Efficacy of serial casting protocols in idiopathic toe-walking.

OBJECTIVE: Idiopathic toe-walking (ITW) is a diagnosis of exclusion. A relationship between ITW and decreased range of motion (ROM) is postulated. Treatments focus on increasing ankle dorsiflexion including serial casting. There is no consensus for duration of serial casting. This study aimed to determine ROM changes with cast change intervals of one vs. two weeks, and the rate of ITW recurrence. METHODS: This was a retrospective study of 86 patients, ages 0-9 years with ITW undergoing weekly casting (N = 29) and two-week casting (N = 57) at a children's hospital from 2014-2020. ROM at baseline, two weeks, four weeks, and final cast removal were collected. Statistical analyses included chi-squared tests, two-sample t-tests, and linear mixed regression. Outcome distributions were assessed for normality. P-values < 0.05 were considered statistically significant. RESULTS: After adjusting for baseline ROM, the mean change in ROM from baseline to two weeks was 10.6∘ vs 7.5∘ in the one-week vs. two-week casting interval, respectively (p < 0.001). The baseline to final measurement was 13.4∘ vs 9.8∘ in the one-week vs. two-week casting interval, respectively (p < 0.001). The rate of recurrence of ITW was similar between the two groups. CONCLUSION: This study suggests greater improvement in ROM in the one-week vs. two-week casting interval group.

Gut Microbiome Dysbiosis as a Potential Risk Factor for Idiopathic Toe-Walking in Children: A Review.

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.

NGS-Panel Diagnosis Developed for the Differential Diagnosis of Idiopathic Toe Walking and Its Application for the Investigation of Possible Genetic Causes for the Gait Anomaly.

Idiopathic toe walking (ITW) describes a condition affecting approximately 4.5% of children. Toe walking is an accompanying symptom for many hereditary disorders. This retrospective study uses next-generation sequencing-panel-diagnosis to investigate the feasibility of genetic testing to research the possible genetic causes of ITW and for differential diagnosis. Data were taken from our inhouse database, the minimum age for participants was 3 years. Underlying neurological or orthopaedic conditions were tested for and ruled out prior to diagnosing ITW. Patients, who experienced complications before, during or immediately after birth, children with autism, and patients toe walking less than 50% of the time were excluded. Eighty-nine patients were included in the study, in which 66 (74.2%) patients were boys and 23 (25.8%) girls. Mean age at testing was 7.7 years (range: 3-17 years). Fifteen of the 89 patients included in the study (16.9%) had a genetic variant identified as likely pathogenic or pathogenic by the genetics laboratory. Additionally, we found 129 variants of uncertain significance. About 65.2% of patients showed a pes cavus foot deformity, 27% of patients reportedly had at least one relative who also displayed the gait anomaly, and 37.1% had problems with their speech development. Despite the limitations of the sample size and the scope of our genetic testing targets, our results indicate that research into the genetic causes of ITW could better our understanding of the causes of ITW in otherwise healthy children, to help develop novel methods to detect serious conditions early. ITW could be an early onset symptom for further hereditary conditions.

Does use of ankle foot orthoses affect the dynamic motor control index during walking in cerebral palsy and idiopathic toe walking populations?

