Online CPD: introduction to paediatric physiotherapy tutorials

[Bobby Nabeyama]

Hello everyone

The SfA Webmanual has been updated with a new page on idiopathic toe walking and information on the role of fascia in flexibility.

best wishes

Pam

I appreciated your description of the idiopathic toe-walking. It was consise with large consideration of the literature.

Although, I am not sure how you've assessed joint, muscle length or myofascial restrictions. These assertions are certainly not evidence-based. Where is the source of your theory of restrictions in myofascial and neural structures? Are there any data to confirm these hypotheses?

Also, I don't see how addressing these 'movement restrictions' affect the motor behavior of toe-walking even if restrictions exist. You're not changing the actual problem, but a proposed problem that might otherwise be irrelevant.

[PamVersfeld]

Thank you Bobby for your comments.

You are quite correct - there is no published evidence to support my claims that idiopathic toe walking is associated with decreased flexibility of mutiple-joint structures that cross from the lumbar region across the hips and knees.

However, any physiotherapy assessment starts with an assessment of range of movement and strength. This is standard and accepted practice. All I am claiming is that if you assess range of movement that is considered to be restricted by extensibility of two joint muscles (and the associated fascial structures) or by neural tissue mobility, there is a pattern of restriction that is commonly seen. In particular straight leg raise with dorsiflexion is more limited than straight leg raise. Hip external rotation with the hip in extension is also restricted, often to less that 10 degrees. In addition hip adduction with the hip in extension (modified Thomas test) is also restricted, with a loss of range of up to 10 - 20 degrees.

In contrast to this there may be 90 degrees of passive dorsiflexion - so the range of dorsiflexion may not be the limiting factor at all.

And yes you are correct - the gait pattern needs to be addressed - along with the child's poorly developed ankle balance strategies etc.

My argument is that when assessing a child with habitual toe walking, we need to look beyond the obvious, which in this case is the decreased range of dorsiflexion, and address the interaction between body segments and possible factors that impact on the child's gait pattern.

At present there is limited evidence to guide clinical decision making in idiopathic toe walking. What research has been done has been very narrow in its analysis of the possible causative and contributing factors. What I am proposing is a broader analysis of possible factors. Clinical assessment of the individual child will either confirm or refute my suggestions.

And yes, you are right, research is needed to either confirm or refute my basic hypothesis. This hypothesis is based on detailed clinical observation and recognition of a pattern of findings, which is a good place to start when formulating a research question. And I hope that some young researcher will look at my ideas and maybe do the needed research. In the meantime, the individual clinician who has read my article will perhaps broaden her view of the underlying problem and the possible solutions. My experience is that by addressing both flexibility and coordination issues children's gait pattern can be changed.

Pam