toe walking (Full Version)

All Forums >> [RehabEdge Forum] >> Pediatrics



Message

cozziew -> toe walking (October 20, 2002 4:59:00 PM)

I am currently in outpt orthopedics but recently we had a peds pt that I am not too updated on. The kid is 2 years old and has been toe walking since 1 year when she started walking. We have tried various activites such as stickers on her heels, manual contact with ambulation but no success. I may be way off but what about orthotic with PF stop and articulating so that gait can remain normal. She has tight hams that we are stretching but can at least get to neutral with DF.
Thanks



Andrew M. Ball PT PhD -> Re: toe walking (October 20, 2002 5:50:00 PM)

Orthotic intervention may be a good strategy, but I'd advise you to also find the biomechanical root of the problem. If the scaps are retracted, that will throw the body forward on it's center of mass. If this is the case, you may want to try some bilateral reaching games as the serratus anterior is likely to be weak resulting from rhomboid overactivity. The scaps, in turn, may be retracted due to the child's desire to maintain trunk control despite poorly strenghened and coordinated lower trunk muscles. Test this on a swiss therapy ball, making sure to facilitate by moving the child's plevis and NOT the ball so as to elongate the weight bearing side.

If lower trunk control isn't a problem for this child (and it usually is in my experience of toe walkers), you may want to consider sensory integration dysfunctions and autistic behaviors in your diagnostic thought process.

Drew



Mindy -> Re: toe walking (October 22, 2002 11:18:00 AM)

Sorry I don't have the refferences with me, but I can get them to you if you are interested. Here are some interesting findings on toe-walking which may help to plan your treatment program. The plantarflexor tourqe and power required for toe-walking are LESS than that required for normal heel-toe gait. Quadriceps power is also less, but there is increased activity in the glutes. Loading response is increased in toe-walking, and this energy can be utilised to further reduce the power required in the lower limb muscles as it is translated into forward momentum - look at the spring-type gait seen just after toe-strike. In other words, what this may mean is that toe-walkers actually have weak plantar flexors (think of your muscular dystrophies)and besides stretching, you also need to strengthen them.
From clinical experiance, I have found articulated AFO's to be quite effective in treating toe-walkers, espescially before you gain adequate ROM (90 degrees is not adequate) as 1. they assist with continuous stretching throughout the day (you need at least 2 hours/day to improve ROM) 2. they prevent compensations of tight TA's such as Calcaneal valgus and loss of the longitudinal arch and 3. they help train a more normal sensory-motor gait experiance and break the existing gait pattern. I usually use the splints in therapy innitially for proprioceptive retraining, but once I have gained adequate range and the child can manage a normal heel-toe gait pattern voluntarily, ie no back-setting of knees or external rotation of lower extremities and adequate stride length, I normally do therapy without the splints and concentrate on strengthening (espescially eccentric plantarflexors)and proprioceptive retraining of the ankle joint. I then let the child wear the splints for a gradually reduced number of hours during the day. Don't forget the benfits of myofascial massage also.



Andrew M. Ball PT PhD -> Re: toe walking (October 22, 2002 2:06:00 PM)

I'd differ with Mindy on the idea about a hinged orthotic. She's on good company as Laura Case, PT, MS over at Duke (one of the best in the nation when it comes to orthotic decision making and fabrication, feels the same way). She feels that a better heelstrike is achieved with a hinged block, and I agree, especially for kids over the age of 4. I suggest, and it's just an opinion, that there are a few other things to consider.

Personally, for a 2 year old, I'd go with a pseudohinge (see Cascade's at [URL=http://www.dafo.com).]www.dafo.com).[/URL] My reasoning has more to do with the fact that the pseudohinge works, in biomechanical terms, almost exactly like the hinged-block. The difference is that it's narrower (as there are no metal pieces), and that makes it much easier for a parent to get in and out of shoes. The easier it is for a family to donn and doff, the more likely that it will actually be worn by the child. I may be a bit skewed in that I tend to work with parents with lower education levels than most, so I've found that for my population that ease of use beats a good parent education every time.

I'd rather see a near-perfect gait pattern and higher compliance than a perfect pattern that's not realized because the orhosis tends to end up in the closet and not on the kid's feet.

It's a matter of opinion, and a great example of how clinical science and evidence-based decision making must always be filtered through clinical art and clinical experience.

Drew



Mindy -> Re: toe walking (October 23, 2002 11:17:00 AM)

Good point Andrew, I guess it depends how good the orthotist you work with is. I tend to get my kids orthotics custom made by an excellent orthotist who specialises in paediatric orthotics so they are comfortable and easy to use in a normal shoe.



lesley -> Re: toe walking (January 2, 2003 12:17:00 PM)

One question about the toe walker, was there any significant history - slow development? use of baby walker? family history?
Lesley



carol rosenau -> Re: toe walking (October 1, 2003 11:54:00 AM)

[QUOTE]Originally posted by Mindy:
Good point Andrew, I guess it depends how good the orthotist you work with is. I tend to get my kids orthotics custom made by an excellent orthotist who specialises in paediatric orthotics so they are comfortable and easy to use in a normal shoe.[/QUOTE]

Do any of you have any advice for a 22 month old that is a unilateral toe walker? At what age do you start considering bracing?