BACKGROUND: The dynamic motor control (walk-DMC) index during walking is a measure of the complexity of muscle activation pattern. Ankle Foot Orthoses (AFO) are frequently used to improve the gait of children with Cerebral Palsy (CP) and Idiopathic Toe Walking (ITW). The purpose of this study was to assess the change in walk-DMC index secondary to AFO use. RESEARCH QUESTION: Does the change in walk-DMC reflect the change in walking kinematics with the use of AFO. METHODS: Individuals with diagnosis of CP or ITW with gait analysis data available for barefoot and AFO condition were retrospectively identified. For each individual, the walk-DMC index, Gait Deviation Index (GDI) and Gait Variable Scores (GVS) of knee and ankle kinematics were computed for BF and AFO conditions. Paired t-tests were used to compare key variables between BF and AFO conditions. Multi-variate stepwise regression analysis was performed to identify variables that may predict the increase in walk-DMC between BF and AFO condition. RESULTS: 253 individuals were included in the study. For CP individuals (n = 208), statistically significant but quantitatively minimal improvement was observed in walk-DMC (1 ± 9), GDI (2 ± 9) and ankle GVS (2 ± 7). For ITW individuals (n = 45), larger improvements were observed in walk-DMC (11 ± 13), GDI (9 ± 11) and ankle GVS (6 ± 7). Diagnosis of ITW, use of Solid-AFO and Posterior Leaf Spring-AFO were the significant predictor of increase in walk-DMC with AFO. Higher ankle GVS at BF condition (larger deviation from TD) led to larger increase in walk-DMC. Higher knee GVS (larger deviation from TD) led to smaller increase in walk-DMC. SIGNIFICANCE: Use of AFO can lead to improvement in walking kinematics that is reflected in increase in walk-DMC with AFO compared to BF for ITW individuals. The change in kinematics and walk-DMC with use of AFO was minimal for CP individuals.

Development of the Idiopathic Toe Walking Outcome (iTWO) proforma: A modified delphi study and online parent survey for measurement consensus.

BACKGROUND: Idiopathic toe walking (ITW) is an exclusionary diagnosis given when children toe walk without a medical reason. Treatment effectiveness studies rarely collect data other than ankle range of motion or presence of toe walking. RESEARCH QUESTION: To develop a set of outcome measures identified by health professionals for use when providing treatment with children who have ITW, to understand if parents agreed with this set, and if parents believed they could perform these measures in clinician absence. METHODS: Study 1 developed consensus and agreement on outcome measures for children receiving treatment for ITW through the modified Delphi technique with 10 expert health professionals. Parents of children who toe walked were invited to participate in an online survey for the second study, in which they were asked to rate the importance of these measures and if they believed they may be able to collect the data about their child without the health professional being present. RESULTS: Ten health professionals developed nine questions and assessments through consensus and agreement over the three rounds. There were 34 parents providing information about satisfaction with toe walking assessments and treatments. Of these, 27 provide detailed responses about the outcome questions and assessments. The majority (91 % of 24 parents) in support of the outcome measures identified by experts. Parents expressed a willingness to self-complete questions or be taught assessments to monitor their child's progress. SIGNIFICANCE: Use of these clinically based measures may enable consistent data collection regardless of the setting and provide the foundation for large data pooling in future treatment research.

Two-point discrimination responses in children with idiopathic toe walking: A feasibility fMRI study.

Idiopathic toe walking (ITW) is a diagnosis given to children who walk with an absence or limitation of heel strike in the contact phase of the gait cycle, that are otherwise typically developing. There is emerging evidence that this gait pattern may occur in children who experience tactile sensory processing challenges. This feasibility study aimed to determine if children were able to respond to a sensory stimulus during a fMRI. Children aged between 8-16 years of age, with and without idiopathic toe walking were recruited from general public advertising. Participants were required to perform a two-point discrimination test (task block) and press a button without being tested (control block) during an fMRI using a standard block design. Activation differences were examined in the left frontal pole, left supramarginal gyrus, left parahippocampal gyrus, left paracingulate gyrus and the right superior temporal. Five children were in the typically developing (TD) group and three were in the ITW group. There were between-group activation differences in the decision-making block compared to the control block in the left frontal lobe, parahippocampal gyrus and the right superior temporal gyrus. There was greater variation in activation in the left supramarginal gyrus and the left paracingulate gyrus in the ITW group compared to the typically developing group. Based on this study a future sample size of 15 children per group will be required to detect an adequate effect across chosen regions of interest Conducting fMRI using two-point discrimination testing on this population is feasible. Further research is required with larger population sizes to determine if brain activation patterns during the sensory input decision-making process are different in this population.

Physical activity and quality of life in children with idiopathic toe walking: a cross sectional study.

