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Flaugh RA, May CJ, Curran P, Miller PE, Kasser JR, Shore BJ. MRI of the Spine in Patients who Toe Walk: Is There a Role? J Pediatr Orthop 2024; 44:267-272. [PMID: 38299252 DOI: 10.1097/bpo.0000000000002633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND Little is known about the prevalence of intraspinal pathology in children who toe walk, but magnetic resonance imaging (MRI) may be part of the diagnostic workup. The purpose of this study was to examine the role of MRI for children who toe walk with a focus on the rate of positive findings and associated neurosurgical interventions performed for children with said MRI findings. METHODS A single-center tertiary hospital database was queried to identify a cohort of 118 subjects with a diagnosis of toe walking who underwent spinal MRI during a 5-year period. Patient and MRI characteristics were summarized and compared between subjects with a major abnormality, minor abnormality, or no abnormality on MRI using multivariable logistic regression. Major MRI abnormalities included those with a clear spinal etiology, such as fatty filum, tethered cord, syrinx, and Chiari malformation, while minor abnormalities had unclear associations with toe walking. RESULTS The most common primary indications for MRI were failure to improve with conservative treatment, severe contracture, and abnormal reflexes. The prevalence of major MRI abnormalities was 25% (30/118), minor MRI abnormalities was 19% (22/118), and normal MRI was 56% (66/118). Patients with delayed onset of toe walking were significantly more likely to have a major abnormality on MRI ( P =0.009). The presence of abnormal reflexes, severe contracture, back pain, bladder incontinence, and failure to improve with conservative treatment were not significantly associated with an increased likelihood of major abnormality on MRI. Twenty-nine (25%) subjects underwent tendon lengthening, and 5 (4%) underwent neurosurgical intervention, the most frequent of which was detethering and sectioning of fatty filum. CONCLUSIONS Spinal MRI in patients who toe walk has a high rate of major positive findings, some of which require neurosurgical intervention. The most significant predictor of intraspinal pathology was the late onset of toe walking after the child had initiated walking. MRI of the spine should be considered by pediatric orthopedic surgeons in patients with toe walking who present late with an abnormal clinical course. LEVEL OF EVIDENCE Level III Retrospective Comparative Study.
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Affiliation(s)
| | - Collin J May
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Patrick Curran
- Department of Orthopedic Surgery, Rady Children's Hospital, University of California, San Diego, CA
| | | | - James R Kasser
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Benjamin J Shore
- Department of Orthopaedics, Boston Children's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Kononova S, Kashparov M, Xue W, Bobkova N, Leonov S, Zagorodny N. Gut Microbiome Dysbiosis as a Potential Risk Factor for Idiopathic Toe-Walking in Children: A Review. Int J Mol Sci 2023; 24:13204. [PMID: 37686011 PMCID: PMC10488280 DOI: 10.3390/ijms241713204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
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.
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Affiliation(s)
- Svetlana Kononova
- Institute of Protein Research, Russian Academy of Sciences, 142290 Pushchino, Russia
| | - Mikhail Kashparov
- Department of Traumatology and Orthopedics, Peoples’ Friendship University of Russia, 117198 Moscow, Russia; (M.K.); (N.Z.)
- Scientific and Practical Center for Child Psychoneurology, 119602 Moscow, Russia
| | - Wenyu Xue
- School of Biological and Medical Physics, Moscow Institute of Physics and Technology, 141700 Dolgoprudny, Russia; (W.X.); (S.L.)
| | - Natalia Bobkova
- Institute of Cell Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia;
| | - Sergey Leonov
- School of Biological and Medical Physics, Moscow Institute of Physics and Technology, 141700 Dolgoprudny, Russia; (W.X.); (S.L.)
- Institute of Cell Biophysics, Russian Academy of Sciences, 142290 Pushchino, Russia;
| | - Nikolaj Zagorodny
- Department of Traumatology and Orthopedics, Peoples’ Friendship University of Russia, 117198 Moscow, Russia; (M.K.); (N.Z.)
- N.N. Priorov Central Research Institute of Traumatology and Orthopedics, 127299 Moscow, Russia
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Hines D, Armstrong-Heimsoth A, Schoen SA. A Pilot Study of Idiopathic Toe Walking: Measures and Outcomes. Occup Ther Health Care 2023:1-27. [PMID: 37598376 DOI: 10.1080/07380577.2023.2246552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/06/2023] [Indexed: 08/22/2023]
Abstract
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.
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Affiliation(s)
- Debra Hines
- Northern Arizona University, Phoenix, Arizona, USA
| | | | - Sarah A Schoen
- Rocky Mountain University of Health Professions, Provo, Utah, USA
- STAR Institute, Centennial, Colorado, USA
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Pomarino D, Emelina A, Heidrich J, Rostásy K, Schirmer S, Schönfeldt JO, Thren A, Wagner F, Thren JR, Berger N. 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. Glob Med Genet 2023; 10:63-71. [PMID: 37091313 PMCID: PMC10121371 DOI: 10.1055/s-0043-57230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Jens Heidrich
- Labor Dr. Heidrich und Kollegen MVZ GmbH, Hamburg, Germany
| | | | | | | | - Anneke Thren
- Kinderorthopädie am Pferdeturm, Hanover, Germany
| | - Ferdinand Wagner
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich, University Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Johanna Ronja Thren
- Anthropology Department, Durham University, Durham, United Kingdom
- Address for correspondence Johanna Ronja Thren, BA, MSc Department of Anthropology, Durham UniversityDurham DH15BXUnited Kingdom
| | - Nina Berger
- Institut für Kinderneurologie, Hamburg, Germany
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Brasiliano P, Mascia G, Di Feo P, Di Stanislao E, Alvini M, Vannozzi G, Camomilla V. Impact of Gait Events Identification through Wearable Inertial Sensors on Clinical Gait Analysis of Children with Idiopathic Toe Walking. Micromachines (Basel) 2023; 14:277. [PMID: 36837977 PMCID: PMC9962364 DOI: 10.3390/mi14020277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 06/18/2023]
Abstract
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.
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Affiliation(s)
- Paolo Brasiliano
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro De Bosis 6, 00135 Rome, Italy
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, 00135 Rome, Italy
| | - Guido Mascia
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro De Bosis 6, 00135 Rome, Italy
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, 00135 Rome, Italy
| | - Paolo Di Feo
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro De Bosis 6, 00135 Rome, Italy
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, 00135 Rome, Italy
| | - Eugenio Di Stanislao
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, 00135 Rome, Italy
- “ITOP SpA Officine Ortopediche”, Via Prenestina Nuova 307/A, 00036 Palestrina, Italy
| | - Martina Alvini
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, 00135 Rome, Italy
- “ITOP SpA Officine Ortopediche”, Via Prenestina Nuova 307/A, 00036 Palestrina, Italy
| | - Giuseppe Vannozzi
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro De Bosis 6, 00135 Rome, Italy
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, 00135 Rome, Italy
| | - Valentina Camomilla
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro De Bosis 6, 00135 Rome, Italy
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, 00135 Rome, Italy
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Bauer JP, Sienko S, Davids JR. Idiopathic Toe Walking: An Update on Natural History, Diagnosis, and Treatment. J Am Acad Orthop Surg 2022; 30:e1419-30. [PMID: 36084329 DOI: 10.5435/JAAOS-D-22-00419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/30/2022] [Indexed: 02/01/2023] Open
Abstract
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.
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Filippetti M, Picelli A, Di Censo R, Vantin S, Randazzo PN, Sandrini G, Tassorelli C, De Icco R, Smania N, Tamburin S. IncobotulinumtoxinA Injection for Treating Children with Idiopathic Toe Walking: A Retrospective Efficacy and Safety Study. Toxins (Basel) 2022; 14:toxins14110792. [PMID: 36422966 PMCID: PMC9694855 DOI: 10.3390/toxins14110792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/25/2022] [Accepted: 11/11/2022] [Indexed: 11/16/2022] Open
Abstract
There is no gold-standard treatment for idiopathic toe walking (ITW). Some previous evidence suggested that botulinum neurotoxin-A injection might improve ITW. This is a single-center retrospective study on children with ITW treated with incobotulinumtoxinA injection in the gastrocnemius medialis/lateralis muscles. We screened the charts of 97 ITW children treated with incobotulinumtoxinA (January 2019-December 2021), and the data of 28 of them, who satisfied the inclusion/exclusion criteria, were analyzed. The maximal passive ankle dorsiflexion (knee extended) was assessed at three time points, i.e., immediately before incobotulinumtoxinA injection (T0), after incobotulinumtoxinA injection during the timeframe of its effect (T1), and at follow-up, when the effect was expected to disappear (T2). The maximal passive ankle dorsiflexion was improved by incobotulinumtoxinA injection, and the effect lasted up to 6 months in some children. No adverse effects were reported to incobotulinumtoxinA injections. The treatment with incobotulinumtoxinA might improve the maximal passive ankle dorsiflexion and is safe and well-tolerated in ITW with a longer-than-expected effect in comparison to cerebral palsy. These results may offer ground to future randomized controlled trials and studies assessing the effect of BoNT-A in combination with other non-invasive approaches and exercise programs in children with ITW.
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Affiliation(s)
- Mirko Filippetti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
| | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress (CANOSC), Kingston, ON K7K 1Z6, Canada
- Correspondence: (A.P.); (S.T.)
| | - Rita Di Censo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
| | - Sabrina Vantin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
| | - Pietro Nicola Randazzo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
| | - Giorgio Sandrini
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Roberto De Icco
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
- Headache Science & Neurorehabilitation Center, IRCCS Mondino Foundation, 27100 Pavia, Italy
| | - Nicola Smania
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
| | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37100 Verona, Italy
- Correspondence: (A.P.); (S.T.)
