marybeth barkocy, pt, dpt, pcs teresa ziomek,...

67
Idiopathic toe walking: a multidisciplinary approach Marybeth Barkocy, PT, DPT, PCS Teresa Ziomek, MOTR/L With contributions from ExplorAbilities Therapy Center physical therapists and students APTA Clinical Practice Guideline Group on ITW

Upload: lexuyen

Post on 03-May-2018

222 views

Category:

Documents


3 download

TRANSCRIPT

Idiopathic toe walking:a multidisciplinary approach

Marybeth Barkocy, PT, DPT, PCS

Teresa Ziomek, MOTR/LWith contributions from ExplorAbilities Therapy Center physical therapists and students

APTA Clinical Practice Guideline Group on ITW

Learning objectives Differentiate between musculoskeletal, neuromuscular,

and sensory contributions to toe walking.

Recognize assessments to determine impairments in the musculoskeletal, neuromuscular, and sensory systems in children who toe walk.

Identify evidence based and/or clinically relevant assessments and interventions targeted to musculoskeletal, neuromuscular, sensory, and visual system impairments in children who exhibit toe walking.

Case 1 intro Daniel

9 years old

Case 2 intro MB's Kiddo

5 years old

Evidence-based practice

Sackett BMJ

1996;312:71-72

Special thanks toShannon Brausch, PT, DPT,Sally LeCras, PT, DPT, PCS,

Nancy Muir, PT, DPT, PCS, and Julie Bouck, PT, MPT

For their 2017 APTA CSM presentation on Idiopathic Toe Walking Evidence Updates, as

well as the clinical practice guideline group

Summary of general research Evidence that toe walking is a normal deviation of gait

development in 1 to 3 year olds is lacking

Referrals are often made to PT after a child is 2 years old

Children do not typically “outgrow” toe walking

There are long term sequelae of toe walking, if not treated or resolved

Summary of general research MSK and NM research

Primarily type I fibers in gastrocnemius (usually more Type II) (Eastwood, 1997)

Three times more likely to develop tendoachillestightness; ankle joint stiffness; higher incidence of other muscle tightness (like hamstrings); strength and bone density normal (Englebert, 2011)

Hallmarks of gait include lack of heel strike at initial contact, premature heel rise, reversal of 2nd rocker, shortened loading response, early gastrocnemius activity in stance, excessive hip flexion and knee extension in stance, excessive hip flexion in swing for foot clearance (Crenna, 2004; Leung, 2014)

Sensory Processing Research: General Processing

Using the Short Sensory Profile (SSP) and Sensory Profile (SP):

73 % of toe walkers (TW) “Probable difference” or “Definite difference” vs. 7 % of non TW (Ganley & Behnke, 2016; Len & Rao, 2012)

Children with ITW scored “Probable Difference” in two quadrants: Sensory Seeking and Low Registration (Williams, Tinley, Curtin, Wakefield, & Nielson, 2014; Williams, Tinley, & Curtin, 2011)

Children with ITW had notable differences in Sensory Modulation (Williams, Tinley, & Curtin, 2011)

Sensory Processing Research:Tactile

Differences in vibration threshold Mean vibration

threshold (Ganley & Behnke, 2016; Williams, Tinley, Curtin &

Nielson, 2012 ; Williams, Tinley, Curtin, Wakefield, & Nielson,

2014)

Walking surface may influence gait pattern in children with ITW (Fanchiang, Geil, Wu, Chen, & Wang, 2016)

Improved heel strike when ambulating barefoot on pea gravel vs carpet or tile (Fanchiang, Geil, Wu, Chen, & Wang, 2016)

Using the Sensory Integration and Praxis Test (SIPT), children with ITW demonstrated sensory processing difficulties with tactile processing being the most impacted (Len & Rao, 2012)

Sensory Processing Research:Vestibular, Proprioception, and Vision

Using the Sensory Integration and Praxis Test (SIPT)

• Significant differences in Standing Walking Balance subtest (Williams, Tinley, Curtin, Wakefield, & Nielson, 2014)

• Significant difference in post-rotary nystagmus (Williams, Tinley, & Curtin, 2011)

• Delay in Standing Walking Balance and Postural Praxis (Len & Rao, 2012)

Using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2)

• ITW group “below average” on Bilateral Coordination, Balance, and Upper-Limb Coordination (Williams, Tinley, Curtin, Wakefield, & Nielson, 2014)

• ITW group scored lower on Balance (Williams, Tinley, & Curtin, 2011)

