Is Idiopathic Toe Walking Really Idiopathic?

NewsBot · Mar 30, 2023

Ankle Kinematics Characterization in Children with Idiopathic Toe Walking: Does the Foot Model Change the Clinical Evaluation?
Paolo Brasiliano et al
Healthcare (Basel). 2023 Mar 16;11(6):873.

Idiopathic toe walking (ITW) is a gait deviation characterized by forefoot contact with the ground, sometimes observed in children, that alters ankle kinematics, possibly leading to health-related issues. When studying foot and ankle gait deviations, the adoption of a single-segment foot model entails a significant simplification of foot and ankle movement, and thus may potentially mask some important foot dynamics. Differences in ankle kinematics between single- (conventional gait model, PiG, or Davis) and multi-segment (Oxford foot model, OFM) foot models were investigated in children with ITW. Fourteen participants were enrolled in the study and underwent instrumented gait analysis. Children were asked to walk barefoot and while wearing a foot orthosis that modified the ankle movement pattern toward a more physiological one without blocking foot intrinsic motion. ITW gait abnormalities, e.g., the absence of heel rocker and the presence of anticipated forefoot rocker, were found/not found according to the foot model. Walking conditions significantly interacted with the foot model effect. Finally, the different characterization of gait abnormalities led to a different classification of ITW, with a possible impact on the clinical evaluation. Due to its closer adhesion to ankle anatomy and to its sensitivity to ITW peculiarities, OFM may be preferable for instrumented gait analysis in this population.
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NewsBot · May 3, 2023

Dense & Attention Convolutional Neural Networks for Toe Walking Recognition
Junde Chen, Rahul Soangra, Marybeth Grant-Beuttler, Y A Nanehkaran, Yuxin Wen
IEEE Trans Neural Syst Rehabil Eng. 2023 May 2;PP. doi: 10.1109/TNSRE.2023.3272362. Online ahead of print.

Idiopathic toe walking (ITW) is a gait disorder where children's initial contacts show limited or no heel touch during the gait cycle. Toe walking can lead to poor balance, increased risk of falling or tripping, leg pain, and stunted growth in children. Early detection and identification can facilitate targeted interventions for children diagnosed with ITW. This study proposes a new one-dimensional (1D) Dense & Attention convolutional network architecture, which is termed as the DANet, to detect idiopathic toe walking. The dense block is integrated into the network to maximize information transfer and avoid missed features. Further, the attention modules are incorporated into the network to highlight useful features while suppressing unwanted noises. Also, the Focal Loss function is enhanced to alleviate the imbalance sample issue. The proposed approach outperforms other methods and obtains a superior performance. It achieves a test recall of 88.91% for recognizing idiopathic toe walking on the local dataset collected from real-world experimental scenarios. To ensure the scalability and generalizability of the proposed approach, the algorithm is further validated through the publicly available datasets, and the proposed approach achieves an average precision, recall, and F1-Score of 89.34%, 91.50%, and 92.04%, respectively. Experimental results present a competitive performance and demonstrate the validity and feasibility of the proposed approach.
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NewsBot · May 9, 2023

Stepping Beyond Efficacy: Understanding the User Experience of Wearables for Children with Idiopathic Toe Walking in the Natural Setting
LouAnne Boyd et al
Human Factors in Healthcare; Volume 3, June 2023, 100044

Highlights
•Important first-time look at family experiences regarding a device for rehabilitation.
•Insights on wearables for physical therapy has a broader impact to other wearables.
•Novel application of Machine Learning to classify gait.
•Provides an important step to ensure wearable devices are usable, acceptable, and adopted.
•This work explores these vital human factor parameters.
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Idiopathic Toe Walking is an atypical gait pattern that results in limited mobility, pain, and higher risk of falling. Current therapeutic interventions lack the ability to be implemented outside the clinic or lab. Beyond this, it is unclear if gait analysis and real-time feedback is technologically feasible to attain within a user's natural environment. In our research we aimed to understand the child and parent participants’ experience of an innovative wearable system. We surveyed children and parents after the deployment of a functional prototype with real time vibrotactile feedback for awareness of toe walking via a shoe insert paired with a smartphone for visual feedback. Findings revealed insights into design considerations for wearable technologies for children. Factors such as comfort of using the system (physically and psychologically), child's perception and response to the vibrotactile feedback, and children and parents’ perception of reduced fall risk, pain, and stigma are discussed.
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NewsBot · May 16, 2023

