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Why is Toe Walking Bad?

Idiopathic toe walking is a type of walking pattern that occurs when children walk on their tip-toes instead of using the more “typical” heel first pattern. Idiopathic is a term that refers to the fact that this toe walking occurs spontaneously, usually out of habit, and is not due to another medical cause. blog-toe walking-main-landscape

A non-idiopathic cause may be cerebral palsy, autism, sensory processing disorder, muscular dystrophy or brain injury. As children learn to walk, some toe walking is to be expected. When this becomes a strong habit that they do not grow out of, or the predominant pattern as they are new walkers, then several issues can arise.

The following are negative consequences of toe walking:

  • Tight ankles or contractures can develop
  • Poor balance reactions, frequent falling
  • Muscle imbalances “up the chain” meaning decreased hip or core strength due to the different postural alignment
  • Difficulty with body mechanics including squatting or performing stairs, secondary to tight calve muscles
  • Inability to stand with heels flat on the ground
  • Pain in ankles, knees or hips due to faulty mechanics
  • Surgery, casting, night splinting or daily bracing may be necessary

While some toe walking should not be alarming, the earlier you intervene, the better. Discuss this with your pediatrician or see a physical therapist who can provide early strategies to stop the cascade of effects that can be seen later.

NSPT offers services in Bucktown, Evanston, Highland Park, Lincolnwood, Glenview, Lake Bluff, Des Plaines, Hinsdale and Milwaukee! If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates!

Meet-With-A-Physical-Therapist

How to Qualify for Physical Therapy Services at School

North Shore Pediatric Therapy recently hosted our first IEP bootcamp, where our school advocate explained how to get the most out of your child’s IEP and school services. Similarly, children can receive physical therapy services at school. Here is a breakdown of how a child would qualify for physical therapy services in a school system and the differences between physical therapy services in a school and physical therapy services in a private setting.

How is Physical Therapy Included in School Services?

Through the Individuals with Disabilities Education Act (IDEA), public education must be accessible toHow to Get Physical Therapy Services in School all children aged 3-21 years old[i]. Physical therapy is a related service used to help implement IDEA. School-based physical therapy must be aimed towards allowing the child to access his educational environment. Some of the things a school-based physical therapist might assess include travel from one area of the school to another, getting onto and off of the bus, safely navigating the bathroom and cafeteria, getting into and out of classroom chairs, and participation in all classes. They will assess independence, safety, and timeliness of the above areas in determining need for physical therapy services.

The Role of the IEP:

If parents, teachers, or students determine a need in the student accessing the school environment, an IEP referral is made.  This begins the process for school-based services. A physical therapist employed by the school district or contracted through an outside agency will evaluate the child and determine eligibility. In Illinois, the physical therapist is required to obtain a prescription for physical therapy from the child’s physician prior to treatment. However, physical therapy services must be provided at no cost to the family when deemed necessary.

Clinic-Based vs. School-Based Physical Therapy:

Clinic-based physical therapy is aimed at improving quality of movement, return to function, and achieving gross motor milestones in an age-appropriate time frame. Many children who would benefit from physical therapy services, but don’t qualify for school-based services due to the restrictions, attend private clinics for physical therapy services. In these settings, a physical therapist determines need based on standardized assessments, functional assessments, strength and range of motion testing, and compares these scores to age-appropriate norms. Some things that may qualify a child for outpatient physical therapy but not school-based physical therapy include gait abnormalities (including toe-walking and in-toeing), developmental coordination disorder, decreased endurance and overall weakness, hypotonia, foot pain, sports injuries, burns, etc. In Illinois, the physical therapist is required to obtain a prescription for physical therapy from the child’s physician prior to treatment. Physical therapy services in an outpatient setting must be covered through insurance or private pay.

Dependent on your child’s needs, physical therapy services may be required in a school setting, in an outpatient setting, or both. If you have any concerns about your child’s gross motor development or access to services in their school district, please contact the professionals at NSPT.

north shore pediatric therapy physical therapy

NSPT offers services in BucktownEvanstonHighland ParkLincolnwoodGlenview and Des Plaines. If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates today!

[i] Fact Sheet. Providing Physical Therapy in Schools Under IDEA 2004. www.pediatricapta.org. 2009. Accessed 07/14/2015.

signs a child may need PT at school

Signs at School a Child May Need Physical Therapy

Teachers can be wonderful allies to the healthcare field. They spend up to 8 hours a day observing and helping children. Often times, they are the first to notice concerning signs, and when given the right tools, can direct parents where to go to get their children the help they need. Here a few signs teachers can look out for that would warrant a physical therapy screen.