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Brasiliano P, Alvini M, Di Stanislao E, Vannozzi G, Di Rosa G, Camomilla V. Effects of wearing a foot orthosis on ankle function in children with idiopathic toe walking during gait. Heliyon 2022; 8:e11021. [PMID: 36281373 PMCID: PMC9587270 DOI: 10.1016/j.heliyon.2022.e11021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022] Open
Abstract
Background Idiopathic toe walking (ITW) is a gait deviation characterized by forefoot contact with the ground, possibly enhancing the risk of falling and causing Achilles' tendon shortening and psychological discomfort. Between possible treatments, foot orthosis may limit ITW when worn. With these premises, the effects of a novel foot orthosis (A.Dyn.O.®) on ankle function were analyzed in children with ITW during gait. Methods Twenty-one children were recruited in the study after ITW diagnosis. At follow-up assessment after a habituation period of at least two weeks, participants walked in barefoot condition and while wearing A.Dyn.O.®. Kinetics and kinematics were derived from a multi-segment foot model using an optoelectronic system. Gait spatiotemporal parameters, ankle kinetic and kinematic and rockers timing were analyzed. Lastly, ITW severity was classified according to Alvarez classification. Differences between conditions were verified with paired t-test. Statistical parametric mapping was used to evaluate differences in the entire kinematic and kinetic waveforms. Findings Wearing A.Dyn.O.®, step cadence was reduced, step length, stance phase and stride duration increased; physiological heel rocker was present, thus postponing the timing of ankle and forefoot rockers; ankle dorsiflexion angular excursion, range of motion, maximal dorsiflexor and plantarflexor moments together with maximal power absorption and production were all amplified. Interpretation While wearing it, A.Dyn.O.® limited gait deviations typical of ITW and improved ITW severity classification for most of the participants. These findings suggest that the use of A.Dyn.O.® may assist ITW treatment, preventing children from toe walking and thus limiting its side effects.
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Affiliation(s)
- Paolo Brasiliano
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, Rome, Italy,Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro De Bosis 6, 00135 Rome, Italy
| | - Martina Alvini
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, Rome, Italy,“ITOP SpA Officine Ortopediche”, Via Prenestina Nuova 307/A, Area Industriale, 00036 Palestrina (RM), Italy
| | - Eugenio Di Stanislao
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, Rome, Italy,“ITOP SpA Officine Ortopediche”, Via Prenestina Nuova 307/A, Area Industriale, 00036 Palestrina (RM), Italy
| | - Giuseppe Vannozzi
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, Rome, Italy,Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro De Bosis 6, 00135 Rome, Italy
| | - Giuseppe Di Rosa
- Division of Pediatric Neurorehabilitation, “Ospedale Pediatrico Bambino Gesù”, Rome, Italy
| | - Valentina Camomilla
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, University of Rome “Foro Italico”, Rome, Italy,Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro De Bosis 6, 00135 Rome, Italy,Corresponding author.
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Donne J, Farrell MJ, Kolic J, Powell J, Fahey M, Williams C. Two-point discrimination responses in children with idiopathic toe walking: A feasibility fMRI study. Sci Prog 2022; 105:368504221132141. [PMID: 36373762 PMCID: PMC10306138 DOI: 10.1177/00368504221132141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
Idiopathic toe walking (ITW) is a diagnosis given to children who walk with an absence or limitation of heel strike in the contact phase of the gait cycle, that are otherwise typically developing. There is emerging evidence that this gait pattern may occur in children who experience tactile sensory processing challenges. This feasibility study aimed to determine if children were able to respond to a sensory stimulus during a fMRI. Children aged between 8-16 years of age, with and without idiopathic toe walking were recruited from general public advertising. Participants were required to perform a two-point discrimination test (task block) and press a button without being tested (control block) during an fMRI using a standard block design. Activation differences were examined in the left frontal pole, left supramarginal gyrus, left parahippocampal gyrus, left paracingulate gyrus and the right superior temporal. Five children were in the typically developing (TD) group and three were in the ITW group. There were between-group activation differences in the decision-making block compared to the control block in the left frontal lobe, parahippocampal gyrus and the right superior temporal gyrus. There was greater variation in activation in the left supramarginal gyrus and the left paracingulate gyrus in the ITW group compared to the typically developing group. Based on this study a future sample size of 15 children per group will be required to detect an adequate effect across chosen regions of interest Conducting fMRI using two-point discrimination testing on this population is feasible. Further research is required with larger population sizes to determine if brain activation patterns during the sensory input decision-making process are different in this population.
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Affiliation(s)
- Jack Donne
- School of Primary and Allied Health, Monash University, Frankston, VIC, Australia
| | - Michael J Farrell
- Department of Medical Imaging and
Radiation Sciences, Monash Biomedical Imaging, Clayton, VIC, Australia
| | - Jessica Kolic
- Allied Health, Peninsula Health, Frankston, VIC, Australia
| | - Jennifer Powell
- School of Medicine, The University of
Queensland, Queensland Children's Hospital, Saint Lucia, Australia
| | - Michael Fahey
- Department of Neurology, Monash
Children's Hospital, Clayton, VIC, Australia
| | - Cylie Williams
- School of Primary and Allied Health, Monash University, Frankston, VIC, Australia
- Allied Health, Peninsula Health, Frankston, VIC, Australia
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Caserta A, Reedman S, Morgan P, Williams CM. Physical activity and quality of life in children with idiopathic toe walking: a cross sectional study. BMC Pediatr 2022; 22:544. [PMID: 36100938 PMCID: PMC9472422 DOI: 10.1186/s12887-022-03583-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 08/23/2022] [Indexed: 11/18/2022] Open
Abstract
Objectives To determine if children with idiopathic toe walking (ITW) reach Australian 24-hour movement guidelines. Additional objectives were to identify any factors associated with moderate to vigorous physical activity time of children with ITW. Design Cross sectional. Setting Private practice, public health outpatient, community clinics. Participants Children between 4 and 14 years, who toe walked and had no medical conditions known to cause ITW. Outcome measures Physical activity intensity, sedentary behaviour and sleep data were collected via an ActiGraph. Physical activity level intensity data were triangulated with the Child Leisure Activities Study Survey (CLASS) to highlight the subjective nature of parent-reported measures. Health related quality of life information was collected using the Parent-Proxy and Child-Self Report Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scale. Regression analyses were used to explore individual factors associated with moderate to vigorous physical activity. Results Twenty-seven participants, 17(63%) male, age mean = 6.62 (SD = 2.29) years, provided information on physical activity (CLASS n = 18, ActiGraph n = 22), physical functioning and psychosocial functioning domains on the PedsQL (Parent-Proxy n = 25, Child n = 22). All participants exceeded Australian recommendations for physical activity, 44% (8/18) met recommended screen time amounts, and two (9%) met recommended sleep times. The Child-Self Report PedsQL scale score of social functioning was the only factor associated with an increase in physical activity (Coef = 0.48, 95%CI = 0.09 to 0.87, p = 0.019). Conclusion Participants achieved high levels of daily moderate to vigorous physical activity, and this was associated with social functioning. Given current uncertainty regarding benefits and effectiveness of treatment choices for children who have ITW, these findings should encourage clinicians to consider how their treatment recommendations interact with the PA level and sleep of children with ITW. Any treatment choice should also be implemented with consideration of how it may impact social functioning. This study had a small sample size therefore results should be cautiously interpreted and not generalised to all children with ITW. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03583-w.
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Affiliation(s)
- Antoni Caserta
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, 47 - 49 Moorooduc Hwy, Frankston, VIC, 3199, Australia. .,Monash Health Community, 140-155 Sladen Street, Cranbourne, VIC, 3977, Australia.
| | - Sarah Reedman
- Queensland Cerebral Palsy and Rehabilitation Research Centre, Child Health Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Prue Morgan
- Department of Physiotherapy, School of Primary and Allied Health Care, Monash University, 47 - 49 Moorooduc Hwy, Frankston, VIC, 3199, Australia
| | - Cylie M Williams
- School of Primary and Allied Health Care, Monash University, 47 - 49 Moorooduc Hwy, Frankston, VIC, 3199, Australia
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Caserta A, Morgan P, McKay MJ, Baldwin JN, Burns J, Williams C. Children with idiopathic toe walking display differences in lower limb joint ranges and strength compared to peers: a case control study. J Foot Ankle Res 2022; 15:70. [PMID: 36089598 PMCID: PMC9465941 DOI: 10.1186/s13047-022-00576-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022] Open
Abstract
Background Idiopathic toe walking (ITW) is an exclusionary diagnosis. There has been limited exploration of lower limb active range of motion and strength measures in children with ITW. This researched aimed to determine any differences in lower limb muscle active range of motion and strength in children who have ITW, compared to normative data collected from children who displayed typical gait. Methods Children were recruited with had a diagnosis of ITW, aged between 4 and 10 years, and no recent treatment. Data collected included parent reported data such as time spent toe walking, percentage of time spent toe walking, and clinician collected data such as age, height and weight. Joint ranges of motion and strength measures were collected by an experience clinician. Active and weight bearing joint ranges of motion were evaluated with a goniometer or digital inclinometer. Lower limb muscle strength measures were evaluated with a hand-held dynamometer. Published normative data sets were used for comparison. Measures were analysed with regression analyses to determine differences between groups in different measures, considering measures known to impact range and strength. Odds ratios (OR), 95% confidence intervals (CI) and p values were reported. Results Twenty-six children with ITW participated. Reduced weight bearing ankle range of motion, when measured with the knee bent, was associated with being in the ITW group (p = 0.009), being older (p < 0.001) and weighing less (p < 0.001). Reduced ankle plantar flexion range was only associated with being in the ITW group (p = 0.015). For all lower limb strength measures, excluding hip external rotation, children who displayed greater strength, did not toe walk (p < 0.002), were older (p < 0.001) and weighed more (p < 0.014). with ITW. Conclusion Children with ITW displayed reduced overall plantar and dorsiflexion at the ankle, compared to non-toe walking children. Reduced plantarflexion is children with ITW has not been described before, however reduced dorsiflexion is commonly reported. Children with ITW were weaker in many lower limb measures, even when age and weight were considered. This should lead clinicians and researchers to pay greater attention to lower limb strength measures in this population.
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Lindsay SE, Bauer J, Bouton D, Do P, Woodmark C, Sienko S, Raney EM. Patient-Reported Outcome Measurement Information System (PROMIS) Scores in Pediatric Idiopathic Toe Walkers. J Pediatr Orthop 2022; 42:e878-81. [PMID: 35797178 DOI: 10.1097/BPO.0000000000002198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Valagussa G, Piscitelli D, Baruffini S, Panzeri V, Perin C, Mazzucchelli M, Cornaggia CM, Pellicciari L, Grossi E. Little Evidence for Conservative Toe Walking Interventions in Autism Spectrum Disorders: a Systematic Review. Rev J Autism Dev Disord 2022. [DOI: 10.1007/s40489-022-00329-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AbstractThis systematic review summarizes the evidence about toe walking (TW) interventions in persons with autism. Following the PRISMA guidelines, a systematic search of MEDLINE, CINAHL, PsycINFO, The Cochrane Library, Google Scholar, and Opengrey was performed. Nine articles (all case reports or case series) were included. Methodological quality was assessed using the Mayo Evidence-Based Practice Centre tool. The included studies considered 17 subjects (16 males; age range: 4–15 years). All studies reported a reduction of TW frequency, but the follow-up was lacking in seven studies. There is a lack of high-quality studies with a sufficiently large and well-characterized sample to assess the effectiveness of TW interventions in autistic persons. These findings strongly support the need for further research in this area.
