Prevention and Reduction of Childhood Idiopathic Toe Walking

Prevention and Reduction of

Childhood Idiopathic Toe Walking (ITW)

Created by: Lindsey Viltrakis, SPT

 Background and Statement of Need

Initially, the driving factor behind this capstone project was my desire to create a tangible product that filled a need related to healthcare. Idiopathic toe walking became that project. A simple need to find a question for my Critically Appraised Topic (CAT) morphed over time into a capstone project as it became apparent that early prevention and intervention is the key to reducing long-term complications. The initial question, was focused on determining the long-term effectiveness of conservative, non-surgical treatment, compared to no treatment. Accessed by visiting My CAT for results. Further curiosity lead to completing my Advanced Orthopedics paper on ITW. Accessed by visiting ITW Paper. Both indicated that treatment is advised and early intervention is preferred over no treatment and to prevent long-term complications.

However, there are minimal resources for providers and teachers to educate themselves on idiopathic toe walking or for them to disperse to parents. Parents may be worried or not recognize the need to seek treatment about their child’s toe walking. Dana McCarty mentioned there has been a recent rise in children displaying toe walking and speculates the cause of this rise may be related to premature infant survival or developmental coordination disorder. Doctor Zimbler verified Dana’s observation with increased ITW in an article he wrote¹, although more substantial and conclusive evidence to confirm the report needs to be undertaken at this time. This information is not presented in any of the ITW research articles, only that the occurrence in the pediatric population is 7-24 percent.^{2, 3} Examining potentially useful statistics, the latest March of Dimes report stated 1 in 10 babies are born premature and in 2015 North Carolina alone had a 9.7 percent rate.^{4, 5} Also, there has been an increase in the United States of children diagnosed with Autism spectrum disorder, a prevalence of 1 in 68 children and developmental coordination disorder (a.k.a dyspraxia) affects around 6% of children.^{6,7, 8} Again, this information may or may not provide clues to the increase rate of ITW seen in children.

Project Overview

The long-term complications, due to ITW, vary with each child and their severity but early intervention has demonstrated to be successful.⁹ At varying regularity, providers and teachers interact with parents and children and are often the ones whom parents voice concerns about their child. Keeping this in mind, I decided to focus my targeted efforts on prevention and early intervention for children who demonstrate ITW through an educational pamphlet for providers and teachers with secondary expansion to parents. Accessed by visiting ITW Pamphlet. Additionally, a pamphlet solely for providers creates a quick reference related to diagnosis, examination, and treatment for suspected children with ITW. Access by visiting Provider Pamphlet. This way, these two professional groups can recommend families seek out professional help and have physical therapy address neuromusculoskeletal issues. By providing resources, the hope is there will be greater awareness and concern for toe walkers, which will lead to improved diagnosis identification, earlier treatment, and reduced long-term effects.

An additional outcome was the production of an evidence table on conservative and surgical treatment interventions that break down the evidence behind each treatment method. Access by visiting ITW Evidence Table.

Self-Assessment

The capstone project and related projects were very time intensive for one specific diagnosis, ITW, which spread throughout the school year. Fortunately, the gradual built-up from Evidence-Based II at the beginning of the year and prior classes lead to increased experience and understanding making the final project much more manageable. Along the way, valuable skills in ascertaining and analyzing resources where gained and a greater knowledge and respect for those who regularly complete some form of research review. It is a mass undertaking!

Similar to other aspects of life, the final ITW pamphlet alone does not markedly reveal the amount of time, resources, or research that was involved in its creation. The largest challenge during my capstone was the time factor. There were many demands both related and not related to 3^rd year that was a constant balancing act. Adhering fairly closely and settling deadlines was the most beneficial aspect towards project completion because it kept me accountable.

Due to the nature of the project and time constraints, I did not have feedback from individual providers, teachers, or parents about the usefulness of the pamphlet. Although, I did created a Pamphlet Feedback Form for use in the future. In addition, creating and delivering the pamphlets has lead to a few great discussions about toe walking, helping to strengthen ties in the community, and in a broader sense the need for greater preventative care services. I was able to deliver pamphlets to three schools and four pediatric clinics, which is more than I had hoped for in the beginning.