Feature Selection using Random Forest Classifier
for Foot Strike Event Detection in Toe Walkers
Meghna Desai, Viral Kapadia
Computational Intelligence and Machine Learning; e-ISSN: 2582-7464 Vol-4, Issue-1, April 2023

Automated Gait event identification of Foot Strike (FS) and Foot Off (FO) in pathological gait data, can be time saving in comparison to
conventional manual annotations done currently. Identification of FS and FO allows breaking walking trials into gait cycles and hence aids
in comparison of gait parameters like joint angles, forces and moments across gait cycles. Automated Gait Event Detection is also useful in
development of wearable sensor devices and robotic systems that assist gait. Researchers have proposed several automatic gait event
detection algorithms based on kinematic parameters and systematic study of the literature suggests specific parameters to have higher
contribution in identification of FS event in all common pathological gait patterns. We used Random Forest Classifier Feature selection
technique to identify high contributing features in FS event in toe walking pediatric pathological gait dataset and the results suggest high
similarity in selected features by the machine learning technique with those suggested by popular event detection algorithms based on
kinematic parameters for pathological gait. Hence we conclude that RFC feature selection is suitable for feature selection in toe walkers gait
dataset for event detection purpose.
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NewsBot · May 16, 2023

Some children with idiopathic toe walking display sensory processing difficulties but not all: a systematic review
Jack H Donne et al
Acta Paediatr. 2023 May 10

Aim: Idiopathic toe walking (ITW) is a diagnosis for children who toe walk without another diagnosis known to cause toe walking. Recent research has suggested that children with ITW may have mild motor planning challenges and sensory processing differences. The primary aim of this systematic review was to determine whether children diagnosed with ITW have differences in their sensory processing compared to typically developing children. Secondary aims included determining how sensory processing was assessed in this population and documenting the broad clinometric and psychometric properties of any assessment tools.

Methods: MEDLINE, CINAHL, AMED and Embase were searched for relevant literature in English. Studies were eligible for inclusion if they described children aged 3 and 18 with idiopathic toe walking and reported a sensory processing domain.

Results: Twelve articles met the inclusion criteria; however, only two papers included data permitting meta-analysis. Meta-analyses of vibration perception threshold using a random effect model were not significant (P=0.31). Other data were synthesised by narrative and showed a high heterogeneity across multiple sensory processing domains.

Conclusion: This study highlights that despite children with ITW often conceptualised as possessing sensory processing challenges, there is little evidence supporting this theory. Further research on sensory processing in children with this gait pattern is necessary.
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NewsBot · Jul 24, 2023

Functional Bandaging in Children with Idiopathic Toe-Walking
Deniz Tuncer et al
J Am Podiatr Med Assoc. 2023 May-Jun;113(3):19-182R1. doi: 10.7547/19-182R1.

Background: Idiopathic toe-walking (ITW) is a persistent gait pattern with no known etiology characterized as premature heel rise or no heel contact. We investigated the effects of functional bandaging in children with ITW on heel contact during stance phase and on gait quality.

Methods: Nineteen children aged 4 to 16 years with ITW and ten age-matched healthy children were included in the study. Elastic adhesive bandages were applied to children with ITW to assist with dorsiflexion. Before bandaging (T0) and immediately (T1) and 1 week (T2) after initial bandaging, the initial contact, loading response, and midstance subphases of gait were analyzed using light pressure sensors and the Edinburgh Visual Gait Score (EVGS). Ten age-matched children with typical gait participated for comparison in T0. The data were analyzed with Friedman and Wilcoxon signed rank tests for within-group comparisons and Mann-Whitney U tests for between-group comparisons.