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Harkness-Armstrong C, Maganaris C, Walton R, Wright DM, Bass A, Baltzoloulos V, O'Brien TD. Children who idiopathically toe-walk have greater plantarflexor effective mechanical advantage compared to typically developing children. Eur J Appl Physiol 2022. [PMID: 35296910 DOI: 10.1007/s00421-022-04913-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The effective mechanical advantage (EMA) of the plantarflexor muscles is important for gait function and is likely different from typical in equinus gait. However, this has never been quantified for children who idiopathically toe-walk (ITW), despite being routinely altered through clinical intervention. METHODS This study quantified the Achilles tendon and ground reaction force (GRF) moment arms, and the plantarflexor EMA of 5 children who ITW and 14 typically developing (TD) children, whilst walking on an instrumented treadmill. RESULTS There was no difference in the Achilles tendon moment arm length throughout stance between groups (p > 0.05). Children who ITW had a significantly greater GRF moment arm length in early stance (20-24% p = 0.001), but a significantly shorter GRF moment arm length during propulsion (68-74% of stance; p = 0.013) than TD children. Therefore, children who ITW had a greater plantarflexor EMA than TD children when active plantarflexion moments were being generated (60-70% of stance; p = 0.007). Consequently, it was estimated that children who ITW required 30% less plantarflexor muscle force for propulsion. CONCLUSION Clinical decision making should fully consider that interventions which aim to restore a typical heel-toe gait pattern risk compromising this advantageous leverage and thus, may increase the strength requirements for gait.
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15
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Sala DA. Idiopathic Toe-Walking: A Review from 1967 to 2021. Journal of Pediatric Neurology 2022. [DOI: 10.1055/s-0042-1742583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractIdiopathic 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.
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Affiliation(s)
- Debra A. Sala
- Pediatric Physical Therapist, Private Practice, New York, New York
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De Oliveira V, Arrebola L, De Oliveira P, Yi L. Investigation of Muscle Strength, Motor Coordination and Balance in Children with Idiopathic Toe Walking: A Case-control Study. Dev Neurorehabil 2021; 24:540-546. [PMID: 33759692 DOI: 10.1080/17518423.2021.1899326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: To compare muscle strength, ankle dorsiflexion range of motion (ROM), motor coordination and balance, between children with and without Idiopathic Toe Walking (ITW).Materials and methods: This is an observational case-control study. The primary outcome is the triceps surae muscle strength. The secondary outcomes are the anterior tibialis muscle strength, lower limb balance, motor coordination, and ankle dorsiflexion ROM. Thirty-eight children were recruited: 19 between 5 to 11 years old with ITW and 19 healthy (control). Ankle dorsiflexion ROM, triceps surae, anterior tibialis muscle strength, motor coordination, and balance were assessed.Results: Children with ITW showed reduced triceps surae strength [mean difference (MD): 16.2 kgf/kg*100; 95% confidence interval (CI) -32.72 to 0.28; p = .05], reduced anterior tibialis strength (MD: 8.5 kgf/kg*100; 95% CI -13.35 to -3.05; p ≤ 0.001), reduced ankle dorsiflexion ROM (MD: 19.6 degrees; 95% CI 15.43 to 23.77; p ≤ 0.001) and impaired motor coordination and balance (MD: 17.7; 95% CI -25.54 to -9.82; p ≤ 0.001) compared to healthy children.Conclusion: Children with Idiopathic Toe Walking, presented in this study, demonstrated triceps surae and anterior tibialis muscle strength reduction, ankle dorsiflexion ROM reduction, impaired motor coordination, and balance compared to healthy children.
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Affiliation(s)
- Vanessa De Oliveira
- Department of Human Movement Sciences, Federal University of São Paulo (UNIFESP), Santos, Brazil.,Physical Therapy Department Institute of Medical Assistance to the State Public Servant (IAMSPE), São Paulo, Brazil
| | - Lucas Arrebola
- Department of Human Movement Sciences, Federal University of São Paulo (UNIFESP), Santos, Brazil.,Physical Therapy Department Institute of Medical Assistance to the State Public Servant (IAMSPE), São Paulo, Brazil
| | - Pedro De Oliveira
- Physical Therapy Department Institute of Medical Assistance to the State Public Servant (IAMSPE), São Paulo, Brazil
| | - Liu Yi
- Department of Human Movement Sciences, Federal University of São Paulo (UNIFESP), Santos, Brazil
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Liu Q, Adami HO, Reichenberg A, Kolevzon A, Fang F, Sandin S. Cancer risk in individuals with intellectual disability in Sweden: A population-based cohort study. PLoS Med 2021; 18:e1003840. [PMID: 34673770 PMCID: PMC8568154 DOI: 10.1371/journal.pmed.1003840] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 11/04/2021] [Accepted: 10/08/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND A knowledge gap exists about the risk of cancer in individuals with intellectual disability (ID). The primary aim of this study was to estimate the cancer risk among individuals with ID compared to individuals without ID. METHODS AND FINDINGS We conducted a population-based cohort study of all children live-born in Sweden between 1974 and 2013 and whose mothers were born in a Nordic country. All individuals were followed from birth until cancer diagnosis, emigration, death, or 31 December 2016 (up to age 43 years), whichever came first. Incident cancers were identified from the Swedish Cancer Register. We fitted Cox regression models to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) as measures of cancer risk in relation to ID after adjusting for several potential confounders. We analyzed ID by severity, as well as idiopathic ID and syndromic ID separately. We performed a sibling comparison to investigate familial confounding. The study cohort included a total of 3,531,305 individuals, including 27,956 (0.8%) individuals diagnosed with ID. Compared with the reference group (individuals without ID and without a full sibling with ID), individuals with ID were in general more likely to be male. The median follow-up time was 8.9 and 23.0 years for individuals with ID and individuals without ID, respectively. A total of 188 cancer cases were identified among individuals with ID (incidence rate [IR], 62 per 1,000 person-years), and 24,960 among individuals in the reference group (IR, 31 per 1,000 person-years). A statistically significantly increased risk was observed for any cancer (HR 1.57, 95% CI 1.35-1.82; P < 0.001), as well as for several cancer types, including cancers of the esophagus (HR 28.4, 95% CI 6.2-130.6; P < 0.001), stomach (HR 6.1, 95% CI 1.5-24.9; P = 0.013), small intestine (HR 12.0, 95% CI 2.9-50.1; P < 0.001), colon (HR 2.0, 95% CI 1.0-4.1; P = 0.045), pancreas (HR 6.0, 95% CI 1.5-24.8; P = 0.013), uterus (HR 11.7, 95% CI 1.5-90.7; P = 0.019), kidney (HR 4.4, 95% CI 2.0-9.8; P < 0.001), central nervous system (HR 2.7, 95% CI 2.0-3.7; P < 0.001), and other or unspecified sites (HR 4.8, 95% CI 1.8-12.9; P = 0.002), as well as acute lymphoid leukemia (HR 2.4, 95% CI 1.3-4.4; P = 0.003) and acute myeloid leukemia (HR 3.0, 95% CI 1.4-6.4; P = 0.004). Cancer risk was not modified by ID severity or sex but was higher for syndromic ID. The sibling comparison showed little support for familial confounding. The main study limitations were the limited statistical power for the analyses of specific cancer types, and the potential for underestimation of the studied associations (e.g., due to potential underdetection or delayed diagnosis of cancer among individuals with ID). CONCLUSIONS In this study, we found that individuals with ID showed an increased risk of any cancer, as well as of several specific cancer types. These findings suggest that extended surveillance and early intervention for cancer among individuals with ID are warranted.
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Affiliation(s)
- Qianwei Liu
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Hans-Olov Adami
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Abraham Reichenberg
- Department of Psychiatry, Ichan School of Medicine at Mount Sinai, New York, New York, United States of America
- Seaver Autism Center for Research and Treatment, Ichan School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Alexander Kolevzon
- Department of Psychiatry, Ichan School of Medicine at Mount Sinai, New York, New York, United States of America
- Seaver Autism Center for Research and Treatment, Ichan School of Medicine at Mount Sinai, New York, New York, United States of America
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Fang Fang
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sven Sandin
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychiatry, Ichan School of Medicine at Mount Sinai, New York, New York, United States of America
- Seaver Autism Center for Research and Treatment, Ichan School of Medicine at Mount Sinai, New York, New York, United States of America
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Harkness‐Armstrong C, Maganaris C, Walton R, Wright DM, Bass A, Baltzopoulos V, O’Brien TD. Muscle architecture and passive lengthening properties of the gastrocnemius medialis and Achilles tendon in children who idiopathically toe-walk. J Anat 2021; 239:839-846. [PMID: 34109625 PMCID: PMC8450476 DOI: 10.1111/joa.13464] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/03/2022] Open
Abstract
Children who idiopathically toe-walk (ITW) habitually operate at greater plantarflexion angles and thus, at shorter muscle-tendon unit (MTU) lengths than typically developing (TD) children. Therefore, it is often assumed that habitual use of the gastrocnemius muscle in this way will cause remodelling of the muscle-tendon architecture compared to TD children. However, the gastrocnemius muscle architecture of children who ITW has never been measured. It is essential that we gain a better understanding of these muscle-tendon properties, to ensure that appropriate clinical interventions can be provided for these children. Five children who ITW (age 8 ± 2 years) and 14 TD children (age 10 ± 2 years) participated in this study. Ultrasound was combined with isokinetic dynamometry and surface electromyography, to measure muscle architecture at common positions and passive lengthening properties of the gastrocnemius muscle and tendon across full range of motion. Regardless of which common condition groups were compared under, both the absolute and normalised to MTU muscle belly and fascicle lengths were always longer, and the Achilles tendon length was always shorter in children who ITW than TD children (p < 0.05; large effect sizes). The passive lengthening properties of the muscle and tendon were not different between groups (p > 0.05); however, passive joint stiffness was greater in children who ITW at maximum dorsiflexion (p = 0.001) and at a joint moment common to all participants (p = 0.029). Consequently, the findings of this pilot study indicate a remodelling of the relative MTU that does not support the concept that children who ITW commonly experience muscle shortening. Therefore, greater consideration of the muscle and tendon properties are required when prescribing clinical interventions that aim to lengthen the MTU, and treatments may be better targeted at the Achilles tendon in children who ITW.