5 Signs at School a Child May Need Physical Therapy:

  1. Unable to keep up with peers during recess or P.E – This may present as a child whosigns a child may need PT at school doesn’t follow friends onto the jungle gym or pulls themselves out of games of tag. A child would benefit from a physical therapy screen if they are unable to perform a jumping jack or skip forward.
  2. “W”-sits or props onto arm when sitting criss-cross – A child who sits in a “w” position or props onto their arm when sitting on the floor may present with weak core muscles. Weak core muscles result in a poor foundation for other fine motor skills, and may present in sloppy or slow handwriting, poor cutting skills, or decreased independence in self care tasks.
  3. Places both feet onto step when going up and down stairs – A child should be able to go up and down a set of stairs, without holding onto a handrail, by the age of 4. A child who presents difficulty, or immature form, during a stair task, may have lower extremity weakness, impaired balance, or developmental coordination disorder.
  4. Toe-Walking Toe-walking or early heel rise during gait (which may looking like bouncing while walking) can arise from a multitude of impairments including muscle tightness, core weakness, impaired balance, etc. Prolonged toe-walking may also result in any of the above, excessive falls, or muscle contractures.
  5. Poor sitting posture at desk – Poor posture may be a sign of decreased endurance of trunk muscles. Trunk weakness may also result in a poor foundation for fine motor skills, resulting in poor handwriting, decreased grasping ability, or decreased independence in self care tasks.

Click here to view our gross motor milestones infographic!

NSPT offers services in BucktownEvanstonHighland ParkLincolnwoodGlenview and Des Plaines. If you have questions or concerns about your child, we would love to help! Give us a call at (877) 486-4140 and speak to one of our Family Child Advocates today!

what is an orthotist

What is an Orthotist?

 

 

 

Pediatric physical therapists and physicians often rely on the help of orthotists and prosthetists to help with patients’ mobility needs. Sometimes, children come to physical therapists with gait and postural deviations (toe-walking, in-toeing, scoliosis, etc) and other conditions where exercises and muscle retraining simply are not enough. In those cases, we often ask for the help of an orthotics and prosthetics (O&P) specialist. Braces and artificial limbs are important to facilitate movement and promote independence.

When we refer children to an orthotist, it means we think that some aspect of their movement and growth could be helped out by an external medical device. An orthotist is a critical part of the rehabilitation and therapy process. Orthotics help correct alignment and improve function of childrens’ neuromuscular or musculoskeletal system. Orthotists evaluate what a child’s functional needs are and will design and construct the orthotic devices as needed. An orthotist is a certified healthcare professional who is knowledgeable in human anatomy and physiology, biomechanics, and engineering. As movement specialists, physical therapist rely heavily on the help of orthotists to achieve the mobility goals for our clients.

Some conditions that may require help of an orthotist:

Not sure if your child will have orthotic needs? Come see a physical therapist and we can point you to the right medical professional depending on your needs.

Click here to read our run-down of the best over the counter foot orthotics.

night splints

The Quick Guide to Night Splints for Children

 

 

 

For many children who are idiopathic toe-walkers, physical therapists often take the conservative approach. We have many things in our arsenal to help children improve without undergoing costly and painful surgery. Outside of stretching and strengthening exercises, we might recommend ankle foot orthoses (AFOs) for day time and/or night time wear. Depending on the child’s range of motion measurements, walking mechanics, and underlying pathology, different types of orthotics might be recommended. We often work closely with orthotists (professionals who design medical supportive devices such as braces) to make sure each child receives the individualized care and equipment he needs to gain full function and optimal alignment.

Here are reasons why your physical therapist might have recommended night splints for your child:

  1. The main goals of physical therapy interventions for toe-walkers are to increase ankle dorsiflexion range of motion and to decrease possible contractures that are associated with the condition. Physical therapy exercise programs include stretching the calf muscles, strengthening the trunk muscles, manual therapy, treadmill training, balance training, and ankle mobility training. Sometimes, in stubborn cases of toe-walking, orthotics are needed to maintain the range of motion gained throughout daily exercise sessions.
  2.  If you’ve ever tried to stretch your pre-schooler’s muscles, you know that children can be active and fidgety. They don’t tolerate passive stretches as well as adults and might complain of boredom, pain, or ticklishness. The most effective stretches are those held for a prolonged period of time at a joint’s end range. Night splints allow for increased stretch time at the ankle joint, because the child is sleeping or resting when they are in place.
  3. The best time to gain range is when a child is relaxed. Since children relax more during sleep, even more range can be gained through passive stretching using a night time AFO.
  4. This is where the night-time splint comes in. While the daytime AFO is a rigid orthosis that keeps your child’s ankles from plantarflexing (pointing down) past neutral while he walks, the night time AFO is a much more dynamic system. Night splints can be adjusted as the ankles gain more range into dorsiflexion. They provide a low-load, prolonged-duration stretch that helps with contracture reduction and counters high tone.
  5. In the literature, night splints have been found to be effective for contractures at a variety of joints, and can be useful in brachial plexus injuries, cerebral palsy, and muscular dystrophy.