Additional Research:Neuropsychiatric Differences

Engstrom, 2012

Purpose: cross-sectional study to assess the incidence of neuropsychiatric symptoms in children with ITW compared to children without ITW

Sample: 51 children (4 - 14 years) with ITW

Motor skills 39%

Executive Function 17/6%

Perception 25.5%

Memory 23/5%

Language 23.5%

Learning 25.9%

Social 25.5%

Emotional behavioral problems 21.6%

Additional Research:Coordination Deficits

Using the BOT-2, ITW group “below average” on Bilateral Coordination, Balance, and Upper-Limb Coordination (Williams, Tinley, Curtin, Wakefield, & Nielson, 2014)

Using the BOT-2, By 8 years old, ITW group scored “average” on all but Upper-Limb Coordination (Williams, Tinley, Curtin, Wakefield, & Nielson, 2014)

Using the Peabody Motor Scales Second Edition, ITW demonstrated delays in gross motor milestones (Len & Rao, 2012)

Parent and child report of coordination problems: (Morris, 2007)

Upcoming Resources and Research

American Physical Therapy Association (APTA) Clinical Practice Guideline

Intervention research

UNM Research Autism and TW

PICO Questions:

In children 2 to 21 years referred to physical therapy for toe walking, what are the most appropriate evidence-based tests and measures for differential diagnosis and examination?

In children aged 2 to 21 years with a primary diagnosis of ITW, what is the natural history and prognosis with or without treatment?

In children 2 to 21 years with a primary diagnosis of ITW, what are the evidence-based plan of care and intervention recommendations?

APTA Clinical Practice Guideline

Intended audience

Pediatric PT

Pediatric OT

Referral Sources

Pediatric SLP

Podiatrists

Orthotist

Orthopedist

Early Intervention Specialists

Psychologists

Chiropractors

Developmental Optometrists

Objectives of CPG

Decrease variation in care

Improve outcomes for children

Earlier referral

Differential diagnosis

Clearer picture of treatment options for the parents

Clinical Practice Guideline

Are you a registered or licensed Health

Professional who diagnoses, treats or refers

children with idiopathic toe walking for treatment?

Neurologists

We are investigating treatment strategies for idiopathic toe walking. All registered or licensed health professionals are invited to participate in this research. For more information on the aims, eligibility to participate and contact details of researchers,

please click on the following link:

http://tinyurl.com/itwHPsurvey

This research has been approved by Monash University Human Ethics: 17-9631

Local ASD TW study

Local study for children with Autism who are toe walking -Individualized therapy program and treatment provided by UNM faculty in Physical Therapy (Dr. Marybeth Barkocy) and Orthotist(Jacque Newman). Call study coordinator for details. (505)272-9870

Insert Isaiah videos here

Why treat ITW: Physical symptoms

Weight bearing skeleton will adapt form to function, especially in young children

Hypertrophy of talar neck

Underdeveloped calcaneus

Pain

Calf pain and increased calluses and corns on balls of feet.

Soft tissue problems

Tendency towards pes cavus (Burns, 2005)

Fixed achilles tendon tightness and calf contractures

Neurodevelopmental impairment, (Martin, 2016)

Strong evidence for increase ankle sprains with gastroctightness (Tabrizi, 2000)

Balance? Vestibular seeking? Back pain?

Why treat ITW: Participation and psychological reasons

Participation restrictions: especially with peers at school

Self-consciousness

(The Oxford Ankle Foot Questionnaire: Morris, 2007)

• Quality of life is impacted

(Williams, 2015)

Why treat ITW: Sensory Processing

“The tactile receptors of the skin may be stimulated through pressure at the ball of the foot or lessened by the reduction of surface contact by raising the heel off the ground.”

“Proprioceptive input may be changed at knee, ankle, and even to joints by unconsciously repositioning the foot posture.”

“The vestibular input may be increased by the vertical stimulation of the bouncy type gait that results from toe walking.”

“These results indicated that the children within this idiopathic toe walking cohort displayed a number of sensory needs that may motivate the toe walking gait to influence or provide increased sensory input.”