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Affiliation(s)
| | - Constantinos Maganaris
- Research Institute for Sport and Exercise SciencesLiverpool John Moores UniversityLiverpoolUK
| | - Roger Walton
- Alder Hey Children’s NHS Foundation TrustLiverpoolUK
| | | | - Alfie Bass
- Alder Hey Children’s NHS Foundation TrustLiverpoolUK
| | - Vasilios Baltzopoulos
- Research Institute for Sport and Exercise SciencesLiverpool John Moores UniversityLiverpoolUK
| | - Thomas D. O’Brien
- Research Institute for Sport and Exercise SciencesLiverpool John Moores UniversityLiverpoolUK
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Barkocy M, Muir N, Le Cras S, Brausch S, Hoffman N, Bouck J, Hendrix I, Thomas C, Foulk A, Quatman-Yates C. Parent Perspectives Regarding Care Delivery for Children With Idiopathic Toe Walking to Inform an American Physical Therapy Association Clinical Practice Guideline. Pediatr Phys Ther 2021; 33:260-266. [PMID: 34432760 DOI: 10.1097/pep.0000000000000820] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Marybeth Barkocy
- Department of Orthopedics, Division of Physical Therapy (Dr Barkocy), The University of New Mexico Health Science Center, Albuquerque, New Mexico; Children's Hospital Colorado, Aurora, Colorado (Dr Muir); Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (Drs LeCras and Brausch); Children's Minnesota, Minneapolis, Minnesota (Dr Hoffman); Primary Children's Hospital, Salt Lake City, Utah (Ms Julie Bouck); Education, Consultation and Reference Services (Ms Ingrid Hendrix), The University of New Mexico, Albuquerque, New Mexico; The University of New Mexico Student Physical Therapists (Mss Cecile Thomas and Allison Foulk), Albuquerque, New Mexico; Division of Physical Therapy; The Ohio State University, Columbus, Ohio (Dr Quatman-Yates)
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20
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Harkness-Armstrong C, Maganaris C, Walton R, Wright DM, Bass A, Baltzopoulos V, O'Brien TD. In vivo operating lengths of the gastrocnemius muscle during gait in children who idiopathically toe-walk. Exp Physiol 2021; 106:1806-1813. [PMID: 34159660 DOI: 10.1113/ep089658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022]
Abstract
NEW FINDINGS What is the central question of this study? What are the in vivo operating lengths of the gastrocnemius muscle in children who idiopathically toe-walk? What is the main finding and its importance? Children who idiopathically toe-walk operate at more plantarflexed positions but at longer fascicle lengths than typically developing children during gait. However, these ranges utilised during gait correspond to where children who idiopathically toe-walk are optimally strong. This should be considered when prescribing clinical treatments to restore typical gait. ABSTRACT Children who idiopathically toe-walk (ITW) habitually operate at greater plantarflexion angles than typically developing (TD) children, which might result in shorter, sub-optimal gastrocnemius fascicle lengths. However, currently no experimental evidence exists to substantiate this notion. Five children who ITW and 14 TD children completed a gait analysis, whilst gastrocnemius fascicle behaviour was simultaneously quantified using ultrasound. The moment-angle (hip, knee and ankle) and moment-length (gastrocnemius) relationships were determined from isometric maximum voluntary contractions (MVC) on an isokinetic dynamometer combined with ultrasound. During gait, children who ITW operated at more plantarflexed angles (Δ = 20°; P = 0.013) and longer muscle fascicle lengths (Δ = 12 mm; P = 0.008) than TD children. During MVC, no differences in the peak moment of any joint were found. However, peak plantarflexor moment occurred at significantly more plantarflexed angles (-16 vs. 1°; P = 0.010) and at longer muscle fascicle lengths (44 vs. 37 mm; P = 0.001) in children who ITW than TD children. Observed alterations in the moment-angle and moment-length relationships of children who ITW coincided with the ranges used during gait. Therefore, the gastrocnemius muscle in children who ITW operates close to the peak of the force-length relationship, similarly to TD children. Thus, this study indicates that idiopathic toe-walking is truly an ankle joint pathology, and children who ITW present with substantial alterations in the gastrocnemius muscle functional properties, which appear well adapted to the characteristic demands of equinus gait. These findings should be considered when prescribing clinical treatments to restore typical gait.
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Affiliation(s)
- Carla Harkness-Armstrong
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Constantinos Maganaris
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Roger Walton
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - David M Wright
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Alfie Bass
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Vasilios Baltzopoulos
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Thomas D O'Brien
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
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Brierty A, Walsh HPJ, Jeffries P, Graham D, Horan S, Carty C. Dynamic muscle-tendon length following zone 2 calf lengthening surgery in two populations with equinus gait: Idiopathic Toe Walkers and Cerebral Palsy. Clin Biomech (Bristol, Avon) 2021; 84:105323. [PMID: 33770533 DOI: 10.1016/j.clinbiomech.2021.105323] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Two populations commonly presenting with equinus gait are Idiopathic Toe-Walkers and children with Cerebral Palsy. Surgical intervention to treat equinus is defined by three zones. Zone three surgery, performed at the Achilles tendon, is most commonly used clinically. There is however, evidence from simulation studies that zone two surgery, performed at the muscle belly, might provide better functional outcomes. The purpose of this study was to investigate the effect of zone two calf-lengthening on post-operative gait in these populations. METHODS A retrospective audit of the Queensland Children's Motion Analysis Service database identified 17 toe-walkers (mean age 10.13 (SD 2.625)) and 11 Cerebral Palsy (mean age 9.72 (SD 4.04)) participants that received calf-lengthening surgery for plantarflexion contracture and had pre- and post-surgery 3D gait analysis. Inverse kinematics, dynamics, and muscle analysis were performed in OpenSim (v3.3) using a modified gait2392 model. Pre to post-surgery comparisons were performed in MATLAB using statistical parametric mapping. Dependent variables included ankle kinematics, powers and muscle-tendon length estimates. FINDINGS The primary outcome of this study was that ankle dorsiflexion increased in both Idiopathic Toe Walking and Cerebral Palsy groups post-calf lengthening across 90% and 85% of the gait cycle respectively. There was an increase in modelled muscle-tendon lengths, specifically in the medial gastrocnemius, of 78% (toe-walkers), and 100% (Cerebral Palsy) of the gait cycle. Power generation during push-off was not affected. INTERPRETATION Overall, the results appear to support the efficacy of zone 2 calf-lengthening for children with Cerebral Palsy and Idiopathic Toe Walking.
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Affiliation(s)
- Alexis Brierty
- School of Allied Health Sciences, Menzies Health Institute Queensland, Griffith University, Parklands Dr, Southport, QLD 4215, Australia; Queensland Children's Motion Analysis Service (QCMAS), Children's Health Queensland Hospital and Health Service, 62 Graham St, South Brisbane, QLD 4101, Australia.
| | - Henry Patrick John Walsh
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, Lady Cilento Children's Hospital, 501 Stanley St, South Brisbane, QLD 4101, Australia
| | - Paula Jeffries
- Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, Lady Cilento Children's Hospital, 501 Stanley St, South Brisbane, QLD 4101, Australia
| | - David Graham
- Department of Health and Human Development, Montana State University, 250 Reid Hall, Bozeman, MT 59717, United States
| | - Sean Horan
- School of Allied Health Sciences, Menzies Health Institute Queensland, Griffith University, Parklands Dr, Southport, QLD 4215, Australia
| | - Chris Carty
- School of Allied Health Sciences, Menzies Health Institute Queensland, Griffith University, Parklands Dr, Southport, QLD 4215, Australia; Queensland Children's Motion Analysis Service (QCMAS), Children's Health Queensland Hospital and Health Service, 62 Graham St, South Brisbane, QLD 4101, Australia; Department of Orthopaedics, Children's Health Queensland Hospital and Health Service, Lady Cilento Children's Hospital, 501 Stanley St, South Brisbane, QLD 4101, Australia
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Barkocy M, Schilz J, Heimerl S, Chee M, Valdez M, Redmond K. The Effectiveness of Serial Casting and Ankle Foot Orthoses in Treating Toe Walking in Children With Autism Spectrum Disorder. Pediatr Phys Ther 2021; 33:83-90. [PMID: 33724238 DOI: 10.1097/pep.0000000000000784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Marybeth Barkocy
- Division of Physical Therapy (Drs Barkocy, Schilz, Chee, Valdez, and Redmond) and Department of Pediatrics (Dr Heimerl), The University of New Mexico, Albuquerque, New Mexico
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Speedtsberg M, Harsted S, Hestbæk L, Lauridsen HH, Bencke J, Holsgaard-Larsen A. Early identification of toe walking gait in preschool children - Development and application of a quasi-automated video screening procedure. Clin Biomech (Bristol, Avon) 2021; 84:105321. [PMID: 33765569 DOI: 10.1016/j.clinbiomech.2021.105321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/15/2021] [Accepted: 03/07/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To develop and test the application of a quasi-automated screening procedure identifying probable toe walking in a large population of preschool children. METHODS The proposed screening procedure was designed to identify children exhibiting signs of toe walking in a previously recruited cohort of preschool children (MiPS cohort). The procedure combines parent observation (step 1), objective parameters of foot contact during gait by an automated screening of 3-D video recordings (step 2), and clinical video screening of the children identified in step 1 and/or 2 (step 3). FINDINGS From 879 children, gait trials were obtained from 87% (n = 766). Step 1 (parent observation) identified 34 children with potential toe walking, step 2 (automated screening) 122. Fourteen were identified in both step 1 and 2. Thus, 142 children were selected for step 3 (clinical video screening), from which 41 children were classified as showing symmetric signs of toe walking, and five children were identified with asymmetrical signs of toe walking. Of the 41, five had been identified by step 1 only, 32 by step 2 only and four by both steps. INTERPRETATION Application of a quasi-automated screening algorithm was feasible and may assist in early detection of toe walking. Disagreements found between parent reported toe walking and video screening, indicate added value in quasi-automated video screening. However, thresholds of heel lift and clinical criteria of toe walking in the algorithm and video screening need to be addressed and validated to confidently identify toe walking gait.
