marybeth barkocy, pt, dpt, pcs teresa ziomek,...
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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.
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
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
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.
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 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:Vision and Coordination
Eye Games: Easy and Fun Visual Exercises
Developing Ocular Motor and Visual Perceptual Skills: An Activity Workbook
http://eyecanlearn.com/
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
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
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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.
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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.
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