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I think there is an important distinction to be made in the case of idiopathic toe walkers.
An idiopathic toe walker may not necessarily have an equinous present, although I am sure there is a high percentage correlation.
If I were being pedantic, I would argue that idiopathic (no known cause) toe walking is an inaccurate diagnosis in the presence of an equinous contracture. It is probably worth talking about ankle joint stiffness as opposed to reduced range of motion(RoM) but I think I will avoid that subject for now
For the sake of arguement, let's say that there is an equinous present, reducing the equinous may well reduce the toe walking and I would very rarely not advocate a fairly intense stretching programme or building a wedge/ramp to use when brushing teeth etc (Trevor Prior style for those that were at Summer school). In cases where I felt that it was a major issue to the parents and the parents and child were well motivated, I might advocate serial plastering or AFO usage to speed up the process.
In many cases, if it is the school health visitor that has flagged up the problem, concordance with any treatment modalities carries a much lower success rate than with parents who are well motivated and have actively sought treatment.
In a true idiopathic toe walker with no equinous/ankle joint stiffness, what am I treating? An unusual gait pattern/parents expectations about their child? In my book that makes treatment pretty difficult to justify, especially when I anecdotally know that success rates with this type of patient are very poor(mainly due to concordance, not the ineffectiveness of treatment). I will generally still advise stretching as less ankle joint stiffness is rarely a bad thing(although i did start a thread on low ankle joint stiffness recently and there appeared to be little evidence of problems)
I hope this helps
Robin
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As far as the lengthening procedure I would agree that in and of itself it is not a great solution.
Even though there is literature to support the casting/botox solution I'm not sold on the long term benefits of this. Yes this is "conservative" but it doesn't knock out the spasticity issue either. Even if you "lengthen" the Gatro-Soleal complex with botox/casting, we are back to the same issue of the return of deformity due to progressive spasticity. I have not seen good long term results with this, but have had good experience with the tendo-achilles advancement/recession combination. I'm also an advocate of serial lengthenings with time. I believe there was a study that advocated this out of Europe some time ago, but can't seem to locate it.I have found that the bracing eventually causes irritation and that new braces are required often and many times the parents get tired of this modality and would like to at least try something more definitive.
I'm 100% with you on conservative management attempts, but ultimately I end up seeing the patients whose families are "been there/done that".
I should have signed up with my real name. I am an Assistant Moderator on another forum that I use "Kidsfeet" on, and can't divulge myself as the other forum can get a little ummm, feisty. Sorry.
You really can't compare the treatment between ITW and CP. The conditions originate from different neural changes.
I am yet to see an ITW child without an equinus and agree with Robin, therefore is not idiopathic. However, they also have a lot of other "stuff" going on, not just at the ankle. Even the major study that used surgical tendon lengthening procedures reported a high percentage of the children still toe walked in the long term. They just had improved dorsiflexion range. Casting, botox, AFO's etc all address any associated equinus only, not the gait style. Therefore there is no successful treatment for ITW. Yes, many get lower with age however, I have shared my view that there are still many ITW adults that adopt instead a bouncy gait style or toe walk only when socially acceptable.
Back to CP, heaps of good advice here but I think the message is a better understanding of both the condition and long term implications are needed before looking at the treatment options.
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Cylie.... in a permanent state of confusion
You really can't compare the treatment between ITW and CP. The conditions originate from different neural changes.
I am yet to see an ITW child without an equinus and agree with Robin, therefore is not idiopathic. However, they also have a lot of other "stuff" going on, not just at the ankle. Even the major study that used surgical tendon lengthening procedures reported a high percentage of the children still toe walked in the long term. They just had improved dorsiflexion range. Casting, botox, AFO's etc all address any associated equinus only, not the gait style. Therefore there is no successful treatment for ITW. Yes, many get lower with age however, I have shared my view that there are still many ITW adults that adopt instead a bouncy gait style or toe walk only when socially acceptable.
Back to CP, heaps of good advice here but I think the message is a better understanding of both the condition and long term implications are needed before looking at the treatment options.
Hi Bug
I brought up the topic of ITW as, Kidsfeet, brought up the suggestion of Achilles tendon lengthening. I thought that it might be worth mentioning that Achilles tendon lengthening would probably be more effective in ITW than CP patients as there is evidence to support it.
Are you implying that the majority of ITW cases you have seen are not idiopathic due to an equinus being present? How can you know for sure, in ITW cases, whether the equinus is primary or secondary (excluding an osseous equinus of course)?. If there are other gait factors involved in toe walking, what if the calf muscle complex undergoes contracture due to the toe walking gait pattern itself?