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Affiliation(s)
- Merete Speedtsberg
- Human Movement Laboratory, Department of Orthopedic Surgery, Hvidovre University Hospital, Copenhagen, Denmark.
| | - Steen Harsted
- Dept. of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Lise Hestbæk
- Dept. of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark
| | - Henrik H Lauridsen
- Dept. of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Jesper Bencke
- Human Movement Laboratory, Department of Orthopedic Surgery, Hvidovre University Hospital, Copenhagen, Denmark
| | - Anders Holsgaard-Larsen
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Bartoletta J, Tsao E, Bouchard M. A Retrospective Analysis of Nonoperative Treatment Techniques for Idiopathic Toe Walking in Children: Outcomes and Predictors of Success. PM R 2020; 13:1127-1135. [PMID: 33201564 DOI: 10.1002/pmrj.12520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/25/2020] [Accepted: 11/02/2020] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- John Bartoletta
- University of Washington School of Medicine, Seattle, WA, USA
| | - Elaine Tsao
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Maryse Bouchard
- Division of Orthopaedic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Bennett JF, Omura J. Toe Walking. Physician Assistant Clinics 2020; 5:477-485. [DOI: 10.1016/j.cpha.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
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.
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Affiliation(s)
- Cylie Williams
- Allied Health, Peninsula Health, Frankston, Victoria, Australia
- School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia
| | - Kristy Robson
- School of Community Health, Charles Sturt University, Albury, New South Wales, Australia
| | - Verity Pacey
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
| | - Kelly Gray
- Department of Health Professions, Macquarie University, Sydney, New South Wales, Australia
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Williams CM, Gray K, Davies N, Barkocy M, Fahey M, Simmonds J, Accardo P, Eastwood D, Pacey V. Exploring health professionals' understanding of evidence-based treatment for idiopathic toe walking. Child Care Health Dev 2020; 46:310-319. [PMID: 31957909 DOI: 10.1111/cch.12745] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/12/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Cylie M Williams
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia.,Peninsula Health, Allied Health, Frankston, Victoria, Australia
| | - Kelly Gray
- Department of Health Professions, Macquarie University, Macquarie, New South Wales, Australia
| | - Nina Davies
- Faculty of Health and Sciences, Staffordshire University, Stoke-on-Trent, UK
| | | | - Michael Fahey
- Department of Paediatrics, Monash Health, Clayton, Victoria, Australia
| | - Jane Simmonds
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Pasquale Accardo
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Virginia, USA
| | - Deborah Eastwood
- Department of Orthopaedics, Great Ormond St Hospital and University College, London, UK
| | - Verity Pacey
- Department of Health Professions, Macquarie University, Macquarie, New South Wales, Australia
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Schlough K, Andre K, Owen M, Adelstein L, Hartford MC, Javier B, Kern R. Differentiating Between Idiopathic Toe Walking and Cerebral Palsy: A Systematic Review. Pediatr Phys Ther 2020; 32:2-10. [PMID: 31842091 DOI: 10.1097/PEP.0000000000000659] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE 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. SUMMARY OF KEY POINTS 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. CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE The authors recommend that clinicians perform specific evidence-based tests and measures in accordance with the International Classification of Functioning, Disability and Health model.
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Abstract
BACKGROUND Idiopathic toe walking (ITW) is an exclusionary diagnosis given to healthy children who persist in walking on their toes after they should typically have achieved a heel-toe gait. The literature discusses conservative and surgical interventions using a variety of treatment modalities. Young children and children without a limitation in ankle dorsiflexion (the upwards movement of the foot towards the shin of the leg) are commonly treated with conservative interventions. Older children who continue toe walking and present with limitations in ankle dorsiflexion are sometimes treated with surgical procedures. This systematic review is needed to evaluate the evidence for any intervention for the treatment of ITW. The conclusions of this review may support decision making by clinicians caring for children with ITW. It may also assist families when deciding on treatment options for their children with ITW. Many of the treatments employed have financial implications for parents or healthcare services. This review also aims to highlight any deficits in the current research base. OBJECTIVES To assess the effects of conservative and surgical interventions in children with ITW, specifically effects on gait normalisation, ankle range of motion, pain, frequency of recurrence, and any adverse effects. SEARCH METHODS On 29 April 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus, and PEDro. We searched the following registers of clinical trials for ongoing and recently completed trials: the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP, apps.who.int/trialsearch), and ClinicalTrials.gov (clinicaltrials.gov). We searched conference proceedings and other grey literature in the BIOSIS databases and System for Information on Grey Literature in Europe (OpenGrey, opengrey.eu). We searched guidelines via the Turning Research Into Practice database (TRIP, tripdatabase.com) and National Guideline Clearinghouse (guideline.gov). We did not apply language restrictions. SELECTION CRITERIA We considered randomised or quasi-randomised trials for inclusion in the review if they involved participants diagnosed with ITW gait in the absence of a medical condition known to cause toe walking, or associated with toe walking. As there is no universally accepted age group for ITW, this review includes ITW at any age, who have been toe walking for more than six months, who can or cannot walk with a heel-toe gait, and who may or may not have limited dorsiflexion of the ankle joint. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. The primary outcome was improvement in toe walking (defined as greater than 50% of time spent heel-toe walking). Secondary outcomes were active and passive range of motion of the ankle joint, pain, recurrence of ITW after treatment, and adverse events. We assessed the certainty of the evidence using the GRADE framework. MAIN RESULTS Four studies, comprising 104 participants, met the inclusion criteria. One study did not report data within the appropriate follow-up timeframe and data from two studies were insufficient for analysis. The single study from which we extracted data had 47 participants and was a randomised, controlled, parallel-group trial conducted in Sweden. It tested the hypothesis that combined treatment with serial casting and botulinum toxin type A (BTX) was more effective than serial casting alone in reducing ITW gait.This study found that more participants treated with BTX improved (defined as toe walking less than 50% of the time, as reported by parents) (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.57 to 2.55; 1 trial, 46 participants; very low-certainty evidence). However, there was little or no difference between groups in passive ankle joint dorsiflexion range of movement on the right with the knee extended (mean difference (MD) -1.48º, 95% CI -4.13 to 1.16; 1 trial, 47 participants), on the right with the knee flexed (MD -0.04º, 95% CI -1.80 to 1.73; 1 trial, 46 participants), on the left with the knee flexed (MD 1.07, 95% CI -1.22 to 3.37), or on the left with the knee extended (MD 0.05, 95% CI -0.91 to 1.91). Nor was there a clear difference between the groups in recurrence of toe-walking gait (assessed via severity of toe walking (graded 1 (mild), 2 (moderate), or 3 (severe)) on gait analysis, analysed as continuous data: MD 0.34 points, 95% CI -0.09 to 0.78; 46 participants). In principle, MDs greater than zero (i.e.) positive values) would favour BTX and casting and negative values would favour casting alone. We have not reported effects as better or worse because all results were from evidence of very low certainty. We downgraded the certainty of evidence because of study limitations (outcome assessment was not blinded) and imprecision. Outcomes of pain and active range of motion were not reported in the included study.In terms of adverse events, calf pain was reported twice in the casting-only group and three times in the BTX group. There were three minor skin problems in each group and one reported case of pain directly after BTX injection. The report did not state if calf pain and skin irritation were from the same or different participants. The study authors reported that adverse events did not alter treatment adherence. AUTHORS' CONCLUSIONS The certainty of evidence from one study, which compared serial casting with serial casting with BTX for ITW in children, was too low for conclusions to be drawn. A further three studies reported outcomes relating to BTX, footwear, exercises, and different types of orthoses as interventions, however the outcome data were too limited to assess their effects.
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Affiliation(s)
- Antoni J Caserta
- Monash HealthChild and Family Team140‐154 Sladen StCranbourneVictoriaAustralia3977
| | - Verity Pacey
- Macquarie UniversityDepartment of Health Professions, Faculty of Medicine and Health Sciences75 Talavera RoadSydneyNSWAustralia2109
| | - Michael C Fahey
- Monash UniversityDepartment of PaediatricsClaytonVictoriaAustralia3168
| | - Kelly Gray
- The Children's Hospital at WestmeadDepartment of EndocrinologyLocked Bag 4001WestmeadNew South WalesAustralia2145
- Macquarie UniversityDepartment of Health Professions, Faculty of Medicine and Health SciencesGround Floor75 Talavera RoadNorth RydeNSWAustralia2109
| | - Raoul HH Engelbert
- Department of Rehabilitation MedicineAcademic Medical Center AmsterdamAmsterdamAmsterdamNetherlands
| | - Cylie M Williams
- Monash UniversityDepartment of PhysiotherapyFrankstonVictoriaAustralia
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de Oliveira VGC, Arrebola LS, de Oliveira PR, de Sá CDS, Yi LC. Effect of Plantar Flexor Muscle Strengthening on the Gait of Children With Idiopathic Toe Walking: A Study Protocol. Pediatr Phys Ther 2019; 31:373-8. [PMID: 31568387 DOI: 10.1097/PEP.0000000000000650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the effect of plantar flexor strengthening associated with conventional physical therapy treatment in participants with idiopathic toe walking. METHODS 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.
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Abstract
PURPOSE The 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. METHODS A 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. RESULTS The 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. CONCLUSION The 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 Evidence: Level II - Therapeutic.
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Affiliation(s)
- F. Thielemann
- University Center for Orthopaedics and Trauma Surgery, Carl Gustav Carus University Hospital, Technical University of Dresden, Dresden, Germany, Correspondence should be sent to Falk Thielemann, MD, Senior Consultant, University Center for Orthopaedics and Trauma Surgery, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstrasse 74, D-01307 Dresden, Germany. E-mail:
| | - G. Rockstroh
- Department of Orthopaedics and Biomechanics, Klinik Bavaria Kreischa, Kreischa, Germany
| | - J. Mehrholz
- Wissenschaftliches Institut, Private Europäische Medizinische Akademie der Klinik Bavaria in Kreischa GmbH, Kreischa, Germany
| | - C. Druschel
- University Center for Orthopaedics and Trauma Surgery, Carl Gustav Carus University Hospital, Technical University of Dresden, Dresden, Germany
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Abstract
Idiopathic toe walking (ITW) causes a common problem in pediatric orthopaedics. In the literature, numerous treatment options have been reported, but consensus about the management of ITW is still missing. The aim of the current study was to evaluate conservative treatment with pyramidal insoles. A total of 193 patients underwent conservative treatment between January 2010 and June 2013. Mean age at the beginning of the treatment was 7.75 ± 0.23 years (range 2.0-17.0 years). For all patients, demographic data, comorbid diseases, passive range of motion (ROM), persistent toe walking, and performed operations were retrospectively evaluated. Following operative treatment was defined failure. Eight (4.15%) patients underwent Achilles tendon lengthening operation after mean therapy time of 2.72 years (range 0.1-7.0 years), 174 cases were treated successfully (90.16%). In 50 cases, toe walking suspended completely after mean therapy time of 2.83 years. In cases of failure, patients were older at diagnosis and at the beginning of the treatment. Mean passive ROM increased over the time. In cases of failure, ROM decreased from the first to the second examination. Conservative treatment of ITW using pyramidal insoles can be effective. Ankle dorsiflexion significantly improved in the patients who were successfully treated. Therapy should start early. A decrease of ROM under therapy should lead to critical revisal of individual therapy. Levels of Evidence: Therapeutic, level IV: Case series.