(Williams, Tinley, Curtin, Wakefield, & Nielson, 2014)

“The upright human body is unstable and its balance is continuously stabilized through the integration of visual, vestibular, proprioceptive, and other sensory inputs.” (O’Connor & Kuo, 2009)

Differential Diagnosis: Ruling out diagnoses needing referral

ITW

Diagnosis of exclusion

Condition in which a child ambulates with a bilateral toe-toe gait without any known reason or pathology

Habitual toe walking

Non-ITW

• ASD

• Cerebral Palsy

• Tethered Cord Syndrome

• Charcot Marie Tooth (CMT)

• Duchenne or Becker Muscular Dystrophy (DMD or BMD)

• Spinal Muscular Atrophy (SMA)

• Talipes Equinovarus(Clubfoot)

Toe Walking ToolThis valid and reliable tool was designed to identify healthy idiopathic toe walkers and exclude children who have a medical condition resulted in toe walking

Questionnaire sections:

1. Demographics.

2. Indicators of trauma.

3. Indictors of neuromuscular influence.

4. Indicators of neurogenic influence.

Williams, C.M., Tinley, P., and Curtin, M. (2011). The Toe-Walking Tool: A novel method for assessing idiopathic toe walking. Gait & Posture, 34(3): 442.

http://www.sciencedirect.com/science/article/pii/S0966636210002158

Clinical presentation, diagnosis, prognosis

Prematurity, admission to NICU, and low birth rate are associated have greater rates of ITW (Baber, 2016)

Family history increases rates of ITW (42-61% of children with ITW) ( Pomarino, 2016 & Engstrom, 2012)

Differences in sensory processing have been identified, especially related to the tactile, vestibular, visual, and proprioceptive systems (Ganley, 2016 & Williams, 2014)

Screening checklist: Liesa Persaud(not validated but seems to be clinically accurate)

Permission by Liesa Persaud granted to share with NM Peds Study Group 2017 from her TW Course http://www.knowtochange.com/about-liesa/

Classification of toe walking severity

Alvarez C, De vera M, Beauchamp R, et al. Classification of idiopathic toe walking based on gait analysis: development and application of the ITW severity classification. Gait Posture. 2007;26:428-435.

Commonly recommended treatment

(1) observation until age 2–3 years

(2) conservative management via stretching, bracing, serial casting, and botulinum toxin injection for dynamic toe walkers without fixed heel cord contractures

(3) consider surgical heel cord lengthening for cases with fixed heel cord contractures with poor response to nonsurgical treatment

Oetgen ME, Peden S. Idiopathic toe walking. J Am Acad Orthop Surg2012292–300.

Clinical Assessment of Participation PT and OT

Interviews

Parents

Child

Child questionnaire

COSA

Parent questionnaires

PODCI

QOL measures

COPM

Using PedsQL 4.0, compared with non TW peers, children with ITW … •Parents of children with ITW reported significantly lower values on Total, Psychosocial, and Emotional subscales:

•Children with ITW self-reported significantly lower values on Physical, Psychosocial, and School subscales.

(Williams 2015)

Referral to other professionals Occupational Therapy

Physical Therapy

Speech language:

Higher incidence of speech/language delays, so ask about this in history and refer if concerned (Shulman, 1997)

Neuroptometric rehab

Orthotist

Orthopedist

Neurologist

Developmental pediatrician

Occupational and physical therapy evaluations found

4 of 12 (33%) had fine motor delays, 4 of 10

(40%) had visuomotor delays, and 3 of 11 (27%) had gross motor delays.

(Shulman, 1997)

ExplorAbilities in house referrals Sensory Screen for ITW

Does the child get car sick?

Does the child pull away from being touched (type? Hug? Tickle?)

Does the child withdraw from tactile input to hands or feet such as food, shaving cream, sand, grass?

Does the child not like to walk in the grass or sand barefoot?

Does the child have significant difficulty with haircuts, hair combing, teeth brushing?

Does the child put their hands over their ears when exposed to loud noises or react in a strong way?

Does the child spend more time in movement play than peers?

Does the child seek out crashing, pushing, big hugs?

Is the child easily distracted by visual input in the environment?

Does the child strongly dislike tags on clothing or having strong clothing preferences?

Additional Sensory Resources STAR Institute for Sensory Processing Disorder

https://www.spdstar.org

SPIRAL Foundation (Sensory Processing Institute for Research and Learning)

http://www.thespiralfoundation.org/

SIGN Sensory Integration Global Network

https://www.siglobalnetwork.org/

PT Clinical Assessment of Function

Gait

OGS

Percentage of TW steps/distance Christiansen, et al (2017)

Foot print analysis

Parent report % of time toe walking

BOT2 Running speed and agility

Balance skills:

BOT-2 balance section

Single leg balance

Standing balance

Motor skills

Stairs

Squat

Heel walking

PT assessments of gait for TW

Measurement of toe walking, in process:

Children’s Hospital Denver

Toe walking severity scale

Bellman 2016

Grade % time TW

Grade 1 76 - 100%

Grade 2 51 - 75%

Grade 3 26 - 50%

Grade 4 10 - 25%

Grade 5 Walking plantigrade but with early heel rise (occasional TW, < 10% accepted)

Grade 6 Walking with normal heel strike

Pomarino Classification System by clinical features

Type I: This group of toe walkers is born with a short triceps suraemuscle, which produces the tiptoe walking pattern. They are recognized by having a heart shaped calf (Figure 1) deep wrinkles (Figure 2) over the Achilles tendon area, and a fat deposit on the forefoot (Figure 3) under the second and third metatarsal bones. Other common features are a pointy heel, a pes cavus, and a short adductor magnus muscle.