I did have a full copy of this a few years back but it has been a while since I specialise in paeds. Not sure how current this is as I haven't done much reading round the subject recently but out did influence the treatment modality at the hospital I worked in at the time.
One of the things about AFO usage its that, although a rigid AFO is not dynamic, the GRV can be tuned to maintaining it's position in front of the knee even into terminal stance. This can create a considerable stretch of gastrocnemius and I'm sure (although I could be very wrong) that elaine owen had some figures on this to demonstrate an increased talocrural ROM . Apologies for this not being well written but I am doing it on my mobile as this is the first chance to reply.
Interesting study though for those of us that routinely deal with CP.
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I see you girls checkin' out my trunks
I see you girls checkin' out the front of my trunks
I see you girls lookin' at my junk, then checkin' out my rump, then back to my sugarlumps
Are you implying that the majority of ITW cases you have seen are not idiopathic due to an equinus being present? How can you know for sure, in ITW cases, whether the equinus is primary or secondary (excluding an osseous equinus of course)?. If there are other gait factors involved in toe walking, what if the calf muscle complex undergoes contracture due to the toe walking gait pattern itself?
Chicken and egg - did the equinus come first or did the toe walking come first, we just don't know but I am yet to see a child with ITW that does not have equinus.
It is semantics but idiopathic means "no known cause" if there is equinus, it is easier to toe walk therefore is it really idiopathic? My belief is that the toe walking causes the equinus from prolonged plantar flexed foot position but in the absence evidence it is an educated presumption.
Really, it's just debating words. I don't believe idiopathic toe walking is really idiopathic anyway but some sort of complex mild neurological change but that is a whole other thread.
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Cylie.... in a permanent state of confusion
Chicken and egg - did the equinus come first or did the toe walking come first, we just don't know but I am yet to see a child with ITW that does not have equinus.
That was my point. I think in the majority of cases the equinus is generally going to be secondary. As a result, I’d say that it’s more of a contributing factor than an actual “cause”. So I would still say idiopathic is the right term.
Quote:
Originally Posted by Bug
Really, it's just debating words. I don't believe idiopathic toe walking is really idiopathic anyway but some sort of complex mild neurological change but that is a whole other thread.
I haven’t come across any literature yet to support what you’re saying, however, this doesn’t mean that I necessarily disagree with your statement. The cause of ITW is largely unknown. I do believe that there has to be a cause but until we are able to determine what that is it will remain unknown.
Cylie, I'm with you on the mild neuro idea. Nothing but a hunch really. I could count on 1 hand the number of true idiopathic toe walkers that I have seen. More often than not, I think there is something else going on. I have seen an idiopathic toe walker without equinous. no other dismay a diagnosis to give but was never convinced there was nothing else there.
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I see you girls checkin' out the front of my trunks
I see you girls lookin' at my junk, then checkin' out my rump, then back to my sugarlumps
Daniel - I think you need to integrate what is out there and known about ITW. While they have normal reflexes etc, we know they tend to toe walk past resolution of equinus, we know there is an association with speech issues, we know there is an issue with some motor development, we know there is anecdotal evidence of sensory concerns. Put them all together and this equals neurological in origin. Sure, there is no one study that proves it all, it would be huge to do but there is plenty of little studies out there that point to a neurological origin.
I'm at the end of a 4 year study working with kids with ITW, all had some sort of soft neuro signs. Not enough to be given a diagnosis of anything at all, but enough to make you wonder what is going on. I think you also need to use a bit of logic: Why walk on toes, with normal muscle tone, normal muscle strength and normal foot function? It's not an abnormal structure, has to be the brain telling it to do so. Brain = neurological.
Hope to have something published soon that will help with the thinking as soon as I get this thesis out of the way (mumble grumble).
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Daniel - I think you need to integrate what is out there and known about ITW. While they have normal reflexes etc, we know they tend to toe walk past resolution of equinus, we know there is an association with speech issues, we know there is an issue with some motor development, we know there is anecdotal evidence of sensory concerns. Put them all together and this equals neurological in origin. Sure, there is no one study that proves it all, it would be huge to do but there is plenty of little studies out there that point to a neurological origin.
I'm at the end of a 4 year study working with kids with ITW, all had some sort of soft neuro signs. Not enough to be given a diagnosis of anything at all, but enough to make you wonder what is going on. I think you also need to use a bit of logic: Why walk on toes, with normal muscle tone, normal muscle strength and normal foot function? It's not an abnormal structure, has to be the brain telling it to do so. Brain = neurological.
