Long-term gait outcomes following conservative management of idiopathic toe walking

Efficacy of serial casting protocols in idiopathic toe-walking

PURPOSE

Idiopathic toe-walking (ITW) is a diagnosis of exclusion. A relationship between ITW and decreased range of motion (ROM) is postulated. Treatments focus on increasing ankle dorsiflexion including serial casting. There is no consensus for duration of serial casting. This study aimed to determine ROM changes with cast change intervals of one vs. two weeks, and the rate of ITW recurrence.

METHODS

This was a retrospective study of 86 patients, ages 0-9 years with ITW undergoing weekly casting (N = 29) and two-week casting (N = 57) at a children's hospital from 2014-2020. ROM at baseline, two weeks, four weeks, and final cast removal were collected. Statistical analyses included chi-squared tests, two-sample t-tests, and linear mixed regression. Outcome distributions were assessed for normality. P-values <  0.05 were considered statistically significant.

RESULTS

After adjusting for baseline ROM, the mean change in ROM from baseline to two weeks was 10.6∘ vs 7.5∘ in the one-week vs. two-week casting interval, respectively (p <  0.001). The baseline to final measurement was 13.4∘ vs 9.8∘ in the one-week vs. two-week casting interval, respectively (p <  0.001). The rate of recurrence of ITW was similar between the two groups.

CONCLUSION

This study suggests greater improvement in ROM in the one-week vs. two-week casting interval group.

Health-related Quality of Life in Idiopathic Toe Walkers: A Multicenter Prospective Cross-sectional Study

OBJECTIVE

Despite idiopathic toe walking (ITW) being a significant source of stress and anxiety for children and parents alike, little is known about the effect on health-related quality of life (HRQoL). The primary research question for this study was "Is ITW associated with impaired HRQoL, and is the degree of equinus contracture related to the degree of impairment?"

METHODS

Twelve pediatric orthopaedic centers across the United Kingdom participated in this prospective, cross-sectional observational study of children younger than 18 years with ITW. Data were collected between May 2022 and July 2022. Using a standardized, piloted proforma, data collected included: demographics, toe-walking duration, passive ankle range of motion (Silfverskiold test), associated autism spectrum disorder or attention deficit hyperactivity disorder, previous and planned treatments, and Oxford Ankle Foot Questionnaire for Children scores. Domain scores were compared with a healthy control group and correlation was made to plantarflexion contracture using standard nonparametric statistical methods.

RESULTS

Data were collected from 157 children. Significant reductions in physical, school and play, and emotional domain scores were noted compared with healthy controls. A significant moderate correlation was noted between passive ankle dorsiflexion and physical domain scores. There were no significant differences in Oxford Ankle Foot Questionnaire for Children scores among patient groups by treatment.

CONCLUSIONS

ITW in children is associated with an impairment in HRQoL, not only across the physical domain but also the school and play and emotional domains. The more severe the equinus contracture, the worse the physical domain scores.

LEVEL OF EVIDENCE

Level II-prospective cross-sectional observational study.

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.

Idiopathic Toe Walking: An Update on Natural History, Diagnosis, and Treatment

Toe walking is a common presenting report to an orthopaedic practice. Evaluation of a child with toe walking includes a thorough history and physical examination to elucidate the diagnosis. When no other diagnosis is suspected, a diagnosis of idiopathic toe walking is often given. Despite the high prevalence of the condition, there is notable controversy of the nomenclature of the disease. Recent research has shed more light on both the natural history and the genetic basis. The use of motion analysis, including EMG and multisegment foot model, may help both differentiate children with mild forms of cerebral palsy and evaluate outcomes after treatment. Early treatment for young children with adequate range of motion (ROM) is generally reassurance because most young children with idiopathic toe walking are expected to resolve spontaneously. When the toe walking persists, treatment options include both surgical and nonsurgical management. Nonsurgical management centers on obtaining ROM through stretching and serial casting, followed by gait retraining and bracing treatment. Surgical lengthening at either the Achilles or gastrocnemius level improves the ROM of the ankle and then similarly requires therapy and bracing treatment to obtain a more normalized gait.