Type II: This group has a positive family predisposition, they present with a “V” sign over the Achilles tendon area (Figure 4), and the gastrocnemius muscle is hypertrophied (Figure 5).

Type III: This group usually can support the heel on the ground while walking. Frequently between 4 and 5 years of age, the tiptoe gait pattern resolves spontaneously. The pattern may continue to appear in some situations such as fear, anxiety, tiredness, or stress.

Pomarino D, Veelkien N, Martin S. Der habituelleZehenspitzengang. Diagnostik, Klassification, Therapie.

Germany: Schattauer; 2012:52-60

Observational Gait ScaleAssesses knee and foot/ankle with emphasis on stance phase of gait

Limitations:• Not validated for use in children with ITW • Does not assess trunk or hip posture

Mackey AH, Lobb GL, Walt SE, Stott NS. Reliability and validity of the Observational Gait Scale in children with spastic diplegia. Dev Med Child Neurol. 2003;45(1):4-11.

50 Foot Walk Test for ITW Number of toe walking steps divided by number of steps

taken gives you a percentage

Excellent concurrent validity and interrater reliability

Can also use accelerometer to count steps, so you just count toe walking steps

Christensen C, Haddad A, Maus E. (2017). Reliability and validity of the 50-ft walk test for idiopathic toe walking. Pediatric Physical Therapy; 29(3): 238-243.

Christensen C, Haddad A, Maus E. (2017). Validity of an accelerometer used to measure step count in children with idiopathic toe walking. Pediatric Physical Therapy, 29(2): 153-157.

PT Clinical Assessment of Impairments

Posture:

Outtoeing? (occasionally intoeing)

Pronation?

Hip flexion?

Knee hyperextension?

Strength:

BOT-2 strength section

Anterior tibialis weakness?

Core weakness?

Gluteus maximus and mediusweakness?

Motor coordination

BOT-2 bilateral coordination

ROM:

R1 and R2 ankle DF with knee ext

R1 and R2 ankle DF with knee flex

Hamstrings, hip flexors

LE assessment: LLD, torsionaldeformities, calcaneal alignment

Tone/Spasticity

MAS, Tardieu

Hypertonia Assessment Tool

Clonus

Tone assessment

Balance/postural control

Righting, equilibrium reactions

Ankle strategy?

Balance with eyes closed vs. open? (vision vs. proprioception)

OT Clinical Assessment of Function

Tactile Does the child’s TW change

depending on the surface?

Is the child bothered by tags on clothing?

Is the child selective about clothing textures or food textures?

Does the child prefer or dislike to be barefoot?

Is the child bothered by seams in clothing, especially socks?

Proprioception: Does the child avoid physical

activities?

Does the child often bump into objects or people while walking in the environment?

Vestibular: Does the child get car sick?

Does the child enjoy spinning more or less than his/her peers?

Become dizzy easily?

Vision: Does the child get car sick?

Does the child frequently rub his/her eyes?

Does the child become tired when reading?

OT Clinical Assessment of Impairments

Tactile, Vestibular, Proprioception, Vision

Child Sensory Profile 2 (CPS 2)

Sensory Processing Measure

Sensory Integration Praxis Test

OT Clinical Assessment of Impairments

Vestibular and Vision:

Post rotary nystagmus(Mailloux, Z., et al, 2014)

Vestibular and Proprioception

Tonic Labyrinthine Reflex (TLR) Prone Extension (Gregory-Flock & Yerxa, 1984)

Tonic Labyrinthine Reflex (TLR) Prone Extension and Supine Flexion (Sellers, 1988)

Asymmetrical and Symmetrical Tonic Neck Reflex (Goddard, 2005)

Proprioception:

BOT-2 Bilateral Coordination

Comprehensive Observations of Proprioception (COP)

http://sensorymetrics.net/COPForm

Vision

BOT-2 Upper Limb Coordination

Tracking vertically and horizontally

Convergence and divergence

Asymmetrical and Symmetrical Tonic Neck Reflex (Goddard, 2005)

