Idiopathic toe walking (ITW) is defined as decreased or absent heel strike in the contact phase of the gait cycle with no known medical cause. Toe walking, or equinus gait, is typical up to 3 months after independent walking and is established as a normal gait variant up to the age of 3 years (Shulman et al., 1997; Williams et al., 2010). In children with no other neuro-orthopedic conditions, ITW beyond the age of 3 years is associated with developmental delays, delayed language development, and sensory processing disorders, including autism (Barrow et al., 2011; Engelbert et al., 2011; Morozova et al., 2017). Children who have developmental delays, delayed language development, and sensory processing disorders related to ITW often have difficulty with life roles such as student, peer, family member, and friend. They also may have difficulty adapting to environmental demands that are necessary for functional occupational performance. Inadequate adaptation leads to poor mastery of occupational challenges. The long-term effects of toe walking include compensatory techniques, such as out-toeing, long-term changes or deformity of the foot and lower leg that lead to pain, and other musculoskeletal changes (Hoppestad, 2013; Sinclair et al., 2018; Stott et al., 2004). In addition, social ramifications are associated with this gait pattern. Children who show ITW often report being teased and called names (Dilger, 2005).
The etiology of ITW is not well established, and various causes and treatments have been reported, with mixed results (Dietz & Khunsree, 2012; Fox et al., 2006; Shulman et al., 1997; Williams et al., 2010). It is estimated that 7% to 24% of the general pediatric population exhibits toe walking (Engelbert et al., 2011; Williams et al., 2014). Many studies of the gait patterns of ITW and possible surgical and nonsurgical treatments have focused on increasing the range of motion of the foot and ankle (Dietz & Khunsree, 2012; Fox et al., 2006; Stricker & Angulo, 1998).
Toe walking has long been associated with autism (Barrow et al., 2011; Mandell et al., 2005; Marcus et al., 2010; Ming et al., 2007; Persicke et al., 2014; Shetreat-Klein et al., 2014; Stricker, 2006; Weber, 1978). As early as 1978, Weber explored this relationship and possible causes. In one study, 324 children with autism were evaluated by a university developmental pediatrician. Of these children, 20.1% exhibited persistent toe walking and 12% had tight heel cords (Barrow et al., 2011). Toe walking is often used as a diagnostic screening tool to identify children with autism. Interestingly, there is also a well-documented correlation between autism and decreased postural control (Fournier et al., 2010; Kohen-Raz et al., 1992; Ming et al., 2007; Minshew et al., 2004; Molloy et al., 2003; Radonovich et al., 2013; Shetreat-Klein et al., 2014).
A study of the correlation among ITW, motor skills, and sensory processing found that children with ITW showed poorer performance on the Bruininks-Oseretsky Test of Motor Proficiency; had a lower vibration perception threshold; showed poorer performance on the standing walking balance subtest of the Sensory Integration and Praxis Test; and showed differences in the sensory seeking and low registration subtests of the Sensory Profile compared with children without ITW (Williams et al., 2014). Little other research has evaluated the possible connection between ITW and postural control.
Sensory processing has been well studied in occupational therapy. In humans, sensory processing refers to the “reception of a physical stimulus, transduction of the stimulus into a neural impulse, and perception, or, the conscious experience of sensation” (Ahn et al., 2004, p. 287). Sensory processes are necessary for learning, perception, and action (Kandel et al., 2000). Impairments in processing can occur in one or more of the seven sensory systems, which include smell, taste, auditory, touch, olfactory, proprioception, and vestibular. Within the general pediatric population, 5% to 16% of children have sensory processing difficulties that are severe enough to interfere with daily functioning, and as many as 40% to 88% of children with various disorders may have poor or impaired sensory processing (Adrien et al., 1993; Ahn et al., 2004; Ben-Sasson et al., 2009; Kientz & Dunn, 1997; Talay-Ongan & Wood, 2000).
Proprioception is one sensory area in which individuals may have difficulty processing information. Proprioception was first defined as the awareness of joint movement and place in space (Sherrington, 1906). The definition was later expanded to include kinesthesia and position sense along with information from the joint capsules, ligaments, muscles, tendons, and skin (Ashton-Miller et al., 2001; Ayres, 2005). According to Ayers (2005), motor planning and regulation of arousal level are influenced by the proprioceptive system. Miller and Fuller (2006) defined proprioceptive discrimination disorder as “impairment in the ability to feel the amount of sensory input to the joints and muscles” (p. 166). A decrease in proprioceptive awareness is associated with sensory seeking, low registration, and decreased body awareness. Tiptoeing has been identified as an observation of proprioceptive difficulty (Blanche et al., 2012; Blanche & Reinoso, 2008). The literature suggests that toe walking may result from difficulty processing information from the proprioceptive system (Blanche et al., 2012); therefore, for children who exhibit this gait pattern, the proprioceptive system should be evaluated.
