilateral heel drop with extended knee and with flexed knee). A dynamic optimization method was used to obtain the modeled triceps surae muscle forces. Force-sharing strategies were calculated at the peak triceps surae muscle force and compared between groups. Lower peak triceps surae forces were obtained for the AT group during dynamic exercises. Across all exercises, the average contribution of the soleus (SOL) to the total triceps surae muscle force was the largest (60.83 ± 13.89% [AT] > 56.90 ± 16.18% [healthy]), followed by the gastrocnemius medialis (29.87 ± 10.67% [AT] < 32.19 ± 12.90% [healthy]) and the gastrocnemius lateralis (9.30 ± 4.31% [AT] < 10.91 ± 4.66% [healthy]). The triceps surae force-sharing strategy was different for the toe walking, heel walking, and the bilateral and unilateral heel drop with extended knee. This study provides evidence for altered triceps surae muscle force-sharing strategies during dynamic tasks in patients with AT. The influence of altered muscle force-sharing on the subtendon nonuniformity and/or the tendon loading should be explored in future work.

Exploring OT for Idiopathic Toe Walking: Comparing Interdisciplinary Practices

Abstract Date Presented 04/22/2023 Idiopathic toe walking (ITW) appears in children without a neurological, orthopedic, or psychiatric diagnosis. A survey of OTs’ perspectives on evidence-based practices was compared with a larger sample of professionals who also treat ITW. Primary Author and Speaker: M Irma Alvarado Additional Authors and Speakers: Kylie Ellington Contributing Authors: Cylie Williams, Leigh Lehman, Ileana S. McCaigue, Delaney Doyle, Katy Hendry, Olivia Trull, Kylie Ellington

Outcome of a Simple Novel Technique to Reduce Soft Tissue Complications in Open Tendoachilles Injury: A Series of 20 Patients.

Open tendoachilles injuries are rare and associated with significant soft tissues complications. The objective of the present study was to assess the clinical outcome and safety of a simple and minimally invasive technique, with a goal to assess if it may help minimise flap and wound related complications in open tendoachilles injuries. This prospective study of four years duration included 20 patients with open tendoachilles injuries managed with a simple minimally invasive tunnel technique. The primary outcome variable was occurrence of a major soft tissue complication. The secondary outcome variables included functional outcome measured using AOFAS Ankle hind foot score, re-rupture of tendoachilles and need for revision surgery. None of the patients in the present series developed a serious soft tissue complication. Based upon the AOFAS hind foot scoring system, good to excellent outcome was achieved in 19 (95%) patients. All the patients were able to perform tip toe walking at six months post-surgery. None of the patients had a re-rupture of the tendoachilles and no patient needed a revision surgery. The complications encountered include thickening of the tendon at the repair site (15%), superficial wound infection (5%), stitch granuloma (5%) and hypertrophic scar (5%). This technique seems to be promising in reducing the soft tissue complications associated with the surgical management of open tendoachilles injuries. Most patients had a good final clinical outcome. The technique is safe, simple and reproducible. However, further randomised control studies with a larger sample size assessing the technique are recommended.

Some children with idiopathic toe walking display sensory processing difficulties but not all: A systematic review.

Idiopathic toe walking (ITW) is a diagnosis for children who toe walk without another diagnosis known to cause toe walking. Recent research has suggested that children with ITW may have mild motor planning challenges and sensory processing differences. The primary aim of this systematic review was to determine whether children diagnosed with ITW have differences in their sensory processing compared to typically developing children. Secondary aims included determining how sensory processing was assessed in this population and documenting the broad clinometric and psychometric properties of any assessment tools. MEDLINE, CINAHL, AMED and Embase were searched for relevant literature in English. Studies were eligible for inclusion if they described children aged 3 and 18 with idiopathic toe walking and reported a sensory processing domain. Twelve articles met the inclusion criteria; however, only two papers included data permitting meta-analysis. Meta-analyses of vibration perception threshold using a random effect model were not significant (p = 0.31). Other data were synthesised by narrative and showed a high heterogeneity across multiple sensory processing domains. This study highlights that despite children with ITW often conceptualised as possessing sensory processing challenges, there is little evidence supporting this theory. Further research on sensory processing in children with this gait pattern is necessary.