Case 1 Examination, Evaluation, and Plan of Care

Examination:Sensory testing/questionsChild Sensory ProfileTrackingConvergence/DivergencePRNTLR ATNRBOT-2

Plan of Care:OT 1 hour/week; Optometry referral

Evaluation:

Impaired VOR, gets car sick

Rubbed eyes during tracking, jerky eye movements during convergence

Prefers to be in socks, bothered by tags, prefers to be clean

Poor postural control

Poor body awareness (imitating body positions and knowing when his heel came in contact with

Case 2 Examination, Evaluation, and Plan of Care

Examination:

ROM

Strength

Posture/Alignment

Balance

Gait

Sensory processing screen

BOT-2

Plan of Care:

PT 1 hour/week; OT referral

Evaluation:

ankle DF with knee ext R -13, L-14

Hamstrings moderately tight

TFA R 17, L 15 = outtoeing

Constant toe walking

Can stand with heels down with knee hyperextension, hip flex, and outtoeing; unable to hold static standing on toes

Poor single leg balance, unable to squat, hesitant down stairs,

PT Interventions Stretching

Night splinting

Ther ex/Strengthening

Joint mobilizations

Balance training (especially standing balance and posterior weight shifting)

Gait training/Treadmill training

Motor Control/Motor Learning Strategies

Taping (not in this case)

NMES (not in this case)

Augmented Auditory Feedback

Biofeedback (faded verbal feedback from PT)

Orthotics (AFOs or ITW inhibiting)

Serial casting

Shoe modifications (not in this case)

Sensory strategies

HEP ExplorAbilities HEP

Evidence based interventions motor control interventions (Clark, 2010)

augmented auditory feedback (Marcus, 2010; Persicke, 2014)

observation (Hirsch, 2004; Dietz, 2012)

serial casting,(LeCras, 2011;Fox, 2006; Griffen, 1997; Brouwer, 2000; Pistilli, 2015)

orthoses (Herrin, 2015)

Serial casting increases passive ankle dorsiflexion range, improves EMG gait variables, and is a safer and less costly intervention than surgery in children with ITW

surgery (Strickler, 1998; van Kuijk, 2014)

Systematic Review 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. (but no long term studies! 6 weeks?)

Ruzbarsky, Joseph J., David Scher, and Emily Dodwell. "Toe walking: Causes, epidemiology, assessment, and treatment." Current Opinion in Pediatrics 28.1 (2016): 40-46.

EB Guideline Cincinnati Children's Hospital Medical Center, 2011

Le Cras S, Bouck J, Brausch S, Taylor-Haas A; Cincinnati Children’s Hospital Medical Center: evidence-based clinical care guideline for management of idiopathic toe walking, http://wwwcincinnatichildrens.org/svc/alpha/h/health-policy/otpt.htm,

Guideline 040, pages 1-17, February 15, 2011.

Brausch, LeCras, Muir Bouck 2017 APTA Combined Sections Meeting

PT InterventionsROM: Serial casting, stretch splinting

Orthotics/insoles

• Following casting, 66% of patients had improved gait on patient and clinician determined outcomes, with the majority of children ceasing to toe-walk. Ankle dorsiflexion significantly improved in those children who were successfully treated (p = 0.001). (Fox, 2006)

• Night splinting HEP showed kinematic gait changes (Lara, 2016)

• Insoles to gradually retrain the foot to make full contact with the ground (Pomarino, 2016)

PT InterventionsMotor Control Training

Balance Training/ ankle strengthening

PT InterventionsGait training

Home exercise program Dinosaur PT http://blog.dinopt.com/toe-walking/

ExplorAbilities HEP

OT Interventions Integration of tactile

input

Integration of vestibular input

Integration of proprioceptive input

Integration of vision

Integration of senses

OT Interventions:Tactile

Therapressure Brushing Protocol

Use of tactile media (rice, beans, water beads, Kinetic Sand)

Vibration (Williams, Michalitsis, Murphy, Rawicki & Haines, 2016)

OT Interventions:Vestibular

Swing

Scooter board

Therapy ball

Therapeutic Listening Protocol

OT Interventions:Proprioception

Body sock

Lycra swing

Yoga

Cloth tunnels

Aquatic therapy

OT Interventions:Vision and Coordination

Eye Games: Easy and Fun Visual Exercises

Developing Ocular Motor and Visual Perceptual Skills: An Activity Workbook

http://eyecanlearn.com/

OT Interventions:Putting it all together

Bal-A-Vis-X

S’Cool Moves

Combining activities

Case 1 Interventions and Progress

Improved score on the BOT-2 in upper limb coordination from a standard score of 10 to standard score of 20 placing him within an average range

Decrease in eyes less fatigue

Decreased report of car sickness

Increase in fluidity of visual pursuits

Increase in body awareness

Case 2 Progress

The Problem Impairments such as ROM, balance, body awareness can

improve, but....

