lack of toe-off in 16month old

[*koni*]

Does anyone have any suggestions how to perform gait reeducation on a 16 month old?
She is generally hypotone and compensates for lack of toe-off by excessive external hip rotation, pushing off with the whole medial side of her feet. (-> reduced balance/stability, power & confidence during walking).
I would like to start by conditioning her calf muscles though am unsure about exercises that are suitable for such a young one.. Ideas are very much appreciated!

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[estherderu]

Dear Koni,
Before answering your questions I have a few myself.
Have you been trained as a paediatric physiotherapist in the Netherlands or are you still studying?
I know how we are trained in Holland.

What do you know about the general development of an infant?
What are the child's problems? Is he/she hypotoon or does he/she supper from general hyperlaxity of the joints?

What would your treatment goal be and why?
What is the parents goal for treatment?
Do you want the child to commence walking with shoes or without?
Did the child have shoes on with the assessment?

In general I can tell you that children that are a little hyperlax in the joints often walk in this manner.
Make sure the child is wearing good supporting shoes (tiny boots). This can make a huge difference.
In most cases a child will want to practice a new skill (such as walking).
If this is not the case I think assessment as to why not is important.

For more information: www.skillsforaction.com
On this wonderful site you can find a lot of theoretical and practical information on generalized hyperlaxity, low tone and much more.

kind regards

Esther

[*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

[junior_physiotherapist]

Hi all,

Nice disscussion................

[estherderu]

dear colleagues,

Have found this article which tells a little about the differences between very young and adult "gait".
Gait kinematic and kinetics of 7 yr old children: a comparison to adults using specific anthropometric data. Authors Ganley KJ Powers CM
Result provide support for the hypothesis that children lack the neuromuscular maturity especially in the ankle to produce an adult like gait.
(N15) kids and (N15) adults most variable are similar but diminished peak plantar flexor moment and less peak power absorption and generation
at the ankle during late stance.
Gait Posture 2005 Feb;21(2)141-5

Remember that most bones are not formed as adult feet at all. By googling maturation bones children I found a lot of different interesting articles... example
Skeletal growth in school children: Maturation and bone mass - Mazess - 2005 - American Journal of Physical Anthropology - Wiley Online Library

If you have time and the possibility and you will be working with children a lot, try to find as much information as possible.
In which country are you working?

that was the theory... now the clinic...
If you do want to exercise as you have said, I suggest asking the child to do something functional such as reaching really high for something.
This means she will have to get on her toes... you can make this into a game...
Remember that everything you do with the child should be functional if possible. This means that the movement can be repeated at home.
The trick is to make it into a game that can be played over and over again.. children love learning a new skill.

Esther

[Bobby Nabeyama]

dear colleagues,

Have found this article which tells a little about the differences between very young and adult "gait".
Gait kinematic and kinetics of 7 yr old children: a comparison to adults using specific anthropometric data. Authors Ganley KJ Powers CM
Result provide support for the hypothesis that children lack the neuromuscular maturity especially in the ankle to produce an adult like gait.
(N15) kids and (N15) adults most variable are similar but diminished peak plantar flexor moment and less peak power absorption and generation
at the ankle during late stance.
Gait Posture 2005 Feb;21(2)141-5

Remember that most bones are not formed as adult feet at all. By googling maturation bones children I found a lot of different interesting articles... example
Skeletal growth in school children: Maturation and bone mass - Mazess - 2005 - American Journal of Physical Anthropology - Wiley Online Library

If you have time and the possibility and you will be working with children a lot, try to find as much information as possible.
In which country are you working?

that was the theory... now the clinic...
If you do want to exercise as you have said, I suggest asking the child to do something functional such as reaching really high for something.
This means she will have to get on her toes... you can make this into a game...
Remember that everything you do with the child should be functional if possible. This means that the movement can be repeated at home.
The trick is to make it into a game that can be played over and over again.. children love learning a new skill.

Esther

I think the member meant the child lacked preswing/initial swing. I.e., toe off. So behaviors such as reaching high probably isn't best.

[estherderu]

dear koni and bobby,

Bobby...you are right.. I misread.
Koni... the mixup came from my not reading properly and misunderstanding that you wanted to do two things:
"I would like to train her calf muscles and 'teach' her proper toe-off to make her gait more efficient ".
My answer was the reaction to the " training of the calf muscles"bit... I forgot to mention the rest. Sorry for this.

So now a little about the toe-off in pre-swing fase...
I would try seeing in which position( in sitting or lying supine or on her side) you can see the most periferal fine motor movement in the foot in general...
I often use the sidelying position, you can see some beautiful, varied movements such as dorsalflexion in the foot and ankle whilst the child is playing in this position.
If you do not see any or little fine motor movement, I suggest you try to enthice the child to do more (toys) with her feet first.
And if this is the case you can imagine that the same movement is not possible against gravity yet.

Children are very good at compensating and using whatever possibilities they have. In a hypermobile child, or a child with extreme mobile hips (ext. rotation) we do see the gait you describe.
If lifting you foot is not possible or very difficult then the child needs to rotate your hip to get ahead.

hope this helps you on

Esther