lack of toe-off in 16month old

[*koni*]

Hi Esther,
thanks for reply.
I´m not a specialized pediatric physio, just a fresh graduate. I studied in NL but now work overseas and there is no specific pediatrics training here. I work at an outpatient practise that treats mainly children but also adults with mainly ortho. problems.
The girl has been diagnosed (by physician & former physio, not me) with ´delayed milestone', not hypermobility. She´s just a little behind in gross motor skills, balance and walking but she´s improving.
We are currently waiting for special boots that will correct her gait pattern but until they arrive I would like to focus on promoting toe-off in her gait.
She is mainly walking in normal but fairly stable shoes, though we have also tried bare-feet several times which didn´t seem to make a difference.
She is generally hypotone and not as strong as she should be for her age, gait practise is the main focus during treatment but balance and coordination etc. are also included.
Hope this helps.
gr.
k.

[estherderu]

dear Koni,

Thanks for the information.

I do have some more questions though...
How do you know she is not as strong as she should be for her age???
What is your reference in this regard?
Why do you want to focus on promoting toe-off in her gait?
Are you familiar with the reason why there is a developmental delay? is it genetic?
What are the parental concerns? and what are yours?
Does this child fall a lot?

Variability is the key word for a child's development. There are very big differences in normal and abnormal development.
Some children start walking when they are as young as 10 months, and others when they are nearly 2.
Children with hypotonia are often a little later with some of their milestones.

I really suggest you become a member of Pam's site.... you will learn an enormous amount about normal and abnormal behaviour from it.
Children are not tiny adults and often need a very different approach.
As you notice, I have not answered your question as of yet.
Giving advice on the treatment of a child is impossible without knowing all the background and the rational behind your choices.
Please share with us.

Esther

I understand and sympathize with your wanting to help this child.

[*koni*]

Hi Esther,

the girl has recently been examined by her physician and he diagnosed general hypotonia, ie. lack of strength. I only recently took over treatment from a collegue who left and her delay was referred to a test (forgot the name..) where she scored way below her age in several categories. This seems to be genetic as her mother and her cousin were/are having similar problems at that age.
The parents aren't too concerned and regard her as just a little behind expecting that she will undergo some developmental spurt later on and catch up. I agree but want to focus my treatment on helping accelerating her development as much as possible to prevent disadvantages in the near future, eg. not being able to keep up when playing with other children, etc.
She doesn't fall that much but she also doesn't really risk that as she's very fearful and careful, ?due to her lack of balance and coordination. One factor that seems to influence her stability is her excessive toeing-out, about 90 deg. as compensation for push off. Apart from the reduced stability this concerns me as it will influence her whole gait pattern, muscle balance over the hips, forces on the knees, etc. and it also causes reduced power of push-off and the resulting propulsion. I would like to train her calf muscles and 'teach' her proper toe-off to make her gait more efficient and therefore easier for her, to boost her confidence and enable her progress with this, she does enjoy walking a lot.
Maybe I do analyse this as I would in an adult, but what are the alternatives, ignore and wait&hope it will resolve by itself?
Thanks for the link btw, very interesting webpage!

-koni

[estherderu]

dear Koni,

In most young children I focus on the trunk and its possibilities first.
How is her trunkcontrol in sitting?
When young children commence comming to sit, and learn how to sit alone they are 'practicing' their trunk control. The initial trunk muscles involved are the rectus abdominis and the erector trunci. This changes in time and is not the same as with adults. There is a good book on trunk control called Wiley: Postural Control : A Key Issue in Developmental Disorders I recommend about this subject.

If you have been looking at Pam's site you may have read her piece on hypotonia and what it is and what it isn't.
If the problem is genetic, you can look at her parents or siblings to see what the results long term are.
Hyperlaxity of ligaments is something you cannot just change.

When I read your remarks I think it would be advisable to get her back on the ground as much as possible,
let her creep and crawl and climb (if this is possible in her culture and country) and
only walk when she wants to.
I do not have much time to go into detail at this moment.... will get back to you soon

Esther