A decrease in proprioceptive awareness, namely, postural instability, is associated with sensory seeking, low registration, and decreased body awareness (Blanche et al., 2012). The relationship between postural instability and ITW has not been fully examined. Williams et al. (2014) found that children who have ITW showed the most significant delays in upper extremity coordination, bilateral coordination, and balance on the Bruinink-Oseretsky Test of Motor Proficiency. Each of these areas correlates with postural control and stability.
The current practice of addressing ankle and foot tightness for children with ITW does not address possible underlying sensory issues. Proprioception and the vestibular and tactile systems provide necessary sensory information for postural control, motor planning, normal body movement, and behavioral regulation (Blanche et al., 2012; Blanche & Reinoso, 2008; Williams et al., 2010). Maintaining balance requires the ability to perceive when balance is challenged or stability is disrupted. Three systems need to work together to provide information and appropriate responses to maintain position: vestibular, proprioceptive, and visual (O'Brien & Williams, 2010).
The goals of this exploratory study were to (1) determine whether children who exhibit the ITW gait pattern show differences compared with children without ITW in time spent in three positions and maintenance in a fourth position where all positions require postural control and (2) determine whether the two groups of children show a difference in body awareness as reported by parents with the Sensory Processing Measure-Home Form (SPM-Home) or Sensory Processing Measure-Preschool Home Form (SPM-P Home).
This exploratory study used a nonrandomized case-control design with concurrent control. The study examined postural control and proprioception among children with ITW and an age- and gender-matched control group without ITW. This design tested the following hypotheses:
Children with ITW will show differences in postural control compared with the cohort without ITW, as evidenced by differences in time spent in the following positions: squatting against a wall, prone extension, and supine flexion.
Children with ITW will show differences in postural control compared with the cohort without ITW, as evidenced by differences in the ability to maintain arm position and inability to disassociate the arms from the trunk with Schilder's arm extension test.
Children with ITW will have a different response to everyday sensory challenges compared with the cohort without ITW, as evidenced by parental responses to questions on body awareness on the SPM-Home or SPM-P Home.
This study included 15 children who were 4 years, 0 months, to 13 years, 2 months, and had a diagnosis of ITW and 15 children who were 3 years, 10 months, to 13 years, 5 months, and did not have ITW. All study subjects were recruited from the community. Table 1 shows the demographic characteristics of the participants.
Demographic Features of Children With Idiopathic Toe Walking and the Control Group
The ITW cohort included 15 children who showed bilateral toe walking without a known neurogenic, neuromuscular, or traumatic cause. The Toe Walking Tool (Williams et al., 2010) was used to determine whether the recruited participants met the inclusion criterion for this cohort. The control cohort included 15 children who did not have a diagnosis of ITW. Children in the control cohort were enrolled consecutively and were matched for age and gender with children in the experimental cohort. The Toe Walking Tool (Williams et al., 2010) was used to determine whether the recruited participants met the inclusion criterion for this cohort.
For the ITW cohort, children who had scores on the Toe Walking Tool that indicated a neurogenic, neuromuscular, or traumatic cause for toe walking were excluded. One child who was evaluated with the Toe Walking Tool was excluded for this reason. Excluded from the study were children who showed unilateral toe walking, those who did not show toe walking, those who had autism and toe walking, and those who showed toe walking as a result of diagnoses such as cerebral palsy, muscular dystrophy, or scoliosis. For the control cohort, children who showed toe walking, as determined by scores on the Toe Walking Tool, for any reason, including neurogenic, neuromuscular, traumatic, or idiopathic causes, were excluded. Children who had a medical or educational diagnosis of autism and did not toe walk would have been excluded from this group as well. One child who was evaluated for participation in the control cohort was excluded based on the results of the Toe Walking Tool.
The Toe Walking Tool (Williams et al., 2010) was used to determine eligibility. This tool has been found to be valid, via a Delphi panel process, and reliable in identifying children who show an ITW gait and excluding those who do not show toe walking as well as those who toe walk as the result of a specific diagnosis (Williams et al., 2010). The Toe Walking Tool was used to ensure that only healthy children who showed toe walking without a known diagnosis were included. It was also used to ensure that participants in the control group did not toe walk or have other risk factors that would eliminate them as part of this group. The tool includes questions on “birth history, lower limb musculoskeletal, and neurological examination and a developmental screen (Brigance Screen)” (Williams et al., 2014, p. 72).