As pediatric physical therapists, we rarely recommend over-the-counter orthotics for your child’s orthopedic needs. By consulting with an orthotist, we make sure each child is fitted to the most comfortable and developmentally appropriate custom foot wear for his condition. Usually, children who adhere to a strict physical therapy program and who receive the right orthoses can see a complete change to their posture and gait mechanics in as short as 6 months’ time.

Click here to view our gross motor milestones infographic!

References:
Cincinnati Children’s Hospital Medical Center. Evidence-based care guideline for management of idiopathic toe walking in children and young adults ages 2 through 21 years. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2011 Feb 15. 17 p. [49 references]

physical therapy for autism

Physical Therapy for Children with Autism

 

 

 

Autism Spectrum Disorders (ASD) is a diagnosis that describes kids with significant social, communicative, and behavioral challenges. While the diagnosis is mostly associated with difficulty with communication, there are also common physical issues experienced by children with ASD.

Some children with autism are not diagnosed until they are older, though retrospective studies have shown gross motor discrepancies in babies and toddlers who were later diagnosed to be on the spectrum. With so much treatment emphasis placed on their social and language impairments, physical limitations only become more amplified in these children as they age. Children with ASD can have trouble with a number of large postural tasks, such as sitting, walking, running, jumping, and balance. Studies have shown the prevalence of low muscle tone (hypotonia), toe-walking, ankle stiffness, motor apraxia, and increased motor stereotypes in children with autism. Hypotonia is the most common motor symptom, affecting up to 51% of these children.

How can physical therapists help children on the autism spectrum?

  1. Collaboration: Having a child on the autism spectrum (click here to view our autism infographic) can be challenging for parents. Limited social, behavioral, speech, and motor skills can lead to difficulties both at home and at school. With balance, coordination, and poor motor control at play, it is important for physical therapists to collaborate with other professionals involved in a child’s care. It is also important for physical therapists to contribute to the conversations involving parents and therapists. Physical therapists can address a child’s balance and postural control to encourage improved endurance and attention with school time activities. Knowing a child’s sensory processing needs and behavioral tendencies helps physical therapists make effective goals to make the most gains for a child with ASD associated gross motor delay.
  2. Education/Resources: Parents may not understand the link between physical performance and behavioral responses. A child with gait changes due to sensory-seeking behaviors or a child with poor balance due to decreased motor control will have a hard time participating in play and social skills. As some children are diagnosed years after gait deviations or musculoskeletal compensations are in place, parents also rely on physical therapists to provide information and resources for their child’s orthopedic or developmental needs. Physical therapists can direct parents to orthotists, equipment, or community sports programs specialized for their child with ASD.
  3. Therapeutic Play/Socialization: A huge focus of therapeutic exercises for children with ASD is to encourage large quality movements and age-appropriate play. For example, a child who walks on his toes will need exercises to increase ankle mobility and calf flexibility. A child who has a hard time holding his trunk upright during school will need exercises for postural control. Some children may have a hard time coordinating their limbs to participate in age-appropriate skills, such as hopping on one foot or skipping. Physical therapists help these kids gain more confidence in the skills they need in the future to navigate different environments and perform challenging tasks in the community as adults. Pediatric physical therapists often design treatment sessions where movements that hinder social participation are reduced and movements that lead to independence are encouraged.

New research on toddlers and preschoolers with autism found that children with better motor skills are more proficient at socialization and communication than those who have physical deficits. In addition, autism spectrum disorder has a wide range of presentations and physical involvements, with impairments varying from mild to severe. Physical therapists are becoming much more involved in the lives of children with ASD, in order to help these kids improve their day to day functioning from early childhood well into adulthood.


References:

Oregon State University. Autistic children with better motor skills more adept at socializing. Available at: http://oregonstate.edu/ua/ncs/archives/2013/sep/autistic-children-better-motor-skills-more-adept-socializing. Accessed on July 7th, 2014.