Results: In T0, for the ITW group, no heel contact was observed during stance. In T1, all of the participants achieved heel contact at initial contact and loading response and 56.8% at midstance. In T2, all of the heels continued contact at initial contact and loading response and 54.3% at midstance. The EVGS significantly improved. The Friedman test showed that there were noteworthy improvements between T0-T1 and T0-T2 in video-based observational gait analysis and EVGSs (P < .001), although no difference was found between T1-T2 in video-based observational gait analysis (P = .913) and EVGSs (P = .450).

Conclusions: In children with ITW, dorsiflexion assistive functional bandaging was an effective tool to help achieve heel contact on the ground and improve walking quality for a short period after application. Further studies with longer follow-up and larger sample sizes are required to confirm the long-term therapeutic effects of this promising functional bandaging.
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NewsBot · Aug 1, 2023

Toe-walking and its impact on first and second rocker in gait patterns with different degrees of artificially emulated soleus and gastrocnemius contracture
M. Attias et al
Gait & Posture; Volume 105, September 2023, Pages 104-109

Highlights
•An exoskeleton artificially emulated contractures during walking at the ankle level.
•Gastrocnemius and soleus were limited to 0°, −10°, −20° and −30° dorsiflexion.
•First and second rocker during walking were analysed.
•These findings could contribute to a better understanding of certain hypotheses that may aid in CGA interpretation.
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Background
Toe-walking is one of the most common gait deviations (due to soleus and/or gastrocnemius muscle contractures), compromising the first (heel rocker) and second (ankle rocker) of the foot during walking.

The aim of this study is to evaluate the effect of emulated artificially gastrocnemius and soleus contractures on the first and second rocker during walking.

Method
An exoskeleton was built to emulate contractures of the bilateral gastrocnemius and soleus muscles. Ten healthy participants were recruited to walk under the following conditions: without emulated contractures or with bilateral emulated contractures at 0°,10°, 20° and 30° of plantarflexion of the soleus or gastrocnemius in order to create an artificial restriction of dorsiflexion ankle movement. A linear regression from the ankle plantar-dorsiflexion angle pattern was performed on 0–5 % of the gait cycle (first rocker) and on 12–31 % of the gait cycle (second rocker) to compute the slope of the curve. The proportion of participants with the presence of the first and second rocker was then computed. A Statistical Parametric Mapping (SPM) analysis assessed the kinematic variations among different degrees of emulated contractures.

Findings
The first and second rockers are completely absent from 10° of plantarflexion emulated contracture. The data indicate there was a non-linear shift of the gait pattern of the ankle kinematics and an important shift toward plantarflexion values with the loss of the rockers.

Interpretation
This study suggests that toe-walking in the experimental simulation situation is not necessarily due to a high emulated contracture level and can occur with a small emulated contracture by an adaptation choice.

This study may improve interpretation of clinical gait analysis and shows that the link between the level of gastrocnemius/soleus emulated contracture and progression of toe-walking (increased plantarflexion during gait) is not linear.
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NewsBot · Aug 7, 2023

Exploring OT for Idiopathic Toe Walking: Comparing Interdisciplinary Practices
M. Irma Alvarado, PhD, OT/L, FAOTA; Cylie Williams, PhD, DPM; Leigh Lehman; Ileana S. McCaigue, OTR; Delaney Doyle; Katy Hendry; Olivia Trull; Kylie Ellington; Kylie Ellington, MS, OTR/L, CPAM
The American Journal of Occupational Therapy, 2023, Vol. 77(Supplement_2), 7711505178p1.