The SPM-Home and SPM-P Home were used to assess possible difficulty processing proprioceptive information (Parham & Ecker, 2007). The SPM-Home and SPM-P Home are rating scales that assess sensory processing issues, praxis, and social participation and are based on the sensory integration theory (Ayers, 2005; Parham & Ecker, 2007). The SPM-P Home evaluates preschool children 2 to 5 years, and the SPM-Home evaluates school-aged children (5–12 years). These questionnaires evaluate a child's unique sensory processing patterns and are completed by caregivers, who are in the strongest position to observe the child's response to sensory interactions that occur throughout the day. The SPM-Home includes 10 questions on body awareness and proprioception; these were used to establish content validity for the Comprehensive Observations of Proprioception (Blanche et al., 2012). The SPM-Home and SPM-P Home have excellent internal consistency and test-retest reliability (Parham & Ecker, 2007).
Clinical observation was used to evaluate postural control in four positions: squat against a wall, prone extension, supine flexion, and Schilder's arm extension test. The positions were chosen to decrease input from the lower extremities (supine flexion and prone extension) and determine control in a position that requires integration of postural control along with stability (squat position and Schilder's arm extension test).
After institutional review board approval and parental consent were obtained, each child was assessed individually. Before the assessment was started, children were asked to give verbal assent. The study evaluations took place at a pediatric therapy clinic or in the child's home. The children were assessed with the Toe Walking Tool to determine eligibility for the study. They were enrolled in the ITW cohort if the tool showed toe walking without an underlying diagnosis or in the control cohort if the tool showed no toe walking. Once eligibility was established, parents were asked to complete the SPM-Home or SPM-P Home.
Each child was evaluated in the four positions in the same order: Schilder's arm extension test, wall squat, supine flexion, and prone extension. Participants were given a 2-minute break between each position and could request to stop the assessment at any time. The primary investigator used a stopwatch to monitor how long, in seconds, each child maintained the wall squat, supine flexion, and prone extension positions. The primary investigator also observed body position, ability to assume the desired position, verbal or physical cues necessary for the child to get into and maintain the position, and stabilization strategies used to maintain the position.
All data collected during the study were analyzed with SPSS, version 22. Independent samples t tests for equality of means were used to determine whether differences between the ITW group and the age- and gender-matched control group were significant.
Independent samples t tests for equality of means were completed for the clinical positions and the SPM-Home and SPM-P Home results to identify possible differences between the ITW and control groups. Table A, available in the online version of the article, shows the results of independent samples t tests for the four clinical observation positions.
Results of t-test and Descriptive Statistics for Clinical Observation Positions
The results of Schilder's arm extension test were separated into two categories for analysis. First, participants were observed based on their ability to maintain the position with the arms extended at shoulder height with the eyes closed while the primary investigator passively moved the subject's head from center to left and from center to right. The primary investigator noted whether each child maintained the extended arm position or dropped the arms less than 5° or whether the participant's arms fell 5° or more. To analyze the data with an independent samples t test, the same scoring system was used for the ITW and and control groups. Children who maintained the position were given a score of 2, and those whose arms fell 5° or more were given a score of 1. The ITW group (n = 15) had a mean score of 1.53 with a standard deviation of 0.52. The control group (n = 15) had a mean score of 1.87 with a standard deviation of 0.35. Next the primary investigator observed each child's ability to disassociate the head from the trunk. Children who maintained the arm position without moving the arms in the direction of the head turn were given a score of 3. Children whose arms moved toward a single direction were given a score of 2. Children who turned the arms toward both directions when the head was turned were given a score of 1. The same scoring system was used for the ITW and control groups. The ITW group (n = 15) had a mean score of 1.67 with a standard deviation of 0.90, and the control group (n = 15) had a mean score of 2.33 with a standard deviation of 0.99. The difference for arm position (p = .049) was significant, and the difference for disassociation (p = .062) approached significance, with alpha set at less than .05. This finding indicated that the ITW group was more likely than the control group to have difficulty maintaining arm position during Schilder's arm extension test.
Of 5-year-olds, 84% can maintain their arm position with the eyes closed and the head passively turned (Dunn, 1981). Because the current study included participants in the ITW (n = 3) and control groups (n = 3) who were younger than 5 years, the primary investigator performed analysis without this population. Table B, available in the online version of the article, shows the results of this analysis. Under these conditions, the findings for both arm position (p = .039) and disassociation (p = .027) were significant, with alpha set at less than .05.