Andrew M. Ball PT PhD -> Re: toe walking (October 20, 2002 5:50:00 PM)

Orthotic intervention may be a good strategy, but I'd advise you to also find the biomechanical root of the problem. If the scaps are retracted, that will throw the body forward on it's center of mass. If this is the case, you may want to try some bilateral reaching games as the serratus anterior is likely to be weak resulting from rhomboid overactivity. The scaps, in turn, may be retracted due to the child's desire to maintain trunk control despite poorly strenghened and coordinated lower trunk muscles. Test this on a swiss therapy ball, making sure to facilitate by moving the child's plevis and NOT the ball so as to elongate the weight bearing side.

If lower trunk control isn't a problem for this child (and it usually is in my experience of toe walkers), you may want to consider sensory integration dysfunctions and autistic behaviors in your diagnostic thought process.

Drew



Mindy -> Re: toe walking (October 22, 2002 11:18:00 AM)

Sorry I don't have the refferences with me, but I can get them to you if you are interested. Here are some interesting findings on toe-walking which may help to plan your treatment program. The plantarflexor tourqe and power required for toe-walking are LESS than that required for normal heel-toe gait. Quadriceps power is also less, but there is increased activity in the glutes. Loading response is increased in toe-walking, and this energy can be utilised to further reduce the power required in the lower limb muscles as it is translated into forward momentum - look at the spring-type gait seen just after toe-strike. In other words, what this may mean is that toe-walkers actually have weak plantar flexors (think of your muscular dystrophies)and besides stretching, you also need to strengthen them.
From clinical experiance, I have found articulated AFO's to be quite effective in treating toe-walkers, espescially before you gain adequate ROM (90 degrees is not adequate) as 1. they assist with continuous stretching throughout the day (you need at least 2 hours/day to improve ROM) 2. they prevent compensations of tight TA's such as Calcaneal valgus and loss of the longitudinal arch and 3. they help train a more normal sensory-motor gait experiance and break the existing gait pattern. I usually use the splints in therapy innitially for proprioceptive retraining, but once I have gained adequate range and the child can manage a normal heel-toe gait pattern voluntarily, ie no back-setting of knees or external rotation of lower extremities and adequate stride length, I normally do therapy without the splints and concentrate on strengthening (espescially eccentric plantarflexors)and proprioceptive retraining of the ankle joint. I then let the child wear the splints for a gradually reduced number of hours during the day. Don't forget the benfits of myofascial massage also.



Andrew M. Ball PT PhD -> Re: toe walking (October 22, 2002 2:06:00 PM)

I'd differ with Mindy on the idea about a hinged orthotic. She's on good company as Laura Case, PT, MS over at Duke (one of the best in the nation when it comes to orthotic decision making and fabrication, feels the same way). She feels that a better heelstrike is achieved with a hinged block, and I agree, especially for kids over the age of 4. I suggest, and it's just an opinion, that there are a few other things to consider.

Personally, for a 2 year old, I'd go with a pseudohinge (see Cascade's at [URL=http://www.dafo.com).]www.dafo.com).[/URL] My reasoning has more to do with the fact that the pseudohinge works, in biomechanical terms, almost exactly like the hinged-block. The difference is that it's narrower (as there are no metal pieces), and that makes it much easier for a parent to get in and out of shoes. The easier it is for a family to donn and doff, the more likely that it will actually be worn by the child. I may be a bit skewed in that I tend to work with parents with lower education levels than most, so I've found that for my population that ease of use beats a good parent education every time.

I'd rather see a near-perfect gait pattern and higher compliance than a perfect pattern that's not realized because the orhosis tends to end up in the closet and not on the kid's feet.

It's a matter of opinion, and a great example of how clinical science and evidence-based decision making must always be filtered through clinical art and clinical experience.

Drew



Mindy -> Re: toe walking (October 23, 2002 11:17:00 AM)

Good point Andrew, I guess it depends how good the orthotist you work with is. I tend to get my kids orthotics custom made by an excellent orthotist who specialises in paediatric orthotics so they are comfortable and easy to use in a normal shoe.



lesley -> Re: toe walking (January 2, 2003 12:17:00 PM)

One question about the toe walker, was there any significant history - slow development? use of baby walker? family history?
Lesley



carol rosenau -> Re: toe walking (October 1, 2003 11:54:00 AM)

[QUOTE]Originally posted by Mindy:
Good point Andrew, I guess it depends how good the orthotist you work with is. I tend to get my kids orthotics custom made by an excellent orthotist who specialises in paediatric orthotics so they are comfortable and easy to use in a normal shoe.[/QUOTE]

Do any of you have any advice for a 22 month old that is a unilateral toe walker? At what age do you start considering bracing?



Page: [1]



Forum Software © ASPPlayground.NET Advanced Edition 2.5.5 Unicode

0.078