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Affiliation(s)
- Kerstin Radtke
- Department of Orthopedic Surgery, Hannover Medical School / DIAKOVERE Annastift, Hannover, Germany (KR, NK, FG, GvL, YN, AT).,Institute of Medical Biometry and Informatics, Hannover Medical School, Hanover, Germany (BV)
| | - Nataliia Karch
- Department of Orthopedic Surgery, Hannover Medical School / DIAKOVERE Annastift, Hannover, Germany (KR, NK, FG, GvL, YN, AT).,Institute of Medical Biometry and Informatics, Hannover Medical School, Hanover, Germany (BV)
| | - Fabian Goede
- Department of Orthopedic Surgery, Hannover Medical School / DIAKOVERE Annastift, Hannover, Germany (KR, NK, FG, GvL, YN, AT).,Institute of Medical Biometry and Informatics, Hannover Medical School, Hanover, Germany (BV)
| | - Bernhard Vaske
- Department of Orthopedic Surgery, Hannover Medical School / DIAKOVERE Annastift, Hannover, Germany (KR, NK, FG, GvL, YN, AT).,Institute of Medical Biometry and Informatics, Hannover Medical School, Hanover, Germany (BV)
| | - Gabriela von Lewinski
- Department of Orthopedic Surgery, Hannover Medical School / DIAKOVERE Annastift, Hannover, Germany (KR, NK, FG, GvL, YN, AT).,Institute of Medical Biometry and Informatics, Hannover Medical School, Hanover, Germany (BV)
| | - Yvonne Noll
- Department of Orthopedic Surgery, Hannover Medical School / DIAKOVERE Annastift, Hannover, Germany (KR, NK, FG, GvL, YN, AT).,Institute of Medical Biometry and Informatics, Hannover Medical School, Hanover, Germany (BV)
| | - Anneke Thren
- Department of Orthopedic Surgery, Hannover Medical School / DIAKOVERE Annastift, Hannover, Germany (KR, NK, FG, GvL, YN, AT).,Institute of Medical Biometry and Informatics, Hannover Medical School, Hanover, Germany (BV)
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Caserta A, Morgan P, Williams C. Identifying methods for quantifying lower limb changes in children with idiopathic toe walking: A systematic review. Gait Posture 2019; 67:181-186. [PMID: 30347291 DOI: 10.1016/j.gaitpost.2018.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/03/2018] [Accepted: 10/08/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Idiopathic toe walking (ITW) is a diagnosis of exclusion for children walking on their toes with no medical cause. This systematic review aimed to identify and evaluate the clinical utility, validity and reliability of the outcome measures and tools used to quantify lower limb changes within studies that included children with ITW. METHODS The following databases were searched from inception until March 2018: Ovid MEDLINE, EBESCO, Embase, CINAHL Plus, PubMed. Inclusion criteria were studies including children with ITW diagnosis, reporting use of measurement tools or methods describing lower limb characteristics, published in peer-reviewed journals, and in English. The relevant psychometric properties of measurement tools were extracted, and assessed for reported reliability and validity. Included articles were assessed for risk of bias using McMaster quality assessment tool. Results were descriptively synthesized and logistic regression used to determine associations between common assessments. RESULTS From 3164 retrieved studies, 37 full texts were screened and 27 full texts included. There were 27 different measurement tools described across joint range of motion measurement, gait analysis, electromyography, accelerometer, strength, neurological or radiology assessment. Interventional studies were more likely to report range of motion and gait analysis outcomes, than observational studies. Alvarez classification tool in conjunction with Vicon motion system appeared the contemporary choice for describing ITW gait. There was no significant association between the use of range of motion and gait analysis outcomes and any other outcome tool or assessment in all studies (p > 0.05).There was limited reliability and validity reporting for many outcome measures. SIGNIFICANCE This review highlighted that a consensus statement should be considered to guide clinicians and researchers in the choice of the most important outcome measures for this population. Having a standard set of measures will enable future treatment trials to collect similar measures thus allowing future systematic reviews to compare results.
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Affiliation(s)
- Antoni Caserta
- Monash Health Community, Cranbourne, Victoria, Australia; Monash University, Department of Physiotherapy, Frankston, Victoria, Australia.
| | - Prue Morgan
- Monash University, Department of Physiotherapy, Frankston, Victoria, Australia
| | - Cylie Williams
- Monash University, Department of Physiotherapy, Frankston, Victoria, Australia; Peninsula Health, Allied Health, Frankston Victoria, Australia
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Vette AH, Watt JM, Lewicke J, Watkins B, Burkholder LM, Andersen J, Jhangri GS, Dulai S. The utility of normative foot floor angle data in assessing toe-walking. Foot (Edinb) 2018; 37:65-70. [PMID: 30326414 DOI: 10.1016/j.foot.2018.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/27/2018] [Accepted: 07/09/2018] [Indexed: 02/04/2023]
Abstract
Initial heel contact is an important attribute of gait, and failure to complete the heel rocker reduces gait stability. One common goal in treating toe-walking is to restore heel strike and prevent or reduce early heel rise. Foot floor angle (FFA) is a measure of toe-walking that is valuable for quantifying foot orientation at initial contact when using ankle dorsiflexion angle alone is misleading. However, no age-standardized FFA norms exist for clinical evaluation. Our objectives were to: (1) obtain normative FFA in typically developing children; and (2) examine its utility in the example of toe-walking secondary to unilateral cerebral palsy. Gait kinematics were acquired and FFA trajectories computed for 80 typically developing children (4-18 years). They were also obtained retrospectively from 11 children with toe-walking secondary to unilateral cerebral palsy (4-10 years), before and after operative intervention, and compared to 40 age-matched, typically developing children. FFA at initial contact was significantly different (P<.001) between pre-surgery toe-walking (-14.7±9.7°; mean±standard deviation) and typical gait (18.7±2.8°). Following operative lengthening of the gastrocnemius-soleus complex on the affected side, FFA at initial contact (-0.9±5.3°) was significantly improved (P<.001). Furthermore, several cases were identified for which the sole use of ankle dorsiflexion angle to capture toe-walking is misleading. The assessment of FFA is a simple method for providing valuable quantitative information to clinicians regarding foot orientation during gait. The demonstrated limitations of using ankle dorsiflexion angle alone to estimate foot orientation further emphasize the utility of FFA in assessing toe-walking.
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Affiliation(s)
- Albert H Vette
- Department of Mechanical Engineering, University of Alberta, Donadeo Innovation Centre for Engineering, 9211 116 Street NW, Edmonton, Alberta T6G 1H9, Canada; Glenrose Rehabilitation Hospital, Alberta Health Services, 10230 111 Avenue NW, Edmonton, Alberta T5G 0B7, Canada.
| | - Joe M Watt
- Glenrose Rehabilitation Hospital, Alberta Health Services, 10230 111 Avenue NW, Edmonton, Alberta T5G 0B7, Canada; Faculty of Medicine and Dentistry, University of Alberta, W.C. Mackenzie Health Sciences Centre, 8440 112 Street NW, Edmonton, Alberta T6G 2R7, Canada
| | - Justin Lewicke
- Glenrose Rehabilitation Hospital, Alberta Health Services, 10230 111 Avenue NW, Edmonton, Alberta T5G 0B7, Canada
| | - Beth Watkins
- Glenrose Rehabilitation Hospital, Alberta Health Services, 10230 111 Avenue NW, Edmonton, Alberta T5G 0B7, Canada
| | - Lee M Burkholder
- Department of Clinical Neurosciences, University of Calgary, Foothills Hospital, 1403 29 Street NW, Calgary, Alberta T2N 2T9, Canada
| | - John Andersen
- Glenrose Rehabilitation Hospital, Alberta Health Services, 10230 111 Avenue NW, Edmonton, Alberta T5G 0B7, Canada; Faculty of Medicine and Dentistry, University of Alberta, W.C. Mackenzie Health Sciences Centre, 8440 112 Street NW, Edmonton, Alberta T6G 2R7, Canada
| | - Gian S Jhangri
- School of Public Health, University of Alberta, Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, Alberta T6G 1C9, Canada
| | - Sukhdeep Dulai
- Glenrose Rehabilitation Hospital, Alberta Health Services, 10230 111 Avenue NW, Edmonton, Alberta T5G 0B7, Canada; Faculty of Medicine and Dentistry, University of Alberta, W.C. Mackenzie Health Sciences Centre, 8440 112 Street NW, Edmonton, Alberta T6G 2R7, Canada
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Pomarino D, Martin S, Pomarino A, Morigeau S, Biskup S. McArdle's disease: A differential diagnosis of idiopathic toe walking. J Orthop 2018; 15:685-689. [PMID: 29881221 PMCID: PMC5990294 DOI: 10.1016/j.jor.2018.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 05/06/2018] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- David Pomarino
- Praxis Pomarino, Rahlstedter Bahnhofstr. 9, 22143 Hamburg, Germany
| | - Stephan Martin
- DIAKOVERE Annastift, Department for Pediatrics and Neuro-orthopedics, Anna-von-Borries-Str. 1–7, 30625 Hannover, Germany
| | - Andrea Pomarino
- Praxis Pomarino, Rahlstedter Bahnhofstr. 9, 22143 Hamburg, Germany
| | | | - Saskia Biskup
- Praxis f. Humangenetik Tübingen, Paul-Ehrlich-Str. 23, 72076 Tübingen, Germany
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Davies K, Black A, Hunt M, Holsti L. Long-term gait outcomes following conservative management of idiopathic toe walking. Gait Posture 2018; 62:214-219. [PMID: 29571089 DOI: 10.1016/j.gaitpost.2018.02.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 02/03/2018] [Accepted: 02/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Idiopathic toe walking is a diagnosis of exclusion characterized by a persistent toe-toe gait pattern after three years of age. Treatment for toe walking includes physical therapy, orthotics, casting, Botulinum Toxin A injection into gastrocnemius/soleus muscles, and/or surgery; yet, little evidence exists regarding long-term treatment effects. RESEARCH QUESTION The objective of this study was to explore the differences in longer-term gait outcomes and severity of idiopathic toe walking between children treated actively with casting or inactively following recommendations for stretching. METHODS Forty-three adolescents and young adults (14.3-28.8 years; 21 females, 22 males) who had participated in an idiopathic toe walking classification study as children, returned for repeat physical examination and three-dimensional computerized gait analysis (13.4 years follow-up, range 9.4-17.8 years); 23 participants had received active treatment with casting and ankle foot orthotics ± Botulinum Toxin A injection as children and 20 participants had received inactive treatment with recommended stretching exercises. Gait analysis data were compared retrospectively from baseline to follow-up using analysis of variance; toe walking severity was compared using a Wilcoxin Signed-Rank Sums test. RESULTS Ankle angle at initial contact, peak dorsiflexion in stance, and toe walking severity improved significantly in the active treatment group only at follow-up. Significant improvement in peak ankle power and timing of ankle kinematics and kinetics in the gait cycle were found in both groups; however, greater changes occurred in the active treatment group. Both groups showed significantly improved internal plantar flexor moments, whereas knee extension increased in stance and passive ankle dorsiflexion decreased in both groups at follow-up (p = 0.001). Intermittent toe walking was reported in 49% (21/43) of participants at follow-up. SIGNIFICANCE The results of this study suggest that improvement in ankle kinematic timing and ankle kinetic gait analysis variables is sustainable, independent of conservative treatment for idiopathic toe walking in childhood.