Stepping Beyond Efficacy: Understanding the User Experience of Wearables for Children with Idiopathic Toe Walking in the Natural Setting

Idiopathic Toe Walking is an atypical gait pattern that results in limited mobility, pain, and higher risk of falling. Current therapeutic interventions lack the ability to be implemented outside the clinic or lab. Beyond this, it is unclear if gait analysis and real-time feedback is technologically feasible to attain within a user's natural environment. In our research we aimed to understand the child and parent participants’ experience of an innovative wearable system. We surveyed children and parents after the deployment of a functional prototype with real time vibrotactile feedback for awareness of toe walking via a shoe insert paired with a smartphone for visual feedback. Findings revealed insights into design considerations for wearable technologies for children. Factors such as comfort of using the system (physically and psychologically), child's perception and response to the vibrotactile feedback, and children and parents’ perception of reduced fall risk, pain, and stigma are discussed.

COVID-19 Infection Presents as Acute Cerebellar Ataxia (P6-10.003)

<h3>Objective:</h3> To describe a rare case of COVID-19 infection presenting as acute cerebellar ataxia in a pediatric patient. <h3>Background:</h3> The COVID-19 virus is well known to cause respiratory tract infections but other body systems can be affected including the nervous system. Most of the reported neurological manifestations of COVID-19 infection occurred sub-acutely between days to weeks after infection onset. Here, we present a pediatric case of COVID-19 infection presenting with associated cerebellar symptoms. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> A 10-year-old male with no past medical history presented to the emergency department with a new onset fever (Tmax: 104F), headache, odynophagia, rhinorrhea, diarrhea associated with blurry vision, and ataxia. The patient denied any falls, dysarthria, diplopia, paresis, hypoesthesias, bladder or bowel incontinence. On exam T: 98.9F, HR: 65, BP: 107/66, RR: 20. Normal physical exam, on neurological exam patient, was alert and oriented, he did not have paresis, hypoesthesia but had ataxia, bilateral nystagmus, dysdiadochokinesia, dysmetria with finger-to-nose and heel-to-shin testing, he was unable to walk unassisted, had wide-based gait, altered heel, toe, and tandem walking. No papilledema was observed on fundoscopy. CBC, CMP were unremarkable, CT head did not show any acute intracranial abnormality. Infectious workup showed a positive COVID-19 polymerase chain reaction and negative blood cultures. Lumbar puncture revealed normal protein and glucose levels with no pleocytosis, the patient had extensive negative serology testing for autoimmune, demyelinating, and alternative infectious etiologies. Brain and cervicothoracic spine MRIs with and without contrast were normal. The patient was diagnosed with viral cerebellitis secondary to COVID-19 infection, and he was started on intravenous methylprednisolone 1 gram for 5 days with symptomatic improvement, the patient was able to walk with minimal assistance by the end of the hospital stay and was discharged with a prednisone taper. <h3>Conclusions:</h3> Neurological manifestations like cerebellar ataxia can be the presenting symptomatology of acute COVID-19 infection. <b>Disclosure:</b> Dr. Carvajal- Gonzalez has nothing to disclose. Dr. Benjamin has nothing to disclose. Dr. Asghar has nothing to disclose.

NGS-Panel Diagnosis Developed for the Differential Diagnosis of Idiopathic Toe Walking and Its Application for the Investigation of Possible Genetic Causes for the Gait Anomaly.

Idiopathic toe walking (ITW) describes a condition affecting approximately 4.5% of children. Toe walking is an accompanying symptom for many hereditary disorders. This retrospective study uses next-generation sequencing-panel-diagnosis to investigate the feasibility of genetic testing to research the possible genetic causes of ITW and for differential diagnosis. Data were taken from our inhouse database, the minimum age for participants was 3 years. Underlying neurological or orthopaedic conditions were tested for and ruled out prior to diagnosing ITW. Patients, who experienced complications before, during or immediately after birth, children with autism, and patients toe walking less than 50% of the time were excluded. Eighty-nine patients were included in the study, in which 66 (74.2%) patients were boys and 23 (25.8%) girls. Mean age at testing was 7.7 years (range: 3-17 years). Fifteen of the 89 patients included in the study (16.9%) had a genetic variant identified as likely pathogenic or pathogenic by the genetics laboratory. Additionally, we found 129 variants of uncertain significance. About 65.2% of patients showed a pes cavus foot deformity, 27% of patients reportedly had at least one relative who also displayed the gait anomaly, and 37.1% had problems with their speech development. Despite the limitations of the sample size and the scope of our genetic testing targets, our results indicate that research into the genetic causes of ITW could better our understanding of the causes of ITW in otherwise healthy children, to help develop novel methods to detect serious conditions early. ITW could be an early onset symptom for further hereditary conditions.

