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Motor control intervention for toe walking

Discussion in 'Pediatrics' started by NewsBot, Mar 8, 2011.

  1. NewsBot

    NewsBot The Admin that posts the news.


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    Effects of motor control intervention for children with idiopathic toe walking: a 5-case series.
    Clark E, Sweeney JK, Yocum A, McCoy SW.
    Pediatr Phys Ther. 2010 Winter;22(4):417-26.
  2. Admin2

    Admin2 Administrator Staff Member

    Related threads:
    Other threads tagged with toe walking
  3. Bug

    Bug Well-Known Member

    What an excellent study with initially disappointing results. Another treatment bites the dust for these kids. I hope they follow these children though to see long term what if any difference it has made.
  4. RobinP

    RobinP Well-Known Member

    Hi Cylie,

    Any pearls of wisdom from you for treatment, anacdotal or otherwise? Must confess to managing parent expectation in these cases more than managing the patient.

  5. Bug

    Bug Well-Known Member

    In my dreams I have pearls of wisdom about toe walkers Robin, unfortunately the reality is, neither pearls nor wisdom reside here. The more I know about them, they harder they are. However I think the key for us is to maintain range and accept that the gait pattern will in all probability continue, getting lower with age.

    Encouraging parents that obtaining the maximum ankle range is the most important component of treatment. We mix and match our treatment dependent on severity of equinus and concern and dedication of parents. We need the parents to accept even with range, the gait will continue too.

    At the moment we put in triplanar wedges, carbon fibre plates in shoes, orthotics, serial casting and referral for botox. Every child though gets eccentric or calf stretches on an incline board, most get weight shift exercises to help them remember where their heels are and lately I've been having a bit of fun with mixed results with kinesio tape. I think the trick is understanding the profile of the child and what might work with them.
  6. footfan

    footfan Active Member

    Cylie it is my understanding that BTX-A is only just being trialed for use in ITW http://clinicaltrials.gov/ct2/show/NCT00175669 , does your clinic use it already???

  7. Bug

    Bug Well-Known Member

    It has been used for the past couple of years in the toe walking clinic at Monash Medical Children's in Melbourne. As a treatment, not as a trial. I'm not associated at all with this clinic but work in the same service and have many patients that attend for assessment and treatment. Not every child gets all or one of those, just reread that and it should read:

    They aren't the only ones:

    The Effect of Botulinum Toxin Type a Combined with Physical Therapy on Gait in Children with Idiopathic Toe Walking
  8. pods86

    pods86 Member

    Hi Cylie, can I ask in what instances and how you have been using kenisio taping. thanks
  9. Bug

    Bug Well-Known Member

    I've only tried it on two now with varied responses. In kids with a normal Gastroc and soleus range I taped Tib Ant to remind it to function. It worked really well for a short period of time in one, longer in the other however you can't get the muscle taped for ages.

    It at least gave me something to work on and to show the parents these kids improve their gait with the muscles working/firing at the right time. Not convinced it is a long term solution but instead a diagnostic tool.
  10. footdrcb

    footdrcb Active Member

    I have found not ONE adult who walks around on their toes.... So i guess you could call the condition self limiting...
    A bit like potty training ...It eventually sorts itself out .

    That is my standard advice to parents that bring a toe walking child in ....Usually worried because a well meaning grandparent or great aunt has told them it will affect the childs walking forever

  11. Bug

    Bug Well-Known Member

    FDCB, it's interesting, about 20% of my toe walkers, the parents still do at times. The literature also supports this. I work with one and have had a recent student that did also, all without a medical reason.

    The thing with toe walkers, they are good at hiding it if they want to. They have tighter gastroc's and soleus and we know the long term impact of this. I don't think it is good enough to dismiss it all. I dismiss the gait as they generally will keep doing it regardless of type of treatment but aim for maintenance of good length.
  12. footdrcb

    footdrcb Active Member

    Ok...great I respect that ..but do they have pain?????
    Pain is my single biggest diagnostic tool....if a patient comes to me with pes planus at 45 and has no pain ..i leave him alone...it the toe walkers come in and they have NO symptoms....leave them alone.....we cannot expect all humans to fall into a category that we agree with ....albert einstein was a disaster ,so was beethoven.......one of 8 kids 5 of other siblings with deformities..... Brad Bevan the most decorated triathete in Australia has hyperpronation and a medially subluxed navicular....but he wins and has no symptoms......My theory is ...If it is not broken ...dont try and fix it
    Kind regards

  13. footdrcb

    footdrcb Active Member

    Hey ..hence your permanent state of confusion....I live in that realm too....Life and people are a mystery .... Nice to chat with you

  14. footdrcb

    footdrcb Active Member

    All that stuff is waffle....... With respect....just let it be...... ask yourself this question .. "does it interfere with their life" if the answer is NO ...then leave it alone....dont try to fix what is perhaps normal for someone

  15. RobinP

    RobinP Well-Known Member

    Not that I disagree with the sentiment that "if it ain't broke don't fix it", however, bullying at school is a fairly.major and legitimate reason for being a concerned parent as far as toe walking is concerned.