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Affiliation(s)
- Karen Davies
- Shriners Gait Lab, Sunny Hill Health Centre for Children, 3644 Slocan Street, Vancouver, British Columbia V5M 3E8, Canada.
| | - Alec Black
- Shriners Gait Lab, Sunny Hill Health Centre for Children, 3644 Slocan Street, Vancouver, British Columbia V5M 3E8, Canada.
| | - Michael Hunt
- Department of Physical Therapy, The University of British Columbia, 212 Friedman Building, 2177 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3, Canada.
| | - Liisa Holsti
- Department of Occupational Science and Occupational Therapy, The University of British Columbia, T325-2211 Wesbrook Mall, Vancouver, British Columbia V6T 2B5, Canada; British Columbia Children's Hospital Research Institute, 950 West 28th Avenue, Vancouver, British Columbia V5Z 4H4, Canada.
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Abstract
BACKGROUND Children with idiopathic toe-walking, a common pediatric condition, walk some or all of the time on their toes. This condition often causes parental concern, with repeated medical contacts and a range of interventions including stretching, casts, injection of botulinum toxin A, and surgical procedures. The purpose of this cohort study was to document the natural history of this condition. METHODS In a population-based cohort of 1,401 healthy 5.5-year-old Swedish children, we found the prevalence of idiopathic toe-walking to be approximately 5% (63 of 1,401). Of the 63 children who had ever been a toe-walker, 26 still were at the age of 5.5 years and were followed in the current study at 8 and 10 years of age. At the 8-year follow-up, parents were asked by telephone whether their child had received any treatment or diagnosis since the 5.5-year assessment, as well as to what extent (approximately 25%, 50%, 75%, or 100% of the time) the child still walked on the toes. At the visit when the children were 10 years of age, their parents were asked the same questions. All 26 children also underwent a neurological examination and an orthopaedic examination focusing on the lower extremities. RESULTS At 8 years of age, 6 of 26 children had ceased toe-walking, and by the age of 10 years, 50 (79%) of the original 63 patients had spontaneously ceased toe-walking. Idiopathic toe-walking did not result in contractures of the triceps surae. One subgroup of children displayed early contracture of the ankle and should thus not be considered idiopathic toe-walkers. Four of the children who still toe-walked at the age of 10 years demonstrated some neurodevelopmental comorbidity. CONCLUSIONS By the age of 10 years, 79% of the children who have ever been a toe-walker spontaneously develop a typical gait, without intervention or contractures of the ankle dorsiflexion. The diagnosis of short tendo Achilles should be retained as a separate diagnosis as there is a subset of children with this entity who should be treated early in childhood. Neurodevelopmental comorbidities are common among those who continue to toe-walk. LEVEL OF EVIDENCE Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Pähr Engström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Blekinge Hospital, Karlskrona, Sweden
| | - Kristina Tedroff
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Lorentzen J, Willerslev-Olsen M, Hüche Larsen H, Svane C, Forman C, Frisk R, Farmer SF, Kersting U, Nielsen JB. Feedforward neural control of toe walking in humans. J Physiol 2018; 596:2159-2172. [PMID: 29572934 DOI: 10.1113/jp275539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 03/12/2018] [Indexed: 12/13/2022] Open
Abstract
KEY POINTS Activation of ankle muscles at ground contact during toe walking is unaltered when sensory feedback is blocked or the ground is suddenly dropped. Responses in the soleus muscle to transcranial magnetic stimulation, but not peripheral nerve stimulation, are facilitated at ground contact during toe walking. We argue that toe walking is supported by feedforward control at ground contact. ABSTRACT Toe walking requires careful control of the ankle muscles in order to absorb the impact of ground contact and maintain a stable position of the joint. The present study aimed to clarify the peripheral and central neural mechanisms involved. Fifteen healthy adults walked on a treadmill (3.0 km h-1 ). Tibialis anterior (TA) and soleus (Sol) EMG, knee and ankle joint angles, and gastrocnemius-soleus muscle fascicle lengths were recorded. Peripheral and central contributions to the EMG activity were assessed by afferent blockade, H-reflex testing, transcranial magnetic brain stimulation (TMS) and sudden unloading of the planter flexor muscle-tendon complex. Sol EMG activity started prior to ground contact and remained high throughout stance. TA EMG activity, which is normally seen around ground contact during heel strike walking, was absent. Although stretch of the Achilles tendon-muscle complex was observed after ground contact, this was not associated with lengthening of the ankle plantar flexor muscle fascicles. Sol EMG around ground contact was not affected by ischaemic blockade of large-diameter sensory afferents, or the sudden removal of ground support shortly after toe contact. Soleus motor-evoked potentials elicited by TMS were facilitated immediately after ground contact, whereas Sol H-reflexes were not. These findings indicate that at the crucial time of ankle stabilization following ground contact, toe walking is governed by centrally mediated motor drive rather than sensory driven reflex mechanisms. These findings have implications for our understanding of the control of human gait during voluntary toe walking.
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Affiliation(s)
- Jakob Lorentzen
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,Elsass Institute, Charlottenlund, Denmark
| | - Maria Willerslev-Olsen
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,Elsass Institute, Charlottenlund, Denmark
| | | | - Christian Svane
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Christian Forman
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Rasmus Frisk
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,Elsass Institute, Charlottenlund, Denmark
| | - Simon Francis Farmer
- Sobell Department of Motor Neuroscience & Movement Disorders, Institute of Neurology, University College London & Department of Clinical Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Uwe Kersting
- Department of sensory-motor interaction, Aalborg university, Aalborg, Denmark
| | - Jens Bo Nielsen
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark.,Elsass Institute, Charlottenlund, Denmark
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Rossi EM, Nevalainen P, Mäenpää H, Lauronen L. Soleus H-Reflex and Its Modulation With Vibration in Idiopathic Toe Walkers and Typically Developing Children. J Child Neurol 2018; 33:351-358. [PMID: 29575996 DOI: 10.1177/0883073818759104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Idiopathic toe walking is a relatively common developmental condition often leading to secondary problems such as pain and muscle contractures in the lower extremities. The cause of idiopathic toe walking is unknown, which hinders the development of treatment strategies. To test whether children with idiopathic toe walking have functional alterations in their spinal motor circuits, we studied the properties of the soleus H-reflex and its modulation with vibration in 26 idiopathic toe walkers and 16 typically developing children. At the group level, the H-reflex properties did not differ, but at the individual level, in 7 of 25 idiopathic toe walkers, some of the H-reflex parameters fell out of normal limits of typically developing children. However, the H-reflex was suppressed by vibration to the Achilles tendon similarly in both the idiopathic toe walkers and typically developing children. In conclusion, idiopathic toe walking in some children can be associated with functional alterations in their spinal motor circuits.
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Affiliation(s)
- Essi Marttinen Rossi
- 1 Pediatric Neurology, Children's Hospital, University of Helsinki and Helsinki University Hospital, HUS, Finland
| | - Päivi Nevalainen
- 2 Clinical Neurophysiology, HUS Medical Imaging Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, HUS, Finland
| | - Helena Mäenpää
- 1 Pediatric Neurology, Children's Hospital, University of Helsinki and Helsinki University Hospital, HUS, Finland
| | - Leena Lauronen
- 2 Clinical Neurophysiology, HUS Medical Imaging Center, Children's Hospital, University of Helsinki and Helsinki University Hospital, HUS, Finland
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Soto Insuga V, Moreno Vinués B, Losada del Pozo R, Rodrigo Moreno M, Martínez González M, Cutillas Ruiz R, Mateos Carmen C. Do children with attention deficit and hyperactivity disorder (ADHD) have a different gait pattern? Relationship between idiopathic toe-walking and ADHD. Anales de Pediatría (English Edition) 2018. [DOI: 10.1016/j.anpede.2017.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Haynes KB, Wimberly RL, VanPelt JM, Jo CH, Riccio AI, Delgado MR. Toe Walking: A Neurological Perspective After Referral From Pediatric Orthopaedic Surgeons. J Pediatr Orthop 2018; 38:152-156. [PMID: 29309384 DOI: 10.1097/bpo.0000000000001115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Toe walking (TW) in children is often idiopathic in origin. Our purpose was to determine the incidence of a neurological etiology for TW in patients seen in the neurology clinic after referral from pediatric orthopaedic surgeons. METHODS We performed an Institutional Review Board approved retrospective review of 174 patients referred to the neurology clinic from orthopaedic surgeons at an academic pediatric tertiary care center between January 2010 and September 2015. Medical records were reviewed and data recorded including pertinent family history, birth history, age of initial ambulation, physical examination findings, and workup results including neuroimaging, neurophysiological studies, and findings of genetic testing and tissue biopsy. RESULTS Sixty-two percent (108/174) of patients were found to have a neurological etiology for TW. Final pathologic diagnoses were: 37% (40/108) previously undiagnosed cerebral palsy (CP), 16.7% (18/108) peripheral neuropathy, 15.7% (17/108) autism spectrum disorder, 13.9% (15/108) hereditary spastic paraparesis, 8.3% (9/108) attention deficit hyperactivity disorder, 5.6% (6/108) syndromic diagnosis, and 2.8% (3/108) spinal cord abnormality. Ankle equinus contractures were noted in idiopathic and neurological patients and did not indicate a pathologic origin. Seventy-one percent of unilateral toe walkers and 32% of bilateral but asymmetric toe walkers were diagnosed with CP (P<0.001). Twenty-six percent of 145 brain magnetic resonance imaging studies diagnosed CP. Of the 125 (72%) with spinal imaging, 3 had spinal pathology to account for TW. Fourteen percent of 87 subjects with an electromyography/nerve conduction study had abnormal results indicating a peripheral polyneuropathy. CONCLUSIONS An underlying pathologic diagnosis was found in 62% of patients referred to neurology for TW. A concerning birth history, delayed initial ambulation, unilateral TW, upper or lower motor neuron signs on examination, or behavioral features may suggest a pathologic diagnosis. Ankle contracture is not predictive of an abnormal diagnosis and can be found in idiopathic patients. CP, peripheral neuropathy, autism spectrum disorder, and hereditary spastic paraparesis are the most common pathologic diagnoses identified in our population. LEVEL OF EVIDENCE Level III-retrospective cohort.