Feature Selection using Random Forest Classifier for Foot Strike Event Detection in Toe Walkers

Automated Gait event identification of Foot Strike (FS) and Foot Off (FO) in pathological gait data, can be time saving in comparison to conventional manual annotations done currently. Identification of FS and FO allows breaking walking trials into gait cycles and hence aids in comparison of gait parameters like joint angles, forces and moments across gait cycles. Automated Gait Event Detection is also useful in development of wearable sensor devices and robotic systems that assist gait. Researchers have proposed several automatic gait event detection algorithms based on kinematic parameters and systematic study of the literature suggests specific parameters to have higher contribution in identification of FS event in all common pathological gait patterns. We used Random Forest Classifier Feature selection technique to identify high contributing features in FS event in toe walking pediatric pathological gait dataset and the results suggest high similarity in selected features by the machine learning technique with those suggested by popular event detection algorithms based on kinematic parameters for pathological gait. Hence we conclude that RFC feature selection is suitable for feature selection in toe walkers gait dataset for event detection purpose. Keyword : Feature selection, foot off, foot strike, pathological gait.

A forefoot strike pattern during 18° uphill walking leads to greater ankle joint and plantar flexor loading

BackgroundThe ankle joint is one of the most involved joints in uphill walking. Furthermore, it is well known that toe walking increases the external dorsiflexion moment in the first half of stance during level walking. However, the effects of different foot-strike patterns on plantar flexor muscle forces, ankle joint forces, and other lower limb joint and muscle forces are unknown. Research questionDo foot-strike patterns during 18° uphill walking affect lower limb sagittal joint angles and moments, as well as joint contact and muscle forces? MethodsThis study was based on a data subset from previous publications, analysing uphill walking on an 18° ramp at a preset speed of 1.1 m/s in 18 male participants (34 limbs analyzed, 27 ± 5 years). Participants were divided into two groups based on their foot-strike pattern at initial contact: heel (HC) and forefoot (FC). Lower limb sagittal joint angles and moments as well as joint contact and muscle forces were assessed. Differences between the groups were assessed using two-sample t-tests. ResultsFC showed increased soleus and gastrocnemius muscle forces as well as ankle joint forces during loading response and mid stance compared to HC. The soleus muscle force impulse was 51.1% higher in the FC group than in the HC group (p < 0.001). On the other hand, FC had a lower absolute centre of mass vertical displacement and reduced knee and hip joint, as well as iliopsoas and hamstring muscle force impulses. SignificanceIn terms of plantar flexor and ankle joint loading, it is advantageous to exhibit a heel strike pattern. The current results can be used to recommend foot-strike patterns for uphill walking, particularly in the presence or prevention of musculoskeletal issues.

Foot Problems and Their Associations with Toe Grip Strength and Walking Speed in Community-Dwelling Older Individuals Using Day Services: A Cross-Sectional Study

Foot disorders in older individuals compromise balance and contribute to postural and gait instabilities, causing a decrease in the activities of daily living and quality of life. In this cross-sectional study, we analyzed the foot-related data of 160 frail older participants who attended day service centers in A prefecture in Japan to determine the prevalence of foot problems and their associations with toe grip strength and walking speed in frail older people. Multiple regression analysis was used to identify foot-related variables that correlated with toe grip strength and walking speed. The prevalence rates of skin dryness (Support level 88.2%, Care level 85.2% for men; Support level 84.9%, Care level 93% for women) and suspected and existing fungal infections in nails (Support level 94.1%, Care level 92.6% for men; Support level 98.1%, Care level 95.2% for women) were high in both sexes regardless of the level of care required. Furthermore, in both sexes, the prevalence rates of toe and arch deformities were significantly increased in the people who required care. Regression analysis revealed that some right-sided foot-related problems were significantly associated with right toe grip strength and walking speed. The decrease in toe grip strength was significantly associated with walking speed. Our study provides evidence that some specific conditions were associated with toe grip force and walking speed. This finding can contribute to future strategies to protect foot health in community-dwelling older individuals.

Child Neurology: KMT2B-Related Dystonia in a Young Child With Worsening Gait Abnormality.