Recurrence rates of toe walking are high with all above stated interventions, including botox (Engstrom, 2010 and Strickler, 1998)

More research needs to be done on orthoses for retraining gait patterns (Herrin, 2016: FOs tolerated better than AFOs, but did not improve toe walking as well)

Early identification and intervention are best before secondary impairments form! ("He/she will "outgrow" it....")

Surgery vs. Conservative management

Systematic review: Due to heterogeneity of patient groups, sample size and follow-up, no firm conclusions on a favorable role of surgery or cast treatment could be drawn in the treatment of ITW or equinus contracture. (VanBemmel, 2014)

8 Idiopathic toe walkers who were treated surgically for triceps surae contractures showed significant improvements in key kinematic and kinetic gait analysis variables at 1 year post-operative that were maintained at 5 years post-operative. Overall, subjects were satisfied with outcomes of the surgery, unrestricted in activities, and reported minimal pain. (McMulkin, 2016)

15 children: Achilles tendon lengthening improves ankle kinematics without compromising triceps surae strength; however, plantarflexion power does not reach normal levels at 1 year after surgery. (Hemo, 2006)

But we all know kids who have returned to toe walking, resumed tightness, and did not tolerate surgery well......

Non-surgical treatment should be considered first, with surgical options reserved for resistant cases (Kiebzak, 2016)

ReferencesAlvarez C, De vera M, Beauchamp R, et al. Classification of idiopathic toe walking based on gait analysis: development and

application of the ITW severity classification. Gait Posture. 2007;26:428-435.

Blanche, E, Bodison, S., Chang, M. C., & Reinoso, G. (2012). Development of the comprehensive observations of proprioception (COP): Validity, reliability, and factor analysis. American Journal of Occupational Therapy, 66, 691–698.

Brouwer B, Davidson LK, Olney SJ. Serial casting in idiopathic toe-walkers and children with spastic cerebral palsy. J Pedatr Orthop. 2000;20(2):221- 225.

Burns,, J. and Crosbie, J. (2005). Weight Bearing Ankle Dorsiflexion Range of Motion in Idiopathic Pes Cavus Compared to Normal and Pes Planus Feet. The Foot 15.2 (2005): 91-94.

Brausch, S., LeCras, S., Muir, N., and Bouck, J. (2017) APTA CSM presentation on Idiopathic Toe Walking EvidenceUpdates, San Antonio, TX

Christensen C, Haddad A, Maus E. (2017). Reliability and validity of the 50-ft walk test for idiopathic toe walking. PediatricPhysical Therapy; 29(3): 238-243.

Clark E, Sweeney JK, Yocum A, McCoy SW (2010). Effects of motor control intervention for children with idiopathic toe walking: a5-case

series. Pediatr PhysTher. 22:417-426Crenna P, Fedrizzi E, Andreucci E, Frigo C, Bono R. The heel-contact gait pattern of habitual toe walkers. Gait & Posture.

2004; 21(3): 311-317.Dietz G, Khunsree S. Idiopathic toe walking: to treat or not to treat, that is the question. Iowa Orthop J. 2012;32:184-188.Eastwood DM, Dennett X, Shield LK, Dickens DR. Muscle abnormalities in idiopathic toe-walkers. J Pediatr Orthop B, 1997;

6(3): 215-8.EngelbertR, Willem GorterJ, UiterwaalC, van de PutteE, HeldersP. Idiopathic toe-walking in children, adolescents and

young adults: a matter of local or generalized stiffness? BMC MusculoskelDis. 2011; 12:61.EngstromP, Gutierrez-FarewikEM, BartonekA, TedroffK, OrefeltC, Haglund-AkerlindY. Does botulinum toxin A improve

the walking pattern in children with idiopathic toe-walking? Journal of Children’sOrthopaedics. 2010; 4(4): 301-8.

Fanchiang, H. D., Geil, M., Wu, J., Chen, Y., & Wang, Y. T. (2014). The effects of vibration on the gait pattern andvibration perception threshold of children with idiopathic toe walking. Journal of Child Neurology, 30(8),2010-1016.

Fox A, Deakin S, Pettigrew G, Paton R. Serial casting in the treatment of idiopathic toe-walkers and review ofthe literature. ActaPaediatricaBelgica.2006; 72(6): 722-730.