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Affiliation(s)
| | - Robert L Wimberly
- Texas Scottish Rite Hospital for Children.,Department of Neurology and Neurotherapeutics at University of Texas Southwestern Medical Center
| | | | | | - Anthony I Riccio
- Texas Scottish Rite Hospital for Children.,Department of Neurology and Neurotherapeutics at University of Texas Southwestern Medical Center
| | - Mauricio R Delgado
- Texas Scottish Rite Hospital for Children.,Department of Orthopaedic Surgery at University of Texas Southwestern Medical Center, Dallas, TX
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Abstract
UNLABELLED The aim of this study was to determine whether persistent idiopathic toe walking leads to compensatory skeletal changes in the pediatric foot and ankle. Foot radiographs of children diagnosed with idiopathic toe walking and sex-matched and age-matched controls were retrospectively reviewed. Five blinded providers assessed the foot radiographs for skeletal changes to the ankle. The relationship between each measure and toe-walking status was examined. Providers observed radiographic evidence of skeletal changes of the talus in idiopathic toe walkers compared with controls, suggesting that persistent toe walking impacts the skeletal development of the talus. LEVEL OF EVIDENCE prognostic level III.
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Soto Insuga V, Moreno Vinués B, Losada Del Pozo R, Rodrigo Moreno M, Martínez González M, Cutillas Ruiz R, Mateos Carmen C. [Do children with attention deficit and hyperactivity disorder (ADHD) have a diferent gait pattern? Relationship between idiopathic toe-walking and ADHD]. An Pediatr (Barc) 2017; 88:191-195. [PMID: 28705637 DOI: 10.1016/j.anpedi.2017.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/09/2017] [Accepted: 01/23/2017] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Idiopathic toe-walking (ITW) is described as a gait pattern with no contact between the heels and the ground in children older than 3years. The diagnosis is clinical, making it necessary to rule out other neurological and orthopaedic conditions. A relationship between ITW and vestibular dysfunction and/or proprioceptive sensibility has been proposed. Children with neurodevelopmental disorders (autism, language and cognitive disorders) often have ITW. OBJECTIVES To determine the frequency of ITW in children with attention deficit disorder and hyperactivity (ADHD). PATIENTS AND METHOD A study was conducted on children diagnosed with ADHD, with normal neurological examination, with no alterations in MRI scan, cognitive disorder or autism. A complete clinical anamnesis was performed and Achilles shortening was measured with a goniometer. RESULTS The study included 312 children with a mean age of 11 years (73.7% boys). The ADHD combined subtype was the most frequent (53.8%), followed by the inattentive (44.9%), and hyperactive (1.3%). ITW was observed in 20.8% of patients, particularly in the combined subtype (P=.054). Only 32 of them (49.2%) had Achilles shortening. ITW was associated with sociability disorders (P=.01), absence of pain in legs (P=.022), and family history of ITW (P=.004). Only 11% had previously visited a doctor for this reason. CONCLUSIONS As in other neurodevelopmental disorders, children with ADHD have frequently more ITW and Achilles shortening than controls, especially if they presented with a social communication disorder or a family history of ITW. An early diagnosis is essential to establish effective treatments.
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Affiliation(s)
- Víctor Soto Insuga
- Servicio de Pediatría, Hospital Universitario Fundación Jiménez Díaz, Madrid, España.
| | - Beatriz Moreno Vinués
- Servicio de Pediatría, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
| | | | - María Rodrigo Moreno
- Servicio de Pediatría, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
| | | | - Raquel Cutillas Ruiz
- Servicio de Rehabilitación, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
| | - Carmen Mateos Carmen
- Servicio de Rehabilitación, Hospital Universitario Fundación Jiménez Díaz, Madrid, España
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Abstract
PURPOSE To evaluate interrater reliability and concurrent validity of the 50-ft walk test (FWT) for children with idiopathic toe walking (ITW). METHODS Thirty children, 6 to 13 years old, with ITW participated. During the 50-FWT, an accelerometer counted total steps. A physical therapist counted the number of toe-walking steps. The number of toe-walking steps was divided by the total steps to calculate a toe-walking percentage. Interrater reliability was assessed by correlating the toe-walking percentage obtained by 2 raters using an intraclass correlation coefficient. Concurrent validity was evaluated by correlating the toe-walking percentage calculated by the GAITRite and therapist using a Spearman ρ. RESULTS There was excellent interrater reliability and concurrent validity. Experience level did not impact the therapist's ability to identify a toe-walking step. CONCLUSIONS The 50-FWT demonstrated excellent interrater reliability and concurrent validity. It can be used to obtain a percentage of toe walking in children 6-13 years of age with ITW.
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Abstract
PURPOSE To assess the validity of accelerometer use in children with idiopathic toe walking (ITW). METHODS Seventy-five children, 2 to 13 years old, with ITW were videotaped ambulating 50 ft wearing a NL-1000 accelerometer. Because of concerns for accelerometer accuracy in young children, 2 groups were created: 5 years or younger (n = 45) and 6 years or older (n = 30). Step counts recorded via accelerometer and video were compared and correlated. RESULTS There was a significant difference in accelerometer and video step counts for 2- to 5-year-olds (W = 72.00, P < .001). No significant difference was found for 6- to 13-year-olds (W = 65.00, P = .24). Spearman ρ values were 0.78 and 0.92 for the 5 years or younger and 6 years or older groups, respectively. CONCLUSION Accelerometers accurately count steps in 6- to 13-year-olds with ITW but are inaccurate in 2- to 5-year-olds.
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Martín-Casas P, Meneses-Monroy A, Ballestero-Pérez R, Beneit-Montesinos JV, Atín-Arratibel MA, Portellano-Pérez JA. Dynamic pedobarographic classification of idiopathic toe-walkers for therapeutical indication. Clínica y Salud 2017. [DOI: 10.1016/j.clysa.2016.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Williams CM, Pacey V, de Bakker PB, Caserta AJ, Gray K, Engelbert RHH. Interventions for idiopathic toe walking. Cochrane Database of Systematic Reviews 2016. [DOI: 10.1002/14651858.cd012363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Cylie M Williams
- Monash University; Department of Physiotherapy; Frankston Victoria Australia
| | - Verity Pacey
- The Children's Hospital at Westmead; Department of Endocrinology; Cnr Hawkesbury Rd and Hainsworth St Westmead NSW Australia 2145
- Faculty of Medicine and Health Sciences, Macquarie University; Department of Health Professions; Sydney New South Wales Australia
| | - Pauline B de Bakker
- Amsterdam School of Health Professions, University of Applied Sciences Amsterdam; Education for Physiotherapy; Tafelbergweg 51, Roomnr. C1.43 Amsterdam Amsterdam Netherlands 1105 BD
| | - Antoni J Caserta
- Monash Health; Child and Family Team; 140-154 Sladen St Cranbourne Victoria Australia 3977
| | - Kelly Gray
- The Children's Hospital at Westmead; Department of Endocrinology; Cnr Hawkesbury Rd and Hainsworth St Westmead NSW Australia 2145
| | - Raoul HH Engelbert
- Department of Rehabilitation Medicine; Academic Medical Center Amsterdam; Amsterdam Amsterdam Netherlands
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49
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Fanchiang HD, Geil MD, Wu J, Ajisafe T, Chen YP. The Effects of Walking Surface on the Gait Pattern of Children With Idiopathic Toe Walking. J Child Neurol 2016; 31:858-63. [PMID: 26733505 DOI: 10.1177/0883073815624760] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 11/06/2015] [Indexed: 11/17/2022]
Abstract
Idiopathic toe walking treatments are not conclusively effective. This study investigated the effects of walking surface on gait parameters in children with idiopathic toe walking. Fifteen children with idiopathic toe walking and 15 typically developing children aged 4 to 10 years completed the study, which included a barefoot gait exam over three 4-m walkways. Each of the walkways was covered with a different surface: vinyl tile, carpet, and pea gravel. Temporal-spatial parameters were recorded along with a measure of early heel rise (HR32). Children with idiopathic toe walking and typically developing children shared similarly changed gait patterns on each surfaces. Only HR32 was significantly different between the groups (P < .001). Children with idiopathic toe walking showed significantly less toe-walking on the gravel walkway (P < .001). Walking surface plays a significant role in altering gait patterns in both children with idiopathic toe walking and typically developing children. Walking on a gravel surface should be further explored for idiopathic toe walking.
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Affiliation(s)
| | | | - Jianhua Wu
- Georgia State University, Atlanta, GA, USA
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Abstract
PURPOSE OF REVIEW The present review includes the most up-to-date literature on the causes, epidemiology, diagnosis, and treatment of toe walking. RECENT FINDINGS The prevalence of toe walking at age 5.5 years is 2% in normally developing children, and 41% in children with a neuropsychiatric diagnosis or developmental delays. A recent systematic review concluded that there is good evidence for casting and surgery in the treatment of idiopathic toe walking, with only surgery providing long-term results beyond 1 year. Botox combined with casting does not provide better outcomes compared with casting alone. Ankle-foot-orthoses restrict toe walking when worn, but children revert to equinus gait once the orthosis is removed. SUMMARY Toe walking can occur because of an underlying anatomic or neuromuscular condition, but in the majority of cases toe walking is idiopathic, without a discernable underlying cause. For some families, toe walking may simply be a cosmetic concern, whereas in other cases it can cause pain or functional issues. Treatment for toe walking is based on age, underlying cause, and the severity of tendon contracture. Described treatments include casting, chemical denervation, orthotics, physical therapy, and surgical lengthening of the gastroc-soleus-Achilles complex. A careful history, clinical exam, and selective diagnostic testing can be used to differentiate between different types of toe walking and determine the most appropriate treatment for each child.
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