Results of t-test for Schilder's Arm Extension Test for children 5 years and older
Comparison was made of the time, in seconds, that the ITW and control groups maintained the position for wall squat, supine flexion, and prone extension. Findings for wall squat (p = .003) were highly significant, whereas those for supine flexion (p = .022) and prone extension (p = .017) were significant, with alpha set at less than .05. The mean time that the ITW group maintained the wall squat position was 30.33 seconds with a standard deviation of 18.31. For the control group, the mean time was 53.47 seconds with a standard deviation of 20.60. The mean time that the ITW group maintained the supine flexion position was 25.80 seconds with a standard deviation of 15.09. For the control group, the mean time was 54.27 seconds with a standard deviation of 41.21. The mean time that the ITW group maintained the prone extension position was 37.00 seconds with a standard deviation of 21.54. For the control group, the mean time was 63.47 seconds with a standard deviation of 33.58. These findings indicate that the ITW group had more difficulty sustaining positions that require postural control compared with the control group.
Parents of the study participants answered the questions on the SPM-Home or SPM-P Home. The interpretive range for the tool for each subtest included typical (T score 40–59), some problems (T score 60–69), and definite dysfunction (T score 70–80). For each subtest, the primary investigator determined whether each child's T score fell into the range for typical, some problems, or definite dysfunction. For each subtest, the primary investigator coded each range for analysis as typical (3), some problems (2), or definite dysfunction (1). Table C, available in the online version of the article, shows the mean score and standard deviation for each subtest. Analysis of the SPM-Home and SPM-P Home findings did not show significant differences between the ITW and control groups in any sensory area, including body awareness.
Mean Scores for Sensory Processing Measure Subtests
This study found significant differences between the ITW and control groups for three of four positions that require engagement of the proprioceptive system and postural control: wall squat (p = .003), supine flexion (p = .026), and prone extension (p = .021). This finding supports the first hypothesis: Children with ITW will show differences in postural control compared with the cohort without ITW, as evidenced by differences in time spent in the following positions: squatting against a wall, prone extension, and supine flexion. For all of the clinical observation positions, the differences between the ITW and control groups were statistically significant, with the difference for wall squat highly significant. Because the positions included in the study are related to postural control and proprioception, this finding indicates that some children with ITW may have difficulty processing information from the proprioceptive system.
For the fourth position, Schilder's arm extension test, a significant difference was found in the ability of the ITW group to maintain extended arm position (p = .049), and the difference between the groups in the ability to disassociate the head from the trunk approached significance (p = .062). When children younger than 5 years were removed from the analysis, the differences between groups for arm position (p = .039) and disassociation (p = .027) were significant. This finding supports the second hypothesis: Children with ITW will show differences in postural control compared with the cohort without ITW, as evidenced by differences in the ability to maintain arm position and inability to disassociate the arms from the trunk with Schilder's arm extension test. This finding also supports the possibility that some children with ITW may have difficulty processing information from the proprioceptive system.
The SPM-Home and SPM-P Home results showed no significant differences in the sensory processing of the ITW group compared with the control group in any area, including body awareness (p = .526). The study findings did not support the third hypothesis: Children with ITW will have a different response to everyday sensory challenges compared with the cohort without ITW, as evidenced by parental responses to questions on body awareness on the SPM-Home or SPM-P Home.
Several factors may have contributed to the lack of significant findings with the SPM-Home and SPM-P Home. The age range of the study participants, 3 years to 13 years, required the use of both tools, the SPM-Home and SPM-P Home. The use of both tools may have led to difficulty analyzing the data. Another consideration may be the lack of control for other factors that could have predisposed the control group to difficulty with sensory processing. For example, the parents of three of the control participants (20%) reported anecdotally that their child had a diagnosis of attention deficit hyperactivity disorder. The literature shows a significant correlation between attention deficit hyperactivity disorder and sensory processing disorders (Pfeiffer et al., 2015). There may have been other underlying factors with the control group that were not controlled for in this study. Future studies should exclude from the control group children who have possible sensory processing difficulties. Although the SPM-Home and SPM-P Home are some of the most commonly used tools for evaluating sensory processing, observation-based assessments may provide more accurate information (Jorquera-Cabrera et al., 2017). The Evaluation of Ayres Sensory Integration tool or the Sensory Processing Scale Assessment may provide more useful information (Mailloux et al., 2018; Schoen et al., 2014).