Ganley KJ, Behnke C. (2016). Distal vibration perception threshold in children who toe walk. Pediatric Physical Therapy, 28(2), 187-191.

Goddard, S. (2005). Reflexes, learning, and behavior: A window into the child’s mind: A non-invasive approach to solving learning and behavior problems. Oregon: Fern Ridge Press.

Gregory-Flock, J.L.,Yerxa, E.J., (1984). Standardization of the prone extension postural test on children ages 4 through 8. American Journal of Occupational Therapy, 38, 187-194.

Griffin PP, Wheelhouse WW, Shiavi R, Bass W. Habitual toe-walkers: a clinical and electromyographic gait analysis. J Bone Joint Surg Am. 1977;59(1):97-101.

Harrin, K., & Geil, M. (2016). A comparison of orthoses in the treatment of idiopathic toe walking: A randomized controlled trial. Prosthetics and Orthotics International, 40(2), 262–269. https://doi.org/10.1177/0309364614564023

Hickman, L., Hutchins, R. (2010). Eye games: Easy and fun visual exercises. Texas: Sensory World.Hirsch G, Wagner B. The natural history of idiopathic toe-walking: a long-term follow-up in fourteen conservatively treated

children. Acta Paediatr. 2004;93:196-199.Hubert, B., (2014). Bal-A-Vis-X: Balance/auditory/vision exercises for brain and brain-body Integration. Kansas: Bal-A-Vis-X, Inc..A. (2005). Developing ocular motor and visual perceptual skills: An activity workbook. New Jersey: Slack Incorporated.Kiebzak, and Ryszard Plinta. "Effect of a Nonsurgical Treatment Program on the Gait Pattern of Idiopathic Toe Walking: A Case

Report." Therapeutics and Clinical Risk Management TCRM (2016): 139.Lara, SL, , Caballero IM, Lorenzo TM, Saiz BM, Mussin, EMP, Moreno, APS, Barragan, AR. (2016). Conservative treatment of

idiopathic toe walking. Gait and Posture. In press.Le Cras S, Bouck J, Brausch S, Taylor-Haas A; Cincinnati Children’s Hospital Medical Center: evidence-based clinical care guideline

for management of idiopathic toe walking, http://wwwcincinnatichildrens.org/svc/alpha/h/health-policy/otpt.htm, Guideline 040, pages 1-17, February 15, 2011.

References Cont.

Lane, KLen, .Y., Rao, S. (2012). 5 Case series- idiopathic toe walking and sensory processing dysfunction. Poster session presented at the American Physical Therapy Association Combined Sections Meeting, Illinois.

Leung, J., Smith, R., Harvey, L. A., Moseley, A. M., & Chapparo, J. (2014). The impact of simulated ankle plantarflexion contracture on the knee joint during stance phase of gait: A within-subject study. Clinical Biomechanics, 29(4), 423–428. https://doi.org/10.1016/j.clinbiomech.2014.01.009

Mackey AH, Lobb GL, Walt SE, Stott NS. Reliability and validity of the Observational Gait Scale in children with spastic diplegia. Dev Med Child Neurol. 2003;45(1):4-11.

McMulkin ML, Gordon AB, Tompkins BJ, Caskey PM, Baird GO. Long term gait outcomes of surgically treated idiopathic toe walkers. Gait Posture. 2016; 44, 216-220.

Mailloux, Z., Lea˜o, M., Becerra, T. A., Mori, A. B., Soechting, E., Roley, S. S., Buss, N., Cermak, S. A. (2014). Modification of the postrotary nystagmus test for evaluating young children. American Journal of Occupational Therapy, 68, 514–521.

Marcus A, Sinnott B, Bradley S, Grey I. Treatment of idiopathic toe-walking in children with autism using GaitSpot Auditory Speakers and simplified habit reversal. Res Autism Spect Dis. 2010;4:260-267. doi:10.1016/j.rasd.2009.09.012.

Montgomery P, Gauger J. (1978). Sensory Dysfunction in children who toe walk. Physical Therapy, 58, 1195-1204.

Martín-Casas, P., Ballestero-Pérez, R., Meneses-Monroy, A., Beneit-Montesinos, J. V., Atín-Arratibel, M. A., & Portellano-Pérez, J. A. (2016). Neurodevelopment in preschool idiopathic toe-walkers. Neurologia (Barcelona, Spain). https://doi.org/10.1016/j.nrl.2016.02.012

Morris, C., K. Liabo, P. Wright, and R. Fitzpatrick. "Development of the Oxford Ankle Foot Questionnaire: Finding out How Children Are Affected by Foot and Ankle Problems." Child: Care, Health and Development Child Care Health Dev 33.5 (2007): 559-68.