KMT2B gene-related dystonia (DYT-KMT2B) is a primarily childhood-onset movement disorder that usually starts with lower limb dystonia progressing into generalized dystonia. Our patient described in this study experienced difficulty gaining weight, laryngomalacia, and feeding difficulties during infancy and later developed gait difficulties, frequent falls, and toe walking. Gait assessment revealed prominent bilateral intoeing, intermittent ankle inversion, and extension of left leg. At times, the gait seemed to be spastic. Whole-exome sequencing revealed a novel de novo heterozygous likely pathogenic variant, c.7913 T > A (p.V2638E), in the KMT2B gene located in chromosome 19. This variant, which has not been previously published as pathogenic or benign in the literature, can be added to the repertoire of KMT2B variants causing inherited dystonias.

Ankle Kinematics Characterization in Children with Idiopathic Toe Walking: Does the Foot Model Change the Clinical Evaluation?

Idiopathic toe walking (ITW) is a gait deviation characterized by forefoot contact with the ground, sometimes observed in children, that alters ankle kinematics, possibly leading to health-related issues. When studying foot and ankle gait deviations, the adoption of a single-segment foot model entails a significant simplification of foot and ankle movement, and thus may potentially mask some important foot dynamics. Differences in ankle kinematics between single- (conventional gait model, PiG, or Davis) and multi-segment (Oxford foot model, OFM) foot models were investigated in children with ITW. Fourteen participants were enrolled in the study and underwent instrumented gait analysis. Children were asked to walk barefoot and while wearing a foot orthosis that modified the ankle movement pattern toward a more physiological one without blocking foot intrinsic motion. ITW gait abnormalities, e.g., the absence of heel rocker and the presence of anticipated forefoot rocker, were found/not found according to the foot model. Walking conditions significantly interacted with the foot model effect. Finally, the different characterization of gait abnormalities led to a different classification of ITW, with a possible impact on the clinical evaluation. Due to its closer adhesion to ankle anatomy and to its sensitivity to ITW peculiarities, OFM may be preferable for instrumented gait analysis in this population.

Does use of ankle foot orthoses affect the dynamic motor control index during walking in cerebral palsy and idiopathic toe walking populations?

BackgroundThe dynamic motor control (walk-DMC) index during walking is a measure of the complexity of muscle activation pattern. Ankle Foot Orthoses (AFO) are frequently used to improve the gait of children with Cerebral Palsy (CP) and Idiopathic Toe Walking (ITW). The purpose of this study was to assess the change in walk-DMC index secondary to AFO use. Research QuestionDoes the change in walk-DMC reflect the change in walking kinematics with the use of AFO. MethodsIndividuals with diagnosis of CP or ITW with gait analysis data available for barefoot and AFO condition were retrospectively identified. For each individual, the walk-DMC index, Gait Deviation Index (GDI) and Gait Variable Scores (GVS) of knee and ankle kinematics were computed for BF and AFO conditions. Paired t-tests were used to compare key variables between BF and AFO conditions. Multi-variate stepwise regression analysis was performed to identify variables that may predict the increase in walk-DMC between BF and AFO condition. Results253 individuals were included in the study. For CP individuals (n = 208), statistically significant but quantitatively minimal improvement was observed in walk-DMC (1 ± 9), GDI (2 ± 9) and ankle GVS (2 ± 7). For ITW individuals (n = 45), larger improvements were observed in walk-DMC (11 ± 13), GDI (9 ± 11) and ankle GVS (6 ± 7).Diagnosis of ITW, use of Solid-AFO and Posterior Leaf Spring-AFO were the significant predictor of increase in walk-DMC with AFO. Higher ankle GVS at BF condition (larger deviation from TD) led to larger increase in walk-DMC. Higher knee GVS (larger deviation from TD) led to smaller increase in walk-DMC. SignificanceUse of AFO can lead to improvement in walking kinematics that is reflected in increase in walk-DMC with AFO compared to BF for ITW individuals. The change in kinematics and walk-DMC with use of AFO was minimal for CP individuals.

Children’s orthopaedics

The February 2023 Children’s orthopaedics Roundup360 looks at: Trends in management of paediatric distal radius buckle fractures; Pelvic osteotomy in patients with previous sacral-alar-iliac fixation; Sacral-alar-iliac fixation in patients with previous pelvic osteotomy; Idiopathic toe walking: an update on natural history, diagnosis, and treatment; A prediction model for treatment decisions in distal radial physeal injuries: a multicentre retrospective study; Angular deformities after percutaneous epiphysiodesis for leg length discrepancy; MRI assessment of anterior coverage is predictive of future radiological coverage; Predictive scoring for recurrent patellar instability after a first-time patellar dislocation.