PURPOSE: OTs work with children to ameliorate the lasting effects of idiopathic toe walking (ITW). A variety of treatment approaches and different therapeutic outcomes are reported. Minimal research exists on the variety of interventions used by professionals to address ITW or OT perspectives for treating ITW. The purpose of this study was to examine OT practice for children with ITW compared to other healthcare professionals from a larger study that did not include OT data (Williams, Gray, et al., 2020). The research question asked, Does occupational therapy differ significantly in therapy for ITW compared to other health professionals?

DESIGN: This quasi-experimental exploratory study used survey data from a Qualtrics survey adapted from a survey on ITW treatments used by a variety of professionals (Williams, Gray, et al., 2020) that excluded OT data due to low response rate. Williams’ survey was replicated with OTs recruited via the survey sent to AOTA, WFOT,and state OT associations with 54 OT responses.

METHOD: Chi square analyses compared interventions use OT compared with other healthcare professionals’ responses from Williams, et al. survey. Simple percentages determined the discipline that used a treatment most frequently.

RESULTS: Significant differences, p values <0.001 were found indicating OT used more motor control strategies, sensory integration, whole body vibration, biofeedback, and vision training. Significant differences were found for other professionals’ use of serial casting, orthotics, stretching, and watch and wait approach.

CONCLUSION: OTs training in sensory integration/sensory approaches, reflex integration, and motor control strategies corresponded with differences in treatment approaches and interventions used by OTs compared to other professionals.

IMPACT STATEMENT: Findings delineate the role of OT and raise awareness of the need for consistent terminology when describing OT rationale for treating ITW.
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NewsBot · Aug 31, 2023

Gut Microbiome Dysbiosis as a Potential Risk Factor for Idiopathic Toe-Walking in Children: A Review
Svetlana Kononova et al
Int. J. Mol. Sci. 2023, 24(17), 13204; https://doi.org/10.3390/ijms241713204

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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NewsBot · Sep 4, 2023

A Pilot Study of Idiopathic Toe Walking: Measures and Outcomes
Debra Hines,Amy Armstrong-Heimsoth &Sarah A. Schoen
Received 28 Mar 2023, Accepted 06 Aug 2023, Published online: 20 Aug 2023

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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NewsBot · Dec 12, 2023

Idiopathic Toe Walking: What’s New? An Integrative Review. P
Santos, L.D.L.; Generoso, T.O.; De Angeli, L.R.A.; Blumetti, F.C.; Barcelos, F.M.
Preprints 2023, 2023120331. https://doi.org/10.20944/preprints202312.0331.v1

Background: Idiopathic Toe Walking (ITW) is the persistence of a forefoot strike pattern at initial contact while walking beyond the age of three years, in the absence of other justifiable causes. This review aims to consolidate the current knowledge on the subject and to highlight recent advancements in literature. Methods: We conducted an electronic search in the following databases up to June 2023: Ovid MEDLINE, EBSCO, Embase, CINAHL Plus, and PubMed. The PICO framework was employed to define search terms. Results: Despite considerable methodological heterogeneity among studies, we found a stronger inclination toward investigating etiological and prognostic factors. There is a trend for a higher prevalence in boys with a positive family history. Novel classifications have been proposed to improve differential diagnosis. Among conservative treatment options, there is stronger evidence for gait improvement with the use of serial casting followed by orthoses. Severe cases may benefit from surgical Zone III gastrocsoleus lengthening. Conclusion: Further studies with standardized methodologies are required to clarify questions about the etiology, classification, and treatment of this condition. Nonetheless, there is a higher level of evidence supporting conservative treatments with serial casting and orthoses, as well as gastrocsoleus Zone III surgical lengthening for severe cases in the second decade of life.
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NewsBot · Dec 26, 2023

Predictive simulations identify potential neuromuscular contributors to idiopathic toe walking
Kirsten Veerkamp et al
Source