Although, I focused my effort on two main populations the pamphlets could easily be used by a variety of health care providers or educators. After speaking with Dana, later I plan on sending the website link to other providers who may benefit from the information. If I had a chance to repeat the project, the main modification I would make is gaining a direct communication link to providers and teachers so that I could ask questions related to their experiences related to toe walking and gain a better way to collect feedback on materials created. Overall, I enjoyed learning form the experience and know it will help with similar challenges down the road. 

Acknowledgements

This project would not have come to fruition or been a success without the support and direction from several key UNC Department of Physical Therapy faculty members. I THANK YOU all very much!

Prue Plummer, PT, Phd., my project advisor, for the initial assistance helped with narrowing down my diverse interests that lead to my CAT, excellent knowledge and feedback throughout this process during Evidence Based Practice II, and culminating capstone assistance.

A huge thank you, to my committee members, for providing wonderful guidance and insight throughout the process of creating my final evidence table and educational resources.

Dana McCarty PT, DPT, PCS, C/NDT for her pediatric knowledge, confidence to go forward with the project, willingness to answer any question, and substantial feedback throughout the process.

Mike Gross PT, Phd, FAPTA, for his very informative feedback on my initial advanced orthopedics course project, Idiopathic Toe Walking, during the Fall 2015 semester and meaningful feedback throughout my capstone project.

Jon Hacke PT, DPT, MA, OCS, for his willingness to review and providing excellent feedback that assisted in producing quality final products in a topic outside his specific musculoskeletal area of interest.

Lastly, a special thank you to my niece, Noelia, for first sparking my interest in toe walking.

List of Products

1. My CAT: “For children who are “idiopathic toe walkers” will corrective interventions (non–surgical) in the long-term be more effective for normalizing gait than not receiving treatment”
2. ITW Paper: Advanced Orthopedics Project Idiopathic Toe Walking
3. ITW Evidence Table: “The effects of conservative and surgical treatment for Idiopathic Toe Walking (ITW)”
4. ITW Pamphlet: Idiopathic Toe Walking
5. ITW Pamphlet Feedback Form
6. Provider Pamphlet:Prevention and Reduction of Childhood Idiopathic Toe Walking
7. My Complete Capstone References

References

For a complete list of references used please view My Complete Capstone References

1. Zimbler, S. Idiopathic Toe Walking: Current Evaluation. [PDF]. The Orthopedic Journal at Harvard Medical School. 2007. http://www.orthojournalhms.org/volume9/manuscripts/ms10.pdf Accessed January 15, 2016.
2. Engelbert R, Gorter JW, Uiterwaal C, van de Putte E, Helders P. Idiopathic toe-walking in children, adolescents and young adults: A matter of local or generalized stiffness? BMC Musculoskelet Disord. 2011;12:61-2474-12-61. doi: 10.1186/1471-2474-12-61 [doi].
3. O’Sullivan R, O’Brien T. Idiopathic toe walking: A gait laboratory review. Ir Med J. 2015;108(7): 214-216.
4. 2015 Premature Birth Report Card: North Carolina. [PDF] March of Dimes Foundation website. http://www.marchofdimes.org/materials/premature-birth-report-card-north-carolina.pdf Update 2015. Accessed January 15, 2016.
5. 2015 Premature Birth Report Cards. March of Dimes Foundation website. http://www.marchofdimes.org/mission/prematurity-reportcard.aspx Accessed January 15, 2016.
6. Facts and Statistics. Autism Society website. http://www.autism-society.org/what-is/facts-and-statistics/ Updated 2014. Accessed January 21, 2016.
7. Dyspraxia Awareness Sheet. Dyspraxia Foundation USA website. http://www.dyspraxiausa.org/ resources/dyspraxia-awareness-sheet/ Accessed January 21, 2016.
8. Autism Spectrum Disorder: Data and Statistics. Center for Disease Control and Prevention Website. http://www.cdc.gov/ncbddd/autism/data.html. Updated March 31, 2016. Accessed April 19, 2016.
9. Ruzbarsky JJ, Scher D, Dodwell E. Toe walking: Causes, epidemiology, assessment, and treatment. Curr Opin Pediatr. 2016;28(1):40-46. doi: 10.1097/MOP.0000000000000302 [doi].