  16. FDCB in patients who have any type of triceps surea equinus or have any type of plantar fascia or forefoot pain that can be associated tension in the triceps surea do you ask if they were toe walkers when they were children ?

    Also what do you think about the effects of Davis law and toe walking ?
  17. Bug

    Bug Well-Known Member

    So do I only treat the ones that are in pain and get leg cramps and leave the others alone that are just almost not tight enough yet but give them another 12-18 months without stretches and they will?

    The gastroc/soleus muscle is designed to be a certain length for good foot and ankle function. Longitudinal studies show these kids continue to toe walk, have a decreased ankle range and an external foot placement position compared to their peers. Sure, don't treat the gait, I get that, but treat the length.

    As for, "does it influence with their life?" Did you ask them? My case load is predominently toe walkers and I ask that of a lot of them and at least 1/2 to 2/3's of them especially the older ones: don't want to walk like it, don't want to be teased and don't want to be different. If you ask a 4 year old that, you will never get a sensible answer, ask a 9 year old and it will be very different.

    Sorry, doesn't cut it with me, kids often don't get pain until things are really messed up. Kids with CP, generally don't get pain until they are older, kids with CMT and MD often don't get pain but have gait disturbances, kids on the spectrum don't or can't express pain. We still need to work with that is normal and what is abnormal and try to less the impact of the thing that is abnormal. This is why we have standardised tests and assessments.

    We know from past studies these kids perform poorly on balance and motor tasks so yes, it does interfere with their lives, it makes it difficult to perform to the same standard as their peers.

    Sure be realistic with your treatment and outcomes, but don't dismiss them or their parent concerns as I get sick of the number of older toe walking kids and teenagers that come in and see me that have been told they will grow out of it by my colleagues. What would be more beneficial is if parent were told, they will probably keep toe walking but in the interim, how about we just make sure their muscles stay long enough, that they can hop, skip, jump etc and if needed a referral for anything else that isn't up to scratch that tends to go hand in hand with the gait pattern ie: Speech, fine motor etc.....
  18. Bug

    Bug Well-Known Member

    PS: Mike...want to collect some data together :)
  19. footdrcb

    footdrcb Active Member

    Never thought of that my friend........ Craig
  20. footdrcb

    footdrcb Active Member

    Holy Hell ..you take life pretty seriously ......Kids just sort themselves out....sooner or later.....Have you ever seen an adult that toe walks...????? I rest my case...

    Love me or hate me ......Sometimes you guys think too much .....:)
  21. footdrcb

    footdrcb Active Member

    Davis Law is something I know nothing about ...please enlighten me Mike...>Good to chat with you mate

    FDCB >>>...:)
  22. footdrcb

    footdrcb Active Member

  23. footdrcb

    footdrcb Active Member

    Also....This type of conversation is good...You have had some buttons pushed.... thats great......tell me what you know so I may learn more....I really mean that..
    Nice to hear your honest opinion....You are obviously a very bright and dedicated practitioner...

    Nice to chat with you

  24. Would be a good one, Ive got a few too many pans on the fire at the moment, and the Kitchen is getting rather hot - Rain Check ? :drinks
  25. this is off the internet...

    Ok Heres my take of Davis law in this case.

    2 year old toe walker, muscle group, triceps surea will over time get stronger, from holding the heel up, and resiting elongation from Ground reaction force under the forefoot. It will also get shorter. ie the muscle and tendon has remodeled - Davis law.

    The other problem is that now the Tibialis Anterior muscle is elongated and weak - Davis law.

    Now over time the heel may or may not start come in contact with the ground - ie toe walking stops - but generally these patients if they have toe walked for a couple of years will still have this muscle imbalance and often will get symptoms which can be related back to Short, strong triceps surea muscle groups. So while the gait looks more normal - kinematics the force balance - kinetic is not and thus symptoms.

    Does that help ?
  26. Bug

    Bug Well-Known Member

    Mike - definite rain check :D kitchen is smokin' here too. That is a lovely explanation of Davis law and it's application to toe walkers. Also, would you give that poor Donkey some coffee!!

    As for kids with ITW having a family history, well documented:

    Familial link

    The body of this talks about 30% with a family history

    A quick google will give you more. As for the parents, that one is anecdotal and often the mum telling me dad does it in the morning still or on cold tiles etc and dad doesn't realise he does.
  27. Cylie Great, rain check and will do - Coffee that is.

    PS FDCB - I had a patient 50´s toe walked his whole life - long story short - after great effort from patient - gait retraining, stretching etc walked with heel strike and not too early a heel lift - Symptoms gone.

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