Highlights
•Predictive forward simulations with a plantarflexor contracture resulted in toe walking.
•The simulation matched experimental gait data from children with idiopathic toe walking.
•Both contracture and altered neural control could contribute to this idiopathic toe walking.
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Background
Most cases of toe walking in children are idiopathic. We used pathology-specific neuromusculoskeletal predictive simulations to identify potential underlying neural and muscular mechanisms contributing to idiopathic toe walking.
Methods
A musculotendon contracture was added to the ankle plantarflexors of a generic musculoskeletal model to represent a pathology-specific contracture model, matching the reduced ankle dorsiflexion range-of-motion in a cohort of children with idiopathic toe walking. This model was employed in a forward dynamic simulation controlled by reflexes and supraspinal drive, governed by a multi-objective cost function to predict gait patterns with the contracture model. We validated the predicted gait using experimental gait data from children with idiopathic toe walking with ankle contracture, by calculating the root mean square errors averaged over all biomechanical variables.
Findings
A predictive simulation with the pathology-specific model with contracture approached experimental ITW data (root mean square error = 1.37SD). Gastrocnemius activation was doubled from typical gait simulations, but lacked a peak in early stance as present in electromyography. This synthesised idiopathic toe walking was more costly for all cost function criteria than typical gait simulation. Also, it employed a different neural control strategy, with increased length- and velocity-based reflex gains to the plantarflexors in early stance and swing than typical gait simulations.
Interpretation
The simulations provide insights into how a musculotendon contracture combined with altered neural control could contribute to idiopathic toe walking. Insights into these neuromuscular mechanisms could guide future computational and experimental studies to gain improved insight into the cause of idiopathic toe walking.
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NewsBot · Feb 3, 2024

Health-related Quality of Life in Idiopathic Toe Walkers: A Multicenter Prospective Cross-sectional Study
Morrow, Eileen et al
Journal of Pediatric Orthopaedics ():10.1097/BPO.0000000000002620, January 26, 2024.

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

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

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

Conclusions:
ITW in children is associated with an impairment in HRQoL, not only across the physical domain but also the school and play and emotional domains. The more severe the equinus contracture, the worse the physical domain scores.
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NewsBot · Feb 26, 2024

Surgery may be best treatment for idiopathic toe-walking in pediatric patients

Key takeaways:
Surgery was linked with higher rates of toe-walking resolution vs. casting and physical therapy or orthoses.
Surgery was linked with better range of motion vs. casting and physical therapy or orthoses.
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NewsBot · Feb 29, 2024

Further evaluation of a hands-on-shoulder plus praise procedure to reduce toe walking
David A. Wilder, Christina Sheppard, Franchesca Izquierdo, Kira Flynn
01 November 2023

Idiopathic toe walking (ITW) refers to ambulation with a toe-to-toe gait in the absence of a known cause. Although it is exhibited by typically developing children, it is more common among children with autism spectrum disorder (ASD). Persistent ITW can cause several long-term medical problems, including ankle deformities and balance and posture abnormalities. In the current study, we first conducted a series of no interaction or alone conditions to verify that ITW exhibited by four children with ASD persisted in the absence of social consequences. We then evaluated a hands-on-shoulder plus praise procedure in which gentle pressure is applied to participants' shoulders to prompt their heels to contact the ground, along with praise for appropriate steps in order to reduce ITW. Results suggest that the procedure was effective with all participants, and measures of social validity indicate that caregivers approved of the procedure. We discuss the results in terms of the putative mechanisms responsible for the effects of the procedure as well as the conditions under which the procedure might be used.
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Is Idiopathic Toe Walking Really Idiopathic?

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Is Idiopathic Toe Walking Really Idiopathic?

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Unraveling the mysteries of idiopathic toe walking (Melbourne)

Neuropsychiatric symptoms and problems among children with idiopathic toe-walking

The Prevalence and Course of Idiopathic Toe-Walking in 5-Year-Old Children

Online survey on idiopathic toe walking and Quality of Life

Online survey on idiopathic toe walking and Quality of Life

Idiopathic toewalking in children

Idiopathic toe walking and sensory processing dysfunction

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