OBJECTIVES: To determine if children with idiopathic toe walking (ITW) reach Australian 24-hour movement guidelines. Additional objectives were to identify any factors associated with moderate to vigorous physical activity time of children with ITW. DESIGN: Cross sectional. SETTING: Private practice, public health outpatient, community clinics. PARTICIPANTS: Children between 4 and 14 years, who toe walked and had no medical conditions known to cause ITW. OUTCOME MEASURES: Physical activity intensity, sedentary behaviour and sleep data were collected via an ActiGraph. Physical activity level intensity data were triangulated with the Child Leisure Activities Study Survey (CLASS) to highlight the subjective nature of parent-reported measures. Health related quality of life information was collected using the Parent-Proxy and Child-Self Report Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scale. Regression analyses were used to explore individual factors associated with moderate to vigorous physical activity. RESULTS: Twenty-seven participants, 17(63%) male, age mean = 6.62 (SD = 2.29) years, provided information on physical activity (CLASS n = 18, ActiGraph n = 22), physical functioning and psychosocial functioning domains on the PedsQL (Parent-Proxy n = 25, Child n = 22). All participants exceeded Australian recommendations for physical activity, 44% (8/18) met recommended screen time amounts, and two (9%) met recommended sleep times. The Child-Self Report PedsQL scale score of social functioning was the only factor associated with an increase in physical activity (Coef = 0.48, 95%CI = 0.09 to 0.87, p = 0.019). CONCLUSION: Participants achieved high levels of daily moderate to vigorous physical activity, and this was associated with social functioning. Given current uncertainty regarding benefits and effectiveness of treatment choices for children who have ITW, these findings should encourage clinicians to consider how their treatment recommendations interact with the PA level and sleep of children with ITW. Any treatment choice should also be implemented with consideration of how it may impact social functioning. This study had a small sample size therefore results should be cautiously interpreted and not generalised to all children with ITW.

Children with idiopathic toe walking display differences in lower limb joint ranges and strength compared to peers: a case control study.

BACKGROUND: Idiopathic toe walking (ITW) is an exclusionary diagnosis. There has been limited exploration of lower limb active range of motion and strength measures in children with ITW. This researched aimed to determine any differences in lower limb muscle active range of motion and strength in children who have ITW, compared to normative data collected from children who displayed typical gait. METHODS: Children were recruited with had a diagnosis of ITW, aged between 4 and 10 years, and no recent treatment. Data collected included parent reported data such as time spent toe walking, percentage of time spent toe walking, and clinician collected data such as age, height and weight. Joint ranges of motion and strength measures were collected by an experience clinician. Active and weight bearing joint ranges of motion were evaluated with a goniometer or digital inclinometer. Lower limb muscle strength measures were evaluated with a hand-held dynamometer. Published normative data sets were used for comparison. Measures were analysed with regression analyses to determine differences between groups in different measures, considering measures known to impact range and strength. Odds ratios (OR), 95% confidence intervals (CI) and p values were reported. RESULTS: Twenty-six children with ITW participated. Reduced weight bearing ankle range of motion, when measured with the knee bent, was associated with being in the ITW group (p = 0.009), being older (p < 0.001) and weighing less (p < 0.001). Reduced ankle plantar flexion range was only associated with being in the ITW group (p = 0.015). For all lower limb strength measures, excluding hip external rotation, children who displayed greater strength, did not toe walk (p < 0.002), were older (p < 0.001) and weighed more (p < 0.014). with ITW. CONCLUSION: Children with ITW displayed reduced overall plantar and dorsiflexion at the ankle, compared to non-toe walking children. Reduced plantarflexion is children with ITW has not been described before, however reduced dorsiflexion is commonly reported. Children with ITW were weaker in many lower limb measures, even when age and weight were considered. This should lead clinicians and researchers to pay greater attention to lower limb strength measures in this population.

Children who idiopathically toe-walk have greater plantarflexor effective mechanical advantage compared to typically developing children.