O’Connor, S.M., Kuo, A.D. (2009). Direction-dependent control of balance during walking and standing. Journal of Neurophysiology, 102. 1411-1419

Persaud, L. (2015) Evaluation and Management of Pediatric Toe Walking form a PT and OT Perspective level 1 and level 2 courses through Progressive Gaitways.

References Cont.

Persicke A, Jackson M, Adams AN. Brief report: an evaluation of TAGteach components to decrease toe-walking in a 4-year-old child with autism. J Autism Dev Disord. 2014;44:965-968. doi:10.1007/s10803-013-1934-4.

Pistilli EE, Rice T, Pergami P, Mandich MB. Non-invasive serial casting to treat idiopathic toe walking in an 18-month old child. Neurorehabilitation. 2014;34:215-220.

Pomarino, D., Ramírez Llamas, J., Martin, S., & Pomarino, A. (2017). Literature Review of Idiopathic Toe Walking. Foot & Ankle Specialist, 1938640016687370. https://doi.org/10.1177/1938640016687370

Pomarino D, Veelkien N, Martin S. Der habituelle Zehenspitzengang. Diagnostik, Klassification, Therapie. Germany: Schattauer; 2012:52-60

Pomarino, D., Ramírez-Llamas, J., Martin, S., & Pomarino, A. (2016). The 3-Step Pyramid Insole Treatment Concept for Idiopathic Toe Walking. Foot & Ankle Specialist. https://doi.org/10.1177/1938640016669794

Ruzbarsky, Joseph J., David Scher, and Emily Dodwell. "Toe walking: Causes, epidemiology, assessment, and treatment." Current Opinion in Pediatrics 28. (2016): 40-46.

Sellers, J.S. (1988). Relationship between antigravity control and postural control in young children. Physical Therapy, 68(4), 486-490.

Shulman, LH, Sala, DA, Chu, MLY, McCaul, PR Sandler, BJ. (1997). Developmental implications of idiopathic toe walking. Journal of Pediatrics, 130(4), 541-546.

Stricker SJ, Angulo JC. Idiopathic toe walking: a comparison of treatment methods. J Pediatr Orthop. 1998; 18(3): 289-293.Tabrizi P, McIntyre WMJ, Quesnel MB, Howard AW. Limited dorsiflexion predisposes to injuries of the ankle in children. J

Bone Joint Surg Br. 2000; 82-B(8): 1103-1106. VanBemmel AF, van de Graaf VA.van den Bekerom MPJ, Vergroesen DA. Outcome after conservative and operative treatment of children with idiopathic toe

walking: a systemic review of the literature. Musculoskelet Surg. 2014; 98: 87-93.Weeks S, Boshoff K, Stewart H. (2012). Systematic review of the effectiveness of the wilbarger protocol with

children. Pediatric Health, Medicine, and Therapeutics, 3, 79-89.Williams, C. M., Michalitsis, J., Murphy, A. T., Rawicki, B., & Haines, T. P. (2016). Whole-body vibration results in short-term

improvement in the gait of children with idiopathic toe walking. Journal of Child Neurology, 31(9), 1143-1149.Williams, C. M., Tinley, P., & Curtin, M. (2011, April). Is idiopathic toe walking a symptom of sensory processing

dysfunction? Poster session presented at the Autralasian Podiatry Council Conference, Melbourne, Australia.

References Cont.

References Cont.Williams, C. M., Tinley, P., & Curtin, M. (2010). Idiopathic toe walking and sensory processing

dysfunction. Journal of Foot and Ankle Research, 3(1).

Williams, C. M., Tinley, P., Curtin, M., & Nielsen, S. (2012). Vibration Perception Thresholds in Children With Idiopathic Toe Walking Gait. Journal of Child Neurology, 27(8), 1017-1021.

Williams, C. M., Tinley, P., Curtin, M., Wakefield, S., & Nielsen, S. (2014). Is Idiopathic Toe Walking Really Idiopathic? The Motor Skills and Sensory Processing Abilities Associated With Idiopathic Toe Walking Gait. Journal of Child Neurology, 29(1), 71-78.

Williams CM, Tinley P, Curtin M. (2010). The Toe Walking Tool: a novel method for assessing idiopathic toe walking children. Gait Posture, 32(4), 508-511.

Williams CM, Tinley P, Rawicki B. (2014). Idiopathic toe-walking: have we progressed in our knowledge of the causality and treatment of this gait type? Journal of the American Podiatric Medical Association, 104(3), 253- 262.