Previously named “Pediatric Toe Walking Online Series”
This course will expand your knowledge incorporating the role of vision and reflexes into the evaluation and treatment of equinus gait. Learn to use the ACT (Assessment Criteria for Toe Walking) tool to assist you in determining whether a particular child’s toe walking is due to musculoskeletal, neurological, sensory issues, or a combination of these three issues. Finally, learn how to recognize Red Flags that would require you to refer a child with idiopathic toe walking and other abnormal lower extremity alignments for further evaluation.
- Discuss red flags for referral
- Discuss normal biomechanics of gait
- Discuss norms of anatomical alignment by age
- List implications of delayed treatment
- Describe the role of vision and reflexes in pediatric equinus gait
- Identify methods of assessment of reflexes
- Execute techniques for reflex integration
- Apply decision making skills by using the ACT!
- Determine if toe walking is due to musculoskeletal, sensory, or vision and reflex issues
- Discuss what the outcome research shows for delayed intervention
Schedule
Toe Walking: Total 2 Hours
A. The ACT (Assessment Criteria for Toe Walking)
0-15 minutes:
Watch Patient VIDEO (Bethany) with ACT form provided
16-30 minutes:
Treatment options discussion
Watch Patient VIEDO (Owen)
31-45 minutes:
Crab walking
Weak gluteus maximus: low tone
Demo with Owen with Kinesiotape: how to sell the idea to a 3 year-old
46 minutes – 1 hour:
Removing the tape: give more input elsewhere (gate theory of pain)
Watch Patient Video (Sara)
Discussion of weakness and hyperextension
1 hour – 1 hour 15 minutes:
Take 15 minutes to review and take the Post Test
B. Footwear
Footwear Modification:
0-15 minutes:
Case Analysis: Kiley
Parental Concerns
Initial Evaluation
Gait and Movement Analysis
16-30 minutes:
Suggested interventions
Video shows changes each month
31-45 minutes:
Treadmill changes the ground forces but if practical can do
Drop duration so increase intensity with TogRite Strapping to increase DF
What do you see after 9 months?
COM is back
Heel strike most of the time
Follow up: do nothing for 3 months and then check
The shoe modification works well although it takes longer than an orthoses
Alternative shoe modifications
Tell parents what it looks like
Case Study: 5 year old with no obvious other issues: no sensory, no weakness, no retained reflexes, good strength. Could do balance beam with flat feet. Could find nothing physically wrong.
Turned out to be a cognitive processing problem. No hemispheric coordination they surmised. Splinter skills. Toe walking is not the priority, but you don’t want her to lose range.
Treatment: night splints
Toe Walking: The Role of Vision and Reflexes
Schedule: 2.5 hours
0-15 minutes:
Assessment & Intervention:
Ambient vs. Focal Vision
Visual Therapy: works with ambient vision
Autism (and other processing issues)
Demonstration: Experiencing impaired vision with magnifying glasses: less trunk rotation, smaller steps, asymmetry in gait
16-30 minutes:
Demonstration continued: Can’t tell where they are in space/anxious/rigidity/less rotation/increased base of support/more flat footed
This demonstrates the link between vision, posture and emotions
31-40 minutes:
Prism Glasses: work on neurological change
Prism lenses alter a patient’s perceived reality: feedback changes the neuromotor system to reorganize visual processing.
Establishes order from disorder.
Physiology of vision cannot be separated from the psychology of behavior
Vestibular System connects: inner ear, cortex, postural and extra ocular muscles and balance
Vestibular rehab may improve visual and motor abilities in children with low birth weight, prematurity and oxygen deprivation
41-50 minutes:
Tracking and Convergence Screening and Exercise:
Take 10 minutes to practice this with a partner
51-60 minutes:
Irlen Syndrome (Helen Irlin, MA, LMFT)
Uses overlays or filters to improve brain’s ability to process visual information
Child sees distortions
Depth perception off
Related to learning disabilities
61-75 minutes:
Eye Games: written by an OT and an Optometrist
Development, Influence, Assessment and Integration of Reflexes
Hierarchical levels
Breathing is a reflex
All reflexes must integrate
Relationship of breathing to posture
Toe walking is a movement disorder
Not related to tight heel cords…why?
Synergy is absent with autism and related disabilities: center of gravity movement coincides with the phase of respiration, causes corresponding changes in posture gait and movement.
76-90 minutes:
Breech: indication that reflexes not normal
Rolling: vestibular, Proprioception and kinesthesia work together
Lab: look at pictures of children and evaluate
91-105 minutes:
Discussion of each reflex and its purpose, and how it is integrated
106-120 minutes:
Reflexes Discussion
120 minutes-135 minutes:
Practice Lab 15 minutes: Find a partner and practice
Take 15 minutes to review and take the post test
C. Toe Walking: Toe Walking & Other Abnormal Lower Extremity Alignments: Red Flags for Referral and Intervention Strategies – 2.5 hours
0-15 minutes:
Normal hip alignment
Reasons for concern
Bones deform until at least 7 years old
Age 1-12
Normal changes in the foot
Length/ligaments
16-30 minutes:
We have norms; what do we do with them?
Treatment can decrease pain, DJD, SCFE, patellofemoral instability stress fractures
Correlation between LE alignment and knee joint
Therefore, assess and correct LE alignment asap
31-45 minutes:
Need 10 degrees of ankle DF and 80 degrees of hallux DF or foot has to pronate
Subtalar joint is compromised/overpronation
Decreased shock absorption, tension on muscles and tendons up the chain
Leg Length Discrepancies
Social development linked to early motor behavior
Peer Interaction: motor skills play a crucial role in the social emotional functioning of a child
45 minutes – 1 hour:
Neurology: repeated movement patterns move from higher cortical functions to reproducible cerebellar motor maps
Practice makes permanence (not “perfect”)
Anatomy, Biomechanics and Kinesiology: LE Review
Stable base
Asymmetry of foot loading can be attributed to immature postural capacity
How to measure calcaneal eversion
1 hour – 1 hour 15 minutes:
Excessive calcaneal eversion: use posting wedges under heel
Normal angle should be 8 degrees minus the child’s age
What if a 4 year old child is off by 2 degrees? It’s 50% off
So should not be ignored
Can buy wedges with the slant in them at AliMed
1 hour 15 minutes – 1 hour 30 minutes:
Orthopedic Assessment
If don’t have the mobility or stability to have motion at the foot you won’t have a smooth coordinated gait.
How to measure
Remove the influence of the pelvis
1 hour 30 minutes – 1 hour 45 minutes:
Subtalar Neutral ideals
Inversion Ideals
In-Toe Gait: is it coming from tibial torsion, femoral torsion, or forefoot adduction?
How to measure each one
Forefoot varus and compensations
Forefoot valgus and compensations
1 hour 45 minutes – 2 hours:
How to measure: remove influence of the pelvis
Orthotics: two studies: make a difference in Down Syndrome but not normally developing children
Decision to treat with orthotics
How to choose a shoe: heel counter resistant, front of shoe should bend with gentle pressure, and look at medial section (if child pronates should be firm)
2 hours – 2 hours 15 minutes:
Reflexes: lack of integration past 6-12 months can interfere with development
Indicates neurological dysfunction or immaturity
Orthopedic