This study suggests a role for occupational therapists in working with children who exhibit an ITW gait pattern. Occupational therapists who use the Occupational Adaptation Model can help children who toe walk to learn how to adapt and reach relative mastery over occupational challenges. According to Schultz & Schkade (1992), “[p]ractice based on occupational adaptation differs from treatment that focuses on acquisition of functional skills because the practice model directs occupational therapy interventions toward the patient's internal processes and how such processes are facilitated to improve occupational functioning” (p. 917). For children who toe walk because they have difficulty responding to sensory cues from the proprioceptive system, an occupational therapist can use activities that are rich in sensory input, especially proprioception, and that develop a greater understanding of sensory needs. This approach will help children to learn how to respond to and meet their own sensory needs. The goal of therapy is not to stop the toe walking, although this outcome also may be achieved. The goal of therapy is to help the child to generate an appropriate adaptive response to occupational challenges in various environments while engaging the sensorimotor, cognitive, and psychosocial person systems. A child who can engage the person systems and regulate the sensory systems may be able to meet occupational challenges without toe walking.
This study had a small sample size for the ITW (n = 15) and control groups (n = 15). A smaller sample makes it difficult to identify significant differences between groups and to generalize the results to a larger population. The small sample size may have been a cause of the lack of differences between the ITW and control groups on the SPM Home and SPM-P Home. The age range of participants, from 3 years, 10 months, to 13 years, 5 months, is also a limitation of the study because it may be difficult to generalize information across this age range. Both the SPM-Home and SPM-P Home were used to evaluate sensory processing for these groups because of the ages of the participants. The use of two tools could have been a factor in the lack of differences found between the ITW and control groups. The primary investigator completed all testing and analyses and was not blinded to the groups. The lack of blinding could have led to bias and encouragement toward one of the groups. To control for this possible bias, the same procedures and directions were used for all participants. To address the potential for bias, future studies should include blinding of the evaluator.
Implications and Future Research
This research highlights the role of occupational therapists and the evaluation of sensory processing when working with children who show an ITW gait pattern. The research cited showed that surgical and nonsurgical treatments for ITW have mixed effectiveness. Occupational therapists, working in collaboration with physical therapists, can help to increase postural control, coordination, and appropriate body mechanics among children with ITW. An occupational therapist can help to guide the child toward proprioceptive-rich activities, and a physical therapist can engage the child in activities to increase strength and coordination.
Future studies should investigate the sensory and proprioceptive systems of children with ITW with less variation in age, which would decrease variability in the group. Studies comparing toe walkers at various ages, including longitudinal studies, would help to increase understanding of the sensory needs of toe walkers. Additional research on the use of occupational therapy that is rich in proprioceptive input for children with ITW is needed to verify that this is an appropriate treatment model for this population.
This study supports the hypothesis that children who show an ITW gait pattern may have decreased proprioceptive awareness and impaired postural control. In this exploratory study, children with ITW had significantly more difficulty than the control group in maintaining positions that require postural control and engagement of the proprioceptive system.
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Demographic Features of Children With Idiopathic Toe Walking and the Control Group
|Characteristic||Idiopathic toe walking (n = 15)||Control (n = 15)|
|Gender, n (%)|
| Male||6 (40.0)||6 (40.0)|
| Female||9 (60.0)||9 (40.0)|
|Ethnicity, n (%)|
| Black||0 (0)||1 (6.7)|
| White||13 (86.7)||12 (80.0)|
| Hispanic/Latino||2 (13.3)||1 (6.7)|
| Unknown||0 (0)||1 (6.7)|
|Services received, n (%)|
| Occupational therapy||2 (13.3)||0 (0)|
| Physical therapy||1 (6.7)||0 (0)|
| Speech-language therapy||1 (6.7)||0 (0)|
Results of t-test and Descriptive Statistics for Clinical Observation Positions
|ITW (n=15)||Control (n=15)|
|Schilder's Arm Position||1.53||.52||1.87||.35||−2.066||.049*|
|Wall Squat (in seconds)||30.33||18.31||53.47||20.59||−3.252||.003**|
|Supine Flexion (in seconds)||25.8||15.09||53.6||41.77||−2.424||.026*|
|Prone Extension (in seconds)||37||21.54||62.93||34.32||−2.479||.021*|
Results of t-test for Schilder's Arm Extension Test for children 5 years and older
|ITW (n=12)||Control (n=12)|
|Schilder's Arm Position||1.67||.49||2||0||−2.345||.039*|
Mean Scores for Sensory Processing Measure Subtests
|Subtest||Group (n=15)||Mean||SD||Results of t-test|
|Body Awareness||Toe Walking||2.53||.74|
|Balance and Motion||Toe Walking||2.53||.64|
|Planning and Ideas||Toe Walking||2.6||.74|