Patient-Reported Outcome Measurement Information System (PROMIS) Scores in Pediatric Idiopathic Toe Walkers

BACKGROUND

Idiopathic toe walking (ITW) can result in early contact with the health care system and be distressing for patients and their families. The natural history of ITW is poorly characterized. Deciding how and when to intervene can be difficult.Patient-reported outcomes are utilized in the clinical setting to assess patient factors and indications that may better inform treatment plans. Patient-Reported Outcomes Measurement Information System (PROMIS) is an instrument designed to collect patient-reported outcomes. Minimum clinically important differences in PROMIS metrics have been established to facilitate clinical relevance and utility of these metrics. The purpose of this study was to characterize the patient perspective of ITW by utilizing the PROMIS scores.

METHODS

Retrospective chart review was performed to identify children aged 5 to 17 with a diagnosis of ITW treated at a single tertiary care center between 2017 and 2020. Inclusion criteria were a diagnosis of ITW and completion of a PROMIS questionnaire. Exclusion criteria were neurologic disease, autism, and previous surgical treatment. Demographic, physical exam, treatment, and available motion analysis data were collected. PROMIS scores for the following domains were available: Mobility, Peer Relationships, and Pain Interference.

RESULTS

Forty-five children were enrolled. Seventy-three percent of PROMIS scores were patient reported while the remainder were parent reported. PROMIS score means for the cohort by domain were Mobility: 45.2±8.2 ( P <0.000); Peer Relationships: 46.4±11.6 ( P =0.047); and Pain Interference: 47.4±9.5 ( P =0.67). Motion analysis data, available for 11 children, noted age-matched gait velocity negatively correlated ( rs =-0.652, P =0.03) with Peer Relationships. No correlations were found between other aspects of gait, body mass index, or limitations in dorsiflexion and PROMIS domains. Parents reported lower Mobility scores than children did. There were no other significant differences between patient-reported and parent-reported PROMIS scores. PROMIS scores did not differ significantly between those <10 years and those ≥10 years.

CONCLUSION

In this cohort of 45 otherwise healthy children without other neurologic diagnoses, there are both clinically and statistically significant differences in PROMIS means between our cohort and the healthy age-matched population. These differences manifested in worse peer relationships and mobility scores.

LEVEL OF EVIDENCE

Level IV.

Idiopathic Toe-Walking: A Review from 1967 to 2021

Idiopathic toe-walking (ITW) is considered a diagnosis of exclusion for which no underlying neurological, neuromuscular, neurodevelopmental, or orthopedic condition can be identified. The purpose of this review was to examine multiple aspects of ITW: natural history, evaluation, treatment, musculoskeletal manifestations, and developmental issues through the review of studies from the initial description of condition in 1967 to the present. From a PubMed search and review of reference lists of individual articles, 64 articles were selected and reviewed. The studied samples were variably described and often not well-defined. Gait analysis found gait characteristics associated with ITW that varied from normal. Children with ITW can be differentiated from children with cerebral palsy on the basis of several gait pattern features, but findings from electromyographic comparisons were variable. Treatments included orthoses, casting, botulinum toxin type A, and surgery. The evidence to support any specific treatment is limited by the small sample size and short duration of follow-up in the majority of studies. The inadequacy of the current literature suggests the need for a longitudinal multi-center study to more clearly define the population of children with ITW and to determine indications, timing, and effectiveness of the various available treatments.