PURPOSE: The effective mechanical advantage (EMA) of the plantarflexor muscles is important for gait function and is likely different from typical in equinus gait. However, this has never been quantified for children who idiopathically toe-walk (ITW), despite being routinely altered through clinical intervention. METHODS: This study quantified the Achilles tendon and ground reaction force (GRF) moment arms, and the plantarflexor EMA of 5 children who ITW and 14 typically developing (TD) children, whilst walking on an instrumented treadmill. RESULTS: There was no difference in the Achilles tendon moment arm length throughout stance between groups (p > 0.05). Children who ITW had a significantly greater GRF moment arm length in early stance (20-24% p = 0.001), but a significantly shorter GRF moment arm length during propulsion (68-74% of stance; p = 0.013) than TD children. Therefore, children who ITW had a greater plantarflexor EMA than TD children when active plantarflexion moments were being generated (60-70% of stance; p = 0.007). Consequently, it was estimated that children who ITW required 30% less plantarflexor muscle force for propulsion. CONCLUSION: Clinical decision making should fully consider that interventions which aim to restore a typical heel-toe gait pattern risk compromising this advantageous leverage and thus, may increase the strength requirements for gait.

Toe Walking as the Initial Symptom of a Spinocerebellar Ataxia 13 in a Patient Presenting with a Mutation in the KCNC3 Gene.

This article at hand described a 4-year-old child patient who initially presented with the symptoms of toe walking. As part of the diagnostic process, the patient was genetically tested to find the cause of the gait anomaly. The genetic test found a mutation in the KCNC3 gene. The variant c.1268G > A; p.Arg423. His was found in a heterozygotic state. This variant is frequently described as a cause for spinocerebellar ataxia type 13 (SCA13) in the literature. Apart from toe walking as the most pronounced symptom, the patient displayed an instable gait with frequent falls and delayed speech development. The genetic test to determine the cause of the gait anomaly successfully diagnosed the patient with a previously undiscovered SCA13 and subsequently enabled the recommendation of personalized further treatment.

Kinematic and Kinetic Gait Parameters Can Distinguish between Idiopathic and Neurologic Toe-Walking.

The differentiation between mild forms of toe-walking (equinus) in cerebral palsy (CP) and idiopathic toe-walking (ITW) is often clinically challenging. This study aims to define kinematic and kinetic parameters using 3D gait analysis to facilitate and secure the diagnosis of "idiopathic toe-walking". We conducted a retrospective controlled stratified cohort study. 12 toe-walking subjects per group diagnosed as ITW or CP were included and stratified according to age, gender and maximal dorsiflexion in stance. We collected kinematic and kinetic data using a three-dimensional optical motion analysis system with integrated floor force plates. Pairwise comparison between ITW and CP gait data was performed, and discriminant factor analysis was conducted. Both groups were compared with typically developing peers (TD). We found kinematic and kinetic parameters having a high discriminatory power and sensitivity to distinguish between ITW and CP groups (e.g., knee angle at initial contact (91% sensitivity, 73% specificity) and foot progression angle at midstance (82% sensitivity, 73% specificity)). The strength of this study is a high discriminatory power between ITW and CP toe-walking groups. Described kinematic parameters are easy to examine even without high-tech equipment; therefore, it is directly transferable to everyday praxis.

In vivo operating lengths of the gastrocnemius muscle during gait in children who idiopathically toe-walk.

NEW FINDINGS: What is the central question of this study? What are the in vivo operating lengths of the gastrocnemius muscle in children who idiopathically toe-walk? What is the main finding and its importance? Children who idiopathically toe-walk operate at more plantarflexed positions but at longer fascicle lengths than typically developing children during gait. However, these ranges utilised during gait correspond to where children who idiopathically toe-walk are optimally strong. This should be considered when prescribing clinical treatments to restore typical gait. ABSTRACT: Children who idiopathically toe-walk (ITW) habitually operate at greater plantarflexion angles than typically developing (TD) children, which might result in shorter, sub-optimal gastrocnemius fascicle lengths. However, currently no experimental evidence exists to substantiate this notion. Five children who ITW and 14 TD children completed a gait analysis, whilst gastrocnemius fascicle behaviour was simultaneously quantified using ultrasound. The moment-angle (hip, knee and ankle) and moment-length (gastrocnemius) relationships were determined from isometric maximum voluntary contractions (MVC) on an isokinetic dynamometer combined with ultrasound. During gait, children who ITW operated at more plantarflexed angles (Δ = 20°; P = 0.013) and longer muscle fascicle lengths (Δ = 12 mm; P = 0.008) than TD children. During MVC, no differences in the peak moment of any joint were found. However, peak plantarflexor moment occurred at significantly more plantarflexed angles (-16 vs. 1°; P = 0.010) and at longer muscle fascicle lengths (44 vs. 37 mm; P = 0.001) in children who ITW than TD children. Observed alterations in the moment-angle and moment-length relationships of children who ITW coincided with the ranges used during gait. Therefore, the gastrocnemius muscle in children who ITW operates close to the peak of the force-length relationship, similarly to TD children. Thus, this study indicates that idiopathic toe-walking is truly an ankle joint pathology, and children who ITW present with substantial alterations in the gastrocnemius muscle functional properties, which appear well adapted to the characteristic demands of equinus gait. These findings should be considered when prescribing clinical treatments to restore typical gait.