Hope to have something published soon that will help with the thinking as soon as I get this thesis out of the way (mumble grumble).
Cylie:
Essentially, I’m not disagreeing with you on the fact that there is a probable neurological component in ITW, which would technically mean that it’s not idiopathic. However, as that idea is still only a likely probability and that we cant actually diagnose what the actual neurological component is yet, I’d say from a clinical stand point, Idiopathic Toe Walking is still the best terminology.
Whichever way we look at this, ITW, would be a difficult one to diagnose, as the obvious underlying pathologies have to be excluded first. I do agree with you that there must be some causative neurological component that we obviously can’t test for yet that causes toe walking. What I don’t agree with though, is your assumption that ITW is not idiopathic if an equinus is present when we both agree that it’s a secondary phenomenon.
Your four year study sounds really interesting. Perhaps there may never be an exclusive neurological factor which I’m getting at but rather a complex sequela associated with the neurological system which causes the phenomenon we currently refer to as ITW. Good luck with getting your material published soon.
The effect of tuning ankle foot orthoses-footwear combination on the gait parameters of children with cerebral palsy.
Eddison N, Chockalingam N. Prosthet Orthot Int. 2012 Jul 24
Quote:
Background: There are a wide variety of ankle foot orthoses used in clinical practice which are characterised by their design, the material used and the stiffness of that material. Changing any of these three components will alter the effect of the ankle foot orthosis on gait.Objectives: The purpose of this article is to provide an overview on the available research on ankle foot orthosis-footwear combination tuning on the gait characteristics of children with cerebral palsy through a structured review.Study Design: Literature review.
Methods: A thorough search of previous studies published in English was conducted within all major databases using relevant phrases without any limits for the dates. These searches were then supplemented by tracking all key references from the appropriate articles identified including hand searching of published books where relevant.
Results: To date, there are 947 papers in the literature pertaining to the study of ankle foot orthosis. Of these, 153 investigated the use of ankle foot orthosis for children with cerebral palsy. All the studies included in this review were of a within-subjects design and the evidence levels were generally low.
Conclusions: The overall results suggested that ankle foot orthosis-footwear combination tuning has the potential to improve the kinematics and kinetics of gait in children with cerebral palsy. However, the review highlights a lack of well-designed and adequately powered studies.
Splint: the efficacy of orthotic management in rest to prevent equinus in children with cerebral palsy, a randomised controlled trial.
Maas JC, Dallmeijer AJ, Huijing PA, Brunstrom-Hernandez JE, van Kampen PJ, Jaspers RT, Becher JG. BMC Pediatr. 2012 Mar 26;12:38.
Quote:
BACKGROUND:
Range of motion deficits of the lower extremity occur in about the half of the children with spastic cerebral palsy (CP). Over time, these impairments can cause joint deformities and deviations in the children's gait pattern, leading to limitations in moblity. Preventing a loss of range of motion is important in order to reduce secondary activity limitations and joint deformities. Sustained muscle stretch, imposed by orthotic management in rest, might be an effective method of preventing a decrease in range of motion. However, no controlled study has been performed.
METHODS:
A single blind randomised controlled trial will be performed in 66 children with spastic CP, divided over three groups with each 22 participants. Two groups will be treated for 1 year with orthoses to prevent a decrease in range of motion in the ankle (either with static or dynamic knee-ankle-foot-orthoses) and a third group will be included as a control group and will receive usual care (physical therapy, manual stretching). Measurements will be performed at baseline and at 3, 6, 9 and 12 months after treatment allocation. The primary outcome measure will be ankle dorsiflexion at full knee extension, measured with a custom designed hand held dynamometer. Secondary outcome measures will be i) ankle and knee flexion during gait and ii) gross motor function. Furthermore, to gain more insight in the working mechanism of the orthotic management in rest, morphological parameters like achilles tendon length, muscle belly length, muscle fascicle length, muscle physiological cross sectional area length and fascicle pennation angle will be measured in a subgroup of 18 participants using a 3D imaging technique.
DISCUSSION:
This randomised controlled trial will provide more insight into the efficacy of orthotic management in rest and the working mechanisms behind this treatment. The results of this study could lead to improved treatments.
Re: Paediatric Cerebral palsy orthoses
.I have found that the bracing eventually causes irritation and that new braces are required often and many times the parents get tired of this modality and would like to at least try something more definitive. 
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