Kinematic and Kinetic Gait Parameters Can Distinguish between Idiopathic and Neurologic Toe-Walking

The differentiation between mild forms of toe-walking (equinus) in cerebral palsy (CP) and idiopathic toe-walking (ITW) is often clinically challenging. This study aims to define kinematic and kinetic parameters using 3D gait analysis to facilitate and secure the diagnosis of “idiopathic toe-walking”. We conducted a retrospective controlled stratified cohort study. 12 toe-walking subjects per group diagnosed as ITW or CP were included and stratified according to age, gender and maximal dorsiflexion in stance. We collected kinematic and kinetic data using a three-dimensional optical motion analysis system with integrated floor force plates. Pairwise comparison between ITW and CP gait data was performed, and discriminant factor analysis was conducted. Both groups were compared with typically developing peers (TD). We found kinematic and kinetic parameters having a high discriminatory power and sensitivity to distinguish between ITW and CP groups (e.g., knee angle at initial contact (91% sensitivity, 73% specificity) and foot progression angle at midstance (82% sensitivity, 73% specificity)). The strength of this study is a high discriminatory power between ITW and CP toe-walking groups. Described kinematic parameters are easy to examine even without high-tech equipment; therefore, it is directly transferable to everyday praxis.

Adherence to serial casting protocols for idiopathic toe walking: A quality improvement initiative

PURPOSE

This initiative aimed to assess adherence to Scottish Rite for Children's serial casting protocol for children with idiopathic toe walking (ITW), factors related to adherence, and outcomes after education regarding the protocol.

METHODS

60 patients aged 7.1±2.7 years who completed serial casting were examined at baseline phase (n = 30) and post-education phase (n = 30). Protocols include weekly serial casting for 4 to 6 weeks to achieve 10° of ankle dorsiflexion (ADF) passive range of motion (PROM) with knees extended (KE), assessing the foot posture index (FPI-6) and single leg stance (SLS). Baseline phase evaluated adherence to protocols. Education phase evaluated factors related to adherence and education regarding serial casting findings. Post-education phase evaluated the impact of the education phase.

RESULTS

Serial casting averaged 4.8±1.5 weeks (n = 60). ADF PROM was measured with 100% adherence. ADF PROM KE averaged -10.7° pre-cast and significantly improved to +6.5° post-cast (n = 60), and it significantly improved post-cast post-education (p = 0.04). FPI-6 and SLS adherence significantly improved post-cast post-education. FPI-6 total score averaged +5.3 at baseline and +5.8 post-cast (n = 35).

CONCLUSION

Education of staff in serial casting protocols improved adherence and patient outcomes. Patients with ITW and ADF PROM KE -10° benefit from serial casting to improve PROM and to allow for orthotic use post-casting.

Parent Perspectives Regarding Care Delivery for Children With Idiopathic Toe Walking to Inform an American Physical Therapy Association Clinical Practice Guideline

PURPOSE

This study summarizes experiences and perceptions of parents whose children received physical therapy for idiopathic toe walking (ITW) to inform clinical practice guideline development and identify perceived strengths and gaps in care.

METHODS

A US-based survey was distributed to parents of children with ITW. Data from 98 respondents were compiled through descriptive statistics of item responses and review of comments.

RESULTS

Parents reported variability in timing of diagnosis and intervention, ITW care, and extent they felt educated and involved in decision making. Rates of confidence, satisfaction, and effectiveness of physical therapy care varied.

CONCLUSIONS

A parent-informed clinical practice guideline for physical therapy management of ITW and family-friendly supplemental knowledge translation tools could reduce care variability, optimize shared decision making, and increase satisfaction of outcomes.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Clinicians should be knowledgeable about ITW diagnosis, prognosis, and treatment options, educating families and engaging them in shared decision making around ITW care.

The Effectiveness of Serial Casting and Ankle Foot Orthoses in Treating Toe Walking in Children With Autism Spectrum Disorder

PURPOSE

This proof of concept study examined the effectiveness of serial casting (SC) and ankle foot orthoses (AFOs) in children with autism spectrum disorder (Ch-ASD) who toe walk (TW). Data collected determined effects of SC, followed by AFO intervention on ankle dorsiflexion (A-DF) passive range of motion and kinematics, and parent-reported functional outcomes for children with autism spectrum disorder who TW and have limited A-DF passive range of motion.

SUMMARY OF KEY POINTS

The 5 participants increased passive range of motion with SC, except for 1 participant's left ankle. Two of 4 participants had near typical A-DF kinematic patterns following SC. The 5 participants improved A-DF during walking following 6 months of AFO use.