Muscle architecture and passive lengthening properties of the gastrocnemius medialis and Achilles tendon in children who idiopathically toe-walk.

Children who idiopathically toe-walk (ITW) habitually operate at greater plantarflexion angles and thus, at shorter muscle-tendon unit (MTU) lengths than typically developing (TD) children. Therefore, it is often assumed that habitual use of the gastrocnemius muscle in this way will cause remodelling of the muscle-tendon architecture compared to TD children. However, the gastrocnemius muscle architecture of children who ITW has never been measured. It is essential that we gain a better understanding of these muscle-tendon properties, to ensure that appropriate clinical interventions can be provided for these children. Five children who ITW (age 8 ± 2 years) and 14 TD children (age 10 ± 2 years) participated in this study. Ultrasound was combined with isokinetic dynamometry and surface electromyography, to measure muscle architecture at common positions and passive lengthening properties of the gastrocnemius muscle and tendon across full range of motion. Regardless of which common condition groups were compared under, both the absolute and normalised to MTU muscle belly and fascicle lengths were always longer, and the Achilles tendon length was always shorter in children who ITW than TD children (p < 0.05; large effect sizes). The passive lengthening properties of the muscle and tendon were not different between groups (p > 0.05); however, passive joint stiffness was greater in children who ITW at maximum dorsiflexion (p = 0.001) and at a joint moment common to all participants (p = 0.029). Consequently, the findings of this pilot study indicate a remodelling of the relative MTU that does not support the concept that children who ITW commonly experience muscle shortening. Therefore, greater consideration of the muscle and tendon properties are required when prescribing clinical interventions that aim to lengthen the MTU, and treatments may be better targeted at the Achilles tendon in children who ITW.

Dynamic muscle-tendon length following zone 2 calf lengthening surgery in two populations with equinus gait: Idiopathic Toe Walkers and Cerebral Palsy.

BACKGROUND: Two populations commonly presenting with equinus gait are Idiopathic Toe-Walkers and children with Cerebral Palsy. Surgical intervention to treat equinus is defined by three zones. Zone three surgery, performed at the Achilles tendon, is most commonly used clinically. There is however, evidence from simulation studies that zone two surgery, performed at the muscle belly, might provide better functional outcomes. The purpose of this study was to investigate the effect of zone two calf-lengthening on post-operative gait in these populations. METHODS: A retrospective audit of the Queensland Children's Motion Analysis Service database identified 17 toe-walkers (mean age 10.13 (SD 2.625)) and 11 Cerebral Palsy (mean age 9.72 (SD 4.04)) participants that received calf-lengthening surgery for plantarflexion contracture and had pre- and post-surgery 3D gait analysis. Inverse kinematics, dynamics, and muscle analysis were performed in OpenSim (v3.3) using a modified gait2392 model. Pre to post-surgery comparisons were performed in MATLAB using statistical parametric mapping. Dependent variables included ankle kinematics, powers and muscle-tendon length estimates. FINDINGS: The primary outcome of this study was that ankle dorsiflexion increased in both Idiopathic Toe Walking and Cerebral Palsy groups post-calf lengthening across 90% and 85% of the gait cycle respectively. There was an increase in modelled muscle-tendon lengths, specifically in the medial gastrocnemius, of 78% (toe-walkers), and 100% (Cerebral Palsy) of the gait cycle. Power generation during push-off was not affected. INTERPRETATION: Overall, the results appear to support the efficacy of zone 2 calf-lengthening for children with Cerebral Palsy and Idiopathic Toe Walking.

