April 2012

Off their toes: Lower-profile device aids toe-walkers

In the moment: O&P

istockphoto.com #8436667

By Emily Delzell

Idiopathic toe-walking is a bilateral toe-to-toe gait diagnosed when children con­tinue this behavior, which is considered part of the normal spectrum of toddlers’ gait development, past age 2.

Research presented in March at the American Academy of Orthotists & Prosthetists (AAOP) annual meeting in Atlanta sug­gests that initially treating children with a rigid footplate rather than a more restrictive ankle foot orthosis (AFO) may help them more easily adopt a normal gait.

“The goal of treatment is to break the toe-walking pattern and, whatever device is used to do that, get children in out and out of it quickly,” said Mark Geil, PhD, associate professor of biomechanics at Georgia State University in Atlanta, who presented the research. “We hypothesized both devices would reduce incidence of toe-walking in the brace and also have some carryover effect after it was removed. If we saw similar results with the smaller, more cosmetically appealing device, it would make sense to use it first and then, if needed, move to the AFO.”

Geil presented data on 12 children (five girls), aged 2 to 8 years, who were randomized to an articulated AFO that blocked plantar flexion at the ankle joint and resisted toe extension at all metatarsophalangeal (MTP) joints or a full-length extra-firm carbon fiber footplate that resisted toe extension at the MTP joints. Investigators asked parents to have children wear the devices at all times for six weeks except during sleeping or sports.

Children, who underwent gait analysis and an L-test of functional mobility (which times patients  during a 20-m walk that includes completing two transfers and making three turns) before application of a device and with and without the device in the same session after six weeks of wear, were more compliant with footplate, wearing it an average of 12.17 hours per days versus 10.33 hours in the AFO. The AFO completely controlled toe-walking, while the footplate still allowed some incidents of abnormal gait.

The investigators found no significant differences between groups on the functional mobility test before or after device application.

“These data may suggest that neither device hindered patients’ overall functionality,” said Kinsey Herrin, MSPO, CO, an orthotist at Children’s Healthcare of Atlanta and the study’s coauthor and AAOP copresenter.

For both walking speed and early heel rise, children wearing the AFO performed better than those wearing the footplate, but the acute carryover effect in these measures was slightly improved in the children who had worn footplates.

Geil said the better carryover seen with the footplate led him to what he called “the rebellious teenager theory,” i.e., the greater constraints imposed by the AFO resulted in more regression than seen with the less-restrictive footplate.

“Our study participants continued to toe-walk some with the footplates, however, when [the footplates were] removed, children toe-walked less than they did initially. With our AFO kids, the toe-walking is beautifully controlled while wearing the devices, but when they come out of them, they are still toe-walking just as much,” Herrin said. “It may be worthwhile to start a patient in rigid footplates and then, six months down the road, if the toe-walking has not improved or has worsened, consider switching them to an articulated AFO. In addition to improved gait control, I think parents appreciate the footplates because they’re less visible; the kids like them because they are less hot and restrictive.”

Results of a parental satisfaction survey seemed to mirror gait lab data, Herrin said.

“Parents reporting reduced time toe-walking in AFOs; however, they saw increased time spent toe-walking when the child wasn’t wearing the device. In contrast, with the footplates, they reported reduced times spent toe-walking both during wear and without the device,” she said.

Geil M, Herrin K. Is a rigid footplate as effective as an articulated AFO in controlling idiopathic toe walking? Presented at the 38th Annual Meeting and Symposium of the American Academy of Orthotists & Prosthetists, Atlanta, March 2012.

Herrin K, Barner K, Geil M. Clinical outcomes after orthotic treatment of idiopathic toe-walking: AFO vs FO. Presented at the 38th Annual Meeting and Symposium of the American Academy of Orthotists & Prosthetists, Atlanta, March 2012.

5 Responses to Off their toes: Lower-profile device aids toe-walkers

  1. Liesa M Persaud says:

    What functional outcome measure(s) was used & how was “time spent toe walking” documented.
    Thank you.

  2. rdubin says:

    Time spent toe walking was documented by parents, who kept a log. In addition to the L-test they also did an l-test of functional mobility (baseline, after wearing the orthoses for the 6-week study period and immediately after removing the orthosis), which measures the patient’s ability to walk a total of 20 meters and complete 2 transfers and 3 turns. The authors said data from the l-test suggests neither device hindered the patient’s overall functionality.

  3. Laurie says:

    I am curious which type of AFOs were used in this study?

  4. Sandy says:

    My mother had a stroke. And is on able to stand on her own . But we also note she now walks on the toe of her left foot. I do not no what I could do for this? Mom will be 91 so we do not want to have her go throw alot at this age.

  5. I am a movement coach in london and really intruiged by this article/techniques used. I came across an adolesent boy, who was a ‘bum skidder’ during his developmental stages. He never crawled and being the youngest of the siblings! His gastroc/soleus complex was extremely tight, had lots of physiotherapy/physical therapy, nothing worked. I put him through a set of movement based tissue ‘stress’ exercises to re-educate the tissue to elongate with gravity and hiw own body weight. I went deeper into the neurology, checking his balance system, inner ear, found he had terrible stability whilst moving quickly. His verticle displacement in the gait cycle is absent whilst toe walking. The Saccule and Utricle organs, up and down motion, was stimulated on a mini tramp (post a decent amount of movement). This combination of treatment I found the best and to this day, his heels are grounded and his is effortless in gait. Hope this helps!

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