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Occupational therapy and habit re-training for idiopathic toe walking

Posted Jan 14 2009 8:57pm
I don't know that I have ever seen any occupational therapy literature on idiopathic toe walking.
For an excellent overview and references on this condition please check this article from the Journal of Family Practice.

As the reference states, it is important to avoid 'over medicalizing' the problem especially since there are not many toe-walking adults that are presenting themselves for intervention. It is possible that toe walking is a self limiting problem in many children. However, there is a reasonable concern when toe walking begins to contribute to pes cavus deformities which of course can have longer term implications. In our clinic we see a few children each year with toe walking that is beginning to cause functional foot deformity.

Idiopathic toe walking is a relatively common condition that is often seen by occupational therapists - but not generally as a primary reason for referral. Some professionals view toe walking as a marker of other developmental immaturities. It is critical to make distinctions between true idiopathic toe walking as opposed to toe walking associated with cerebral palsy, autism, muscular dystrophy, or other conditions. Toe walking should always be evaluated by a medical diagnostician first to rule out these other more severe conditions.

Some occupational therapists attribute toe walking to sensory problems but there is no evidence that this is true. Many occupational therapists leave intervention for toe walking to physical therapy colleagues who are often more specialized in nuances of gait analysis and biomechanics of ambulation. However, I have found that traditional physical therapy interventions often fail to address some of the specific problems associated with idiopathic toe walking.

There is a lot of literature that discusses different treatment options including serial casting, range of motion, and strengthening. Medical interventions often include botox injections or muscle lengthening. There is debate over which of these are most effective, or if they are at all effective.

At our clinic we try to complement traditional biomechanical interventions with re-training for self care (dressing) habits. Many of these children do not like to wear shoes and as soon as they come home from school the shoes are off and the children are tiptoeing around the house and yard barefoot. Toe walking without shoes promotes hyperextension of the toes and exacerbates the muscle imbalances that are already occurring in the foot and lower leg. Even when parents know that allowing their children to be barefoot can exacerbate the problem - it is difficult for them to effect behavioral change.

When there is no orthopedic or neurological cause of the toe walking we add a positive reinforcement component to the intervention program. The goal of this is to promote shoe wearing throughout the day and to break the habit of being barefoot. We find that children respond well to a 'puzzle' that has bones of the foot, and they can 'earn' puzzle pieces each day for successfully keeping their shoes on for a specified duration of time. Each day that they wear their shoes they get a new piece to add to the puzzle.

After the children complete the puzzle by earning all of their foot bones they are able to win a specified reward. Children respond well to the visual cue of the puzzle, are easily able to understand their progress toward the goal of wearing shoes every day, and like to learn about the way their feet work. Parents also benefit from use of the bone puzzle because it is easy to implement and is also helpful as an educational aid for teaching them about biomechanics of the foot.

If shoes fit properly and are supportive it is difficult to toewalk. Thankfully, Converse Chuck Taylors are back in style with kids! We find that compliance with regular shoe wearing is improved with use of 'cool' sneakers and the prospect of earning a reward by completing their puzzles.

It is important to have good dialogue with the orthopedic doctor and orthotist. Depending on the degree of functional foot deformity sometimes it is necessary to have even more modification to shoes including SMOs, AFOs, or modified shoes with a high toe box to avoid pressure sores.

We don't see enough children with idiopathic toe walking in our clinic to do a well designed study but still have had good anecdotal success with our combined biomechanical intervention and behavioral program. It would be interesting to see if the behavioral component increases the length of time that children demonstrate more functional gait patterns following intervention.


Reference:

M. Patrice Eiff. " What is the appropriate evaluation and treatment of children who are "toe walkers"?". Journal of Family Practice. . FindArticles.com. 17 Sep. 2008. http://findarticles.com/p/articles/mi_m0689/is_5_55/ai_n26877929
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