Bullen, D. More than just playtime. Advance: Physical Therapy and Rehab Medicine. Vol.24 No.21. Available at http://physical-therapy.advanceweb.com/Features/Articles/More-than-Just-Playtime.aspx. Accessed on July 7th, 2014.

Ming, Xue, Michael Brimacombe, and George C. Wagner. “Prevalence of motor impairment in autism spectrum disorders.” Brain and Development 29.9 (2007): 565-570.

Child receiving acupuncture

Is Pediatric Acupuncture for Real? – A Physical Therapist Perspective

 

 

 

I recently recommended acupuncture treatment to a client with an especially challenging case of idiopathic toe-walking. Instead of giving me the raised eyebrows I usually see when recommending alternative medicine to children, her mother eagerly set up an appointment with a well-researched practitioner of her choice. Within a month, the weekly acupuncture sessions in combination with weekly physical therapy sessions paid off. My little client, after years of walking on the balls of her feet 100% of the time, was now only toe-walking 5% of the time.

I know what you are thinking. Sticking multiple needles in children? How could I even suggest such a thing?

Child receiving acupunctureThe practice of acupuncture has been around for thousands of years. Not only has it been greatly accepted in China and eastern cultures, it has also been gaining ground in the United States. In 2011, more than a third of pain clinics across the country utilized some sort of acupuncture as therapy for various ailments. Though acupuncture has been found to be effective in treating adults, research on its efficacy in children is still in the beginning stages.  Boston Children’s Hospital, one of the leading institutions for pediatric care, has an entire service designated to acupuncture. Treatment is performed by a physician trained in both western medicine and eastern medicine, making the approach highly integrative and highly effective.

The term “acupuncture” might register thoughts of needles piercing the skin, but it actually describes a family of treatment options that stimulate anatomical points along the body. Licensed acupuncturists are actually trained in multiple components of traditional eastern medicine.  They, much like pediatric physical therapists, are taught to treat the child holistically, taking into account family and medical history, developmental factors, and severity of condition.  In my client’s case, she was treated with a technique called “cupping,” which worked to stimulate muscle relaxation and improve circulation to areas restricting her motion.  Whether through needles, cups, heat, or through other techniques, the basis of acupuncture is to encourage blood flow and promote healing.

Acupuncture has been successful in treating chronic pain and certain systemic conditions without significant side effects. The majority of pediatric patients are seen for everything from headaches and dental pain to back pain, from constipation to gastritis, from side effects of chemotherapy, to cystic fibrosis. Recent research has even supported acupuncture as a treatment of ADHD, lazy eye, and nausea in children. A specialized acupuncturist in pediatric alternative medicine often uses a variety of techniques to treat the child as a whole. The needles used in acupuncture therapy are small, sterilized, nontoxic, and tightly regulated by the US Food and Drug Administration (FDA).  They are nearly painless and have very few complications.

Both the World Health Organization (WHO) and the National Institutes of Health (NIH) have recognized acupuncture as effective in treating a wide variety of health conditions. Acupuncturist training is at the Master’s degree level, which is the entry-level degree for the profession. With growing research on the effectiveness of and the mechanism behind acupuncture, insurance companies often cover the treatment when it is associated with specific medical conditions. More often than not, acupuncture is used in conjunction with more traditional therapies. I have seen its benefits in numerous individuals with some challenging chronic conditions.

Health care providers, such as physical therapists and primary physicians, serve as resources to help parents determine if alternative treatments are right for their child. Talk to your pediatrician if you have concerns that haven’t been remedied by traditional methods alone. Find a qualified and licensed practitioner who meets the education and training standards set by the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM).  Keep an open mind when you bring your child to see an acupuncturist who specializes in pediatric care. Remember, a child’s progress depends on a multitude of factors, and his well-being relies heavily on his health providers staying on the same page about his plan of care.

 

Do you have questions or experiences with alternative therapies? Please let us know.







 

References:

 

  1. Acupuncture, an introduction. National Institute of Health. National Center for Complementary and Alternative Medicine. U.S Department of Health Services Website. Accessed at http://nccam.nih.gov/sites/nccam.nih.gov/files/Backgrounder_Acupuncture_02-20-2013.pdf on June 12, 2014.
  2. Pediatric Acupuncture. Psychology Today website. Accessed at http://www.psychologytoday.com/blog/real-healing/201107/pediatric-acupuncture on June 12, 2014
  3. Acupuncture. Boston Children’s Hospital website. Accessed at http://www.childrenshospital.org/health-topics/procedures/acupuncture on June 15, 2014

Types of Shoes that Will Discourage Toe Walking

Some children may walk on their toes nearly 100% for no apparent reason. This is known as idiopathic (the reason for it is unknown) toe walking. toe walker shoesIdiopathic toe walking may result in muscle shortening in the calf muscles. In turn, it will continue to promote toe walking. Many cases of toe walking require intervention from a professional; however there are still some things at home that you can do in order to help decrease the frequency of toe walking. One such thing is the type of shoe you purchase for your child.