CONCLUSIONS

Serial casting increased A-DF ROM and kinematics during walking. Consistent AFO use for walking training improved function and reduced toe walking. Serial casting followed by AFOs is a potential intervention for children with autism spectrum disorder who TW.

Surgical Outcomes for Severe Idiopathic Toe Walkers

BACKGROUND

Idiopathic toe walking (ITW) is a diagnosis of exclusion and represents a spectrum of severity. Treatment for ITW includes observation and a variety of conservative treatment methods, with surgical intervention often reserved for severe cases. Previous studies reviewing treatment outcomes are often difficult to interpret secondary to a mixture of case severity. The goal of this study was to review surgical outcomes in patients with severe ITW who had failed prior conservative treatment, as well as determine differences in outcomes based on the type of surgery performed.

METHODS

After IRB approval, all patients with surgical management of severe ITW at a single institution were identified. Zone II or zone III plantar flexor lengthenings were performed in all subjects. Clinical, radiographic, and motion analysis data were collected preoperatively and at 1 year following surgery.

RESULTS

Twenty-six patients (46 extremities) with a diagnosis of severe ITW from 2002 to 2017 were included. Zone II lengthenings were performed in 25 extremities (mean age=9.9 y) and zone III lengthenings were performed in 21 extremities (mean age=8.6 y). At the most recent follow-up, 100% of zone III lengthening extremities and 88% of zone II lengthening demonstrated decreased severity of ITW. Six extremities required additional treatment, all of which were initially managed with zone II lengthenings.

CONCLUSIONS

Severe ITW or ITW that has not responded to conservative treatment may benefit from surgical intervention. More successful outcomes, including continued resolution of toe walking, were observed in subjects treated with zone III lengthenings.

LEVEL OF EVIDENCE

Level III-case series.

A Retrospective Analysis of Nonoperative Treatment Techniques for Idiopathic Toe Walking in Children: Outcomes and Predictors of Success

BACKGROUND

The lack of consensus regarding optimal nonoperative management of idiopathic toe walking (ITW) results in wide variation in treatment across providers and institutions. Untreated toe walking can cause persistence of abnormal gait and symptomatic foot deformity in adulthood.

OBJECTIVE

To examine the outcomes of multiple commonly used nonoperative treatment techniques in a large cohort of children with ITW to better inform management of this condition.

DESIGN

Retrospective cohort study.

SETTING

Single tertiary care children's hospital from 2008 to 2015.

PATIENTS

Two hundred four children with ITW, aged 4 to 7 years at time of diagnosis, nonoperatively managed in orthopedic surgery, rehabilitation medicine, neurodevelopmental medicine, neurology, or physical therapy clinics.

INTERVENTIONS

Nonoperative techniques included observation, home stretching program, physical therapy program, use of ankle-foot orthoses (AFOs), and serial casting.

MAIN OUTCOME MEASURES

Greater than or equal to 10° of ankle dorsiflexion with the knee extended or walking on toes less than 25% of the time at last visit. Failure of treatment was defined as not achieving resolution criteria or requiring surgical intervention following failed nonoperative management.

RESULTS

Only 121 children (59.3%) attended at least one follow-up visit. Of those, 55 (45.5%) had a successful outcome. Increasing severity of ITW was associated with increased rate of follow-up (P = .03) and lower rates of successful treatment (P = .03). The use of AFOs was the only treatment modality associated with a successful outcome (unadjusted/adjusted odds ratio 3.97; [95% confidence interval, 1.80-8.74] and 4.81 [95% confidence interval, 1.91-12.1], respectively; P = .001).

CONCLUSIONS

Loss to follow-up is common in children with ITW. Of those children who returned to clinic, less than half had a successful outcome. The only treatment technique statistically associated with short-term resolution of toe walking was the use of AFOs.

American and Australian family experiences while receiving a diagnosis or having treatment for idiopathic toe walking: a qualitative study

OBJECTIVE

To understand parent journeys while navigating diagnosis, assessment or treatment of their children with idiopathic toe walking (ITW).

DESIGN

Mixed methods qualitative study: analyses of survey data from the measure of processes of care-20 (MPOC-20) and semistructured interviews were analysed with an interpretative phenomenological analysis approach. Trustworthiness of data was achieved through member checking, researcher triangulation, reflexivity and transferability and comparison with the MPOC-20 results.

SETTING

USA and Australia.

PARTICIPANTS

Parents of children diagnosed with ITW who had seen more than one health professional during their care and lived in Australia or the USA.

RESULTS

Ten parents of children aged between 3 and 13 years and diagnosed with ITW participated. Parents described complex themes relating to their journeys. The themes relating to their journeys were: (1) riding the rollercoaster of diagnosis; (2) navigating the treatment options and (3) supporting parents in the journey. Each theme was supported by parent quotes about their experiences. Challenges were not localised to one country, in spite of vastly different healthcare systems.

CONCLUSIONS

These findings create opportunities for an international approach to education, treatment recommendations and outcome measures to improve patient and parent experiences. Health professionals should consider the impact on parents in navigating between health professionals when provided with a diagnosis which can have variable outcomes and varied treatment options.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

The Botulinum Treatment of Neurogenic Detrusor Overactivity: The Double-Face of the Neurotoxin

Botulinum neurotoxin (BoNT) can counteract the highly frequent involuntary muscle contractions and the uncontrolled micturition events that characterize the neurogenic detrusor overactivity (NDO) due to supra-sacral spinal cord lesions. The ability of the toxin to block the neurotransmitter vesicular release causes the reduction of contractions and improves the compliance of the muscle and the bladder filling. BoNT is the second-choice treatment for NDO once the anti-muscarinic drugs have lost their effects. However, the toxin shows a time-dependent efficacy reduction up to a complete loss of activity. The cellular mechanisms responsible for BoNT effects exhaustion are not yet completely defined. Similarly, also the sites of its action are still under identification. A growing amount of data suggest that BoNT, beyond the effects on the efferent terminals, would act on the sensory system recently described in the bladder mucosa. The specimens from NDO patients no longer responding to BoNT treatment displayed a significant increase of the afferent terminals, likely excitatory, and signs of a chronic neurogenic inflammation in the mucosa. In summary, beyond the undoubted benefits in ameliorating the NDO symptomatology, BoNT treatment might bring to alterations in the bladder sensory system able to shorten its own effectiveness.

Autism and toe-walking: are they related? Trends and treatment patterns between 2005 and 2016

PURPOSE

This study quantified toe-walking trends and treatment decisions in patients with autism spectrum disorder (ASD) in the United States between 2005 and 2016 using a large national private-payer database.

METHODS

A retrospective database review was performed on paediatric patients with ASD, and for International Classification of Diseases-9/10 diagnosis codes for toe-walking. Patients were filtered based on treatment type by Current Procedural Terminology (CPT) code. Continued toe-walking rates were assessed for each patient population and treatment group. A Pearson's chi-squared test was used to evaluate differences in group characteristics.

RESULTS

Of 2 221 009 paediatric patients in the database, 5739 patients had a diagnosis of ASD, and 8.4% of patients with ASD also had a diagnosis of toe-walking (n = 484). For typically developing children in the database, 0.47% of patients had a diagnosis of persistent toe-walking. In all, 59.3% of ASD patients underwent physical therapy, 7.4% serial casting and 3.3% surgical correction, compared with 38.1%, 3.6% and 1.2% of normally developing children, respectively (chi-square 6.4031; p < 0.040699). Without intervention, 63.6% of patients with ASD continued to toe-walk within ten years of their diagnosis, with 19.3% of patients without ASD (chi-square 82.9762; p < 0.0001).

CONCLUSION

This study supports the association between a greater prevalence of toe-walking in children with ASD. We showed that patients with ASD and toe-walking receive surgical correction at nearly triple the rate of children without ASD who toe-walk. The continued rate of toe-walking is comparable between treatment groups as well as between ASD and typically developing children. Typically developing children have higher rates of toe-walking resolution without intervention than children with ASD.

LEVEL OF EVIDENCE

Level II.