Investigation of Muscle Strength, Motor Coordination and Balance in Children with Idiopathic Toe Walking: A Case-control Study.

Purpose: To compare muscle strength, ankle dorsiflexion range of motion (ROM), motor coordination and balance, between children with and without Idiopathic Toe Walking (ITW).Materials and methods: This is an observational case-control study. The primary outcome is the triceps surae muscle strength. The secondary outcomes are the anterior tibialis muscle strength, lower limb balance, motor coordination, and ankle dorsiflexion ROM. Thirty-eight children were recruited: 19 between 5 to 11 years old with ITW and 19 healthy (control). Ankle dorsiflexion ROM, triceps surae, anterior tibialis muscle strength, motor coordination, and balance were assessed.Results: Children with ITW showed reduced triceps surae strength [mean difference (MD): 16.2 kgf/kg*100; 95% confidence interval (CI) -32.72 to 0.28; p = .05], reduced anterior tibialis strength (MD: 8.5 kgf/kg*100; 95% CI -13.35 to -3.05; p ≤ 0.001), reduced ankle dorsiflexion ROM (MD: 19.6 degrees; 95% CI 15.43 to 23.77; p ≤ 0.001) and impaired motor coordination and balance (MD: 17.7; 95% CI -25.54 to -9.82; p ≤ 0.001) compared to healthy children.Conclusion: Children with Idiopathic Toe Walking, presented in this study, demonstrated triceps surae and anterior tibialis muscle strength reduction, ankle dorsiflexion ROM reduction, impaired motor coordination, and balance compared to healthy children.

Functional Bandaging in Children with Idiopathic Toe Walking.

BACKGROUND: Idiopathic toe walking (ITW) is a persistent gait pattern with no known etiology, which is characterized as premature heel-rise or no-heel contact. The aim of this study was to investigate the effects of functional bandaging in children with ITW on heel-contact during stance phase and gait quality. METHODS: Nineteen children, 4-16 years of age with ITW (mean{plus minus}SD: 7.36{plus minus}3.16) and ten age-matched healthy pairs (mean{plus minus}SD: 7.30{plus minus}2) were included in the study. Elastic adhesive bandages were applied to children with ITW to assist with dorsiflexion. Before bandaging (T0), immediately after initial bandaging (T1), and one week later with the same bandage (T2), the initial contact, loading response, and mid-stance sub-phases 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 was analyzed by using Friedman and Wilcoxon signed-rank tests for within-group comparison and Mann-Whitney U tests for between-group comparison. RESULTS: In T0, for the ITW group, no heel contact was observed during stance. In T1, all the participants achieved heel contact at initial contact and loading response; and 56.8%, at mid-stance. In T2, all the heels continued contact at initial contact and loading response; and 54.3%, at mid-stance. The EVGS significantly improved. The Friedman test showed that there were noteworthy improvements between T0-T1 and T0-T2 in VBOGA and EVGS (p < 0.001), although no difference was found between T1-T2 in VBOGA (p = 0,913) and EVGS (p = 0,450). CONCLUSIONS: In this study, for ITW children, dorsiflexion assistive functional bandaging was an effective tool to help achieving heel contact on the ground and improve walking quality for a short period of time after the application. Further studies with longer follow-ups and larger sample sizes are required to confirm the long duration therapeutic effects of this promising functional bandaging.

Exploring health professionals' understanding of evidence-based treatment for idiopathic toe walking.