Impact of Gait Events Identification through Wearable Inertial Sensors on Clinical Gait Analysis of Children with Idiopathic Toe Walking

Idiopathic toe walking (ITW) is a gait deviation characterized by forefoot contact with the ground and excessive ankle plantarflexion over the entire gait cycle observed in otherwise-typical developing children. The clinical evaluation of ITW is usually performed using optoelectronic systems analyzing the sagittal component of ankle kinematics and kinetics. However, in standardized laboratory contexts, these children can adopt a typical walking pattern instead of a toe walk, thus hindering the laboratory-based clinical evaluation. With these premises, measuring gait in a more ecological environment may be crucial in this population. As a first step towards adopting wearable clinical protocols embedding magneto-inertial sensors and pressure insoles, this study analyzed the performance of three algorithms for gait events identification based on shank and/or foot sensors. Foot strike and foot off were estimated from gait measurements taken from children with ITW walking barefoot and while wearing a foot orthosis. Although no single algorithm stands out as best from all perspectives, preferable algorithms were devised for event identification, temporal parameters estimate and heel and forefoot rocker identification, depending on the barefoot/shoed condition. Errors more often led to an erroneous characterization of the heel rocker, especially in shoed condition. The ITW gait specificity may cause errors in the identification of the foot strike which, in turn, influences the characterization of the heel rocker and, therefore, of the pathologic ITW behavior.

Dense & Attention Convolutional Neural Networks for Toe Walking Recognition.

Idiopathic toe walking (ITW) is a gait disorder where children's initial contacts show limited or no heel touch during the gait cycle. Toe walking can lead to poor balance, increased risk of falling or tripping, leg pain, and stunted growth in children. Early detection and identification can facilitate targeted interventions for children diagnosed with ITW. This study proposes a new one-dimensional (1D) Dense & Attention convolutional network architecture, which is termed as the DANet, to detect idiopathic toe walking. The dense block is integrated into the network to maximize information transfer and avoid missed features. Further, the attention modules are incorporated into the network to highlight useful features while suppressing unwanted noises. Also, the Focal Loss function is enhanced to alleviate the imbalance sample issue. The proposed approach outperforms other methods and obtains a superior performance. It achieves a test recall of 88.91% for recognizing idiopathic toe walking on the local dataset collected from real-world experimental scenarios. To ensure the scalability and generalizability of the proposed approach, the algorithm is further validated through the publicly available datasets, and the proposed approach achieves an average precision, recall, and F1-Score of 89.34%, 91.50%, and 92.04%, respectively. Experimental results present a competitive performance and demonstrate the validity and feasibility of the proposed approach.

Development and Validation of an Outpatient Clinical Predictive Score for the Diagnosis of Duchenne Muscular Dystrophy/Becker Muscular Dystrophy in Children Aged 2-18 Years.

There is no bedside clinical examination-based prediction score for Duchenne muscular dystrophy/Becker muscular dystrophy (DMD/BMD) in children with neuromuscular diseases (NMDs) presenting with proximal limb-girdle weakness. We compared the details of 200 cases of lower motor neuron type of weakness and had some proximal limb-girdle muscle weakness and divided them into 2 groups: with/without a confirmed diagnosis of DMD/BMD. We determined the predictive factors associated with a diagnosis of DMD/BMD using multivariate binary logistic regression. We assessed our proposed prognostic model using both discrimination and calibration and subsequently used the bootstrap method to successfully validate the model internally. A total of 121 patients had DMD/BMD and the rest of the patients had other diagnoses. Male gender, presence of Gower's sign, valley sign, toe walking, calf pseudohypertrophy, and tongue hypertrophy were independent predictors for a confirmed diagnosis of DMD/BMD and included in the final CVT2MG score (Calf pseudohypertrophy, Valley sign, Toe walking, Tongue hypertrophy, Male gender, and Gower's sign). The final model showed good discrimination (AUC = 87.4% [95% CI: 80.5-92.3%, P < 0.001]) and calibration (P = 0.57). A score of 6 or above appeared to be the best cutoff for discriminating between the DMD/BMD group and the rest of the group with both sensitivity and specificity of 98%. The interrater reliability was almost perfect between two pediatric neurologists and strong between a pediatric neurologist and a pediatric neurology trainee resident (k = 0.91 and 0.87). The CVT2MG score has good sensitivity and specificity in predicting a confirmed diagnosis of DMD/BMD in subsequent tests.