Below is a list of shoes that can help reduce your child’s desire to walk on his or her toes:

  • Flat shoes: Avoid putting your child in wedge shoes or shoes with any sort of heel. These types of shoes place the foot in a position where the calf muscles are in a shortened position, which can result in them becoming tighter and facilitate more toe walking.
  • Squeaky shoes: There are some footwear brands that design shoes with squeakers in the heels. Every time your child walks down on their heels, they will hear the squeak. These shoes can be a lot of fun for kids (although they may not be as much fun for parents!). 
  • Shoes with high backs: There are some gym shoes that are designed to have a higher backing compared to other shoes. If a child is wearing these shoes and is walking on his or her toes, the shoe back will press up against the Achilles tendon, which can be uncomfortable for the child. Since these shoes make it uncomfortable for a child to toe walk, these shoes help facilitate walking on flat feet.
  • Light up shoes: Shoes that light up often have the lights towards the back of the shoe by the heel. If a child appropriately walks with feet flat on the ground, the lights will light up more than if the child walks up on toes.

While all of these options can be helpful in discouraging toe walking, your child may continue to walk on his or her toes. If your child toe walks the majority of the time and is over 2 years old, it would be beneficial to speak with your pediatrician and physical therapist to determine if further intervention is needed.

Click here to watch part 1 of the 2 minute Toe Walkers Webisode 

Click here to watch part 2 of the 2 minute Toe Walkers Webisode 

Toe Walkers Part 1: What are Reasons Children Toe Walk | Pediatric Therapy Tv

In today’s Webisode, a pediatric physical therapist explains why children may walk on their toes.

Learn more from this blog called “Is Toe Walking Normal?”

In this video you will learn:

  • How sensory input is related to toe walking
  • What is muscular dystrophy
  • What is idiopathic toe walking

Video Transcription:

Announcer: From Chicago’s leading experts in pediatrics to a worldwide audience, this is Pediatric Therapy TV, where we provide experience and innovation to maximize your child’s potential. Now, your host, here’s Robyn.

Robyn: Hello, and welcome to Pediatric Therapy TV. I’m your host, Robyn Ackerman, and I’m standing here today with Colleen Kearns, a Pediatric Physical Therapist. Colleen, can you give our viewers an explanation of why some children toe walk?

Colleen: Of course, Robyn. There are three main reasons why children may toe walk. The first one is related to sensory issues. Some children may actually be hypersensitive to certain textures on the floors that they are walking on, and the surfaces that they are walking on. So if that occurs, they may be more prone to walk on their toes to avoid those uncomfortable textures.

On the other hand, they may also be seeking extrasensory input. Maybe, some kids need a little bit more of the sensory input, and by walking on their toes they are locking their ankles and knees, and by doing that, they are actually getting more input from their joints. So that’s also why children with autism will walk on their toes, to get that extrasensory input.

The second main reason that children toe walk is due to an underlying diagnosis. Muscular dystrophy is a big one. That’s a genetic disorder where the muscle tissue is destroyed and it’s actually replaced by fat, and the calf muscles are often the first ones to be involved with that. So children with muscular dystrophy will toe walk in an effort to stabilize, due to the decreased strength. Any condition that results in an abnormal increase in muscle tone will also result in toe walking. A common one with that would be cerebral palsy.

The third reason why kids may toe walk is actually unknown. Some children, who don’t have an underlying diagnosis and don’t have sensory issues, just prefer to walk on their toes, and that’s what we call idiopathic toe walking, which means we just don’t know. Unfortunately, they can get into a very strong habit of doing it, and when they do that it results in a shortening of the muscles in their calf, and that actually makes it harder for the child to be able to get their foot flat on the ground. And when that happens, it’s kind of like a vicious cycle. They are more likely to be walking on their toes because they have a strong habit, then their muscles get shorter, then it’s harder for them to walk on their flat feet, so then they are even more prone to walking on their toes.

Robyn: All right. Well, thank you so much, and thank you to our viewers. And remember, keep on blossoming.

Announcer: This has been Pediatric Therapy TV, where we bring peace of mind to your family with the best in educational programming. To subscribe to our broadcast, read our blogs, or learn more, visit our website at learnmore.me. That’s Learnmore.me.