BACKGROUND: Idiopathic toe walking (ITW) is an exclusionary diagnosis resulting in a child walking on the balls of their feet. Preferred treatment options may be due to the severity of the toe or the health professional preference There are limited guidelines supporting consistent treatment recommendations for this condition. This research aimed to understand agreement between health professionals' knowledge of evidence for common treatment strategies for ITW and if health professionals supported these strategies being used in clinical practice. METHODS: An international online survey was opened to registered health professionals who treat children with ITW between July 2017 and March 2018. The survey had two components: (a) demographic variables and variables relating to knowledge of evidence about ITW treatments and (b) support for common treatment strategies. Additional data on strategy use, referrals, and preference were collected. Kappa statistics described intra-rater agreement between evidence knowledge and support. Multivariable regression analyses identified factors associated with the 10 most commonly preferred treatments. RESULTS: There were 908 international responses. Kappa agreement for paired correct responses determined a fair agreement for evidence support knowledge for four strategies including watch and wait (Kappa = 0.24), stretching (Kappa = 0.30), sensory integration strategies (Kappa = 0.40), and motor control strategies (Kappa = 0.24) and moderate responses for 13 others. No strategies had greater than moderate agreement between correct knowledge of evidence and strategy support. Profession, location, number of children seen in practice, and not correctly identifying the evidence factored into many of the most commonly used strategies for ITW (p < .05). CONCLUSIONS: The results from this study, which confirm a variety of interventions, are utilized in the management of ITW around the world. Furthermore, there remains a disconnection between paediatric health professionals' understanding of the evidence of common treatment strategies of ITW and a consensus for the treatment of this condition.

Serial ankle casts for patients with idiopathic toe walking: effects on functional gait parameters.

PURPOSE: The aim of the present study was to investigate the functional effects on gait parameters of serial ankle casts for patients with idiopathic toe walking (ITW), in comparison with an unremarkable control group. METHODS: A prospective trial with a pre-test-post-test control group design included ten patients with ITW and ten healthy matched children. Children with ITW underwent serial casting to stretch the plantar flexors, with two 14-day periods with walking plaster casts set at the maximum available ankle dorsiflexion. Both groups were assessed clinically and using a functional gait analysis before and after serial casting, as well as at a six-month follow-up visit. RESULTS: The normalized plantar heel force increased from 5% pre-interventionally to 79% at the follow-up. The upper ankle-joint angle and the base angle also demonstrated significant changes. Normalized compound action potentials of the medial heads of the gastrocnemius were reduced by 70%. None of these parameters demonstrated any significant differences at the follow-up examination in comparison with the healthy control group. Variations in the displacement of the knee joint on the sagittal plane and of the center of gravity in the transverse plane did not show any significant differences in comparison with the control group. CONCLUSION: The reduction of muscle tone and lengthening of the ankle plantar flexors led to persistent increased active ankle dorsiflexion with significant long-term improvement of functional kinematic parameters. No significant difference in the gait analysis was found between the ITW group and healthy children six months after treatment.Level of Evidence: Level II - Therapeutic.

Idiopathic toe walking-A follow-up survey of gait analysis assessment.

BACKGROUND: Toe-walking is a normal variant in children up to 3 years of age but beyond this a diagnosis of idiopathic toe-walking (ITW) must be considered. ITW is an umbrella term that covers all cases of toe-walking without any diagnosed underlying medical condition and before assigning these diagnosis potential differential diagnoses such as cerebral palsy, peripheral neuropathy, spinal dysraphism and myopathy must be ruled out. Gait laboratory assessment (GLA) is thought to be useful in the evaluation of ITW, and kinematic, kinetic and electromyography features associated with ITW have been described. However, the longer term robustness of a diagnosis based on GLA has not been investigated. The primary aim of this study was to examine if a diagnosis of ITW based on GLA features persisted. METHODS: All patients referred to a national gait laboratory service over a ten year period with queried ITW were sent a postal survey to establish if a diagnosis of ITW which had been offered following GLA persisted over time. The gait and clinical parameters differentiating those reported as typical ITW and not-typical-ITW following GLA were examined in the survey respondents. RESULTS: Of 102 referrals to the laboratory with queried ITW, a response rate of 40.2% (n = 41) was achieved. Of the respondents, 78% (n = 32) were found to be typical of ITW following GLA and this diagnosis persisted in the entire group at an average of 7 years post GLA. The other nine subjects were reported as not typical of ITW following GLA and 44.4% (n = 4) received a subsequent differential diagnosis. The clinical examination and gait analysis features differentiating these groups were consistent with previous literature. CONCLUSION: GLA appears to be a useful objective tool in the assessment of ITW and a diagnosis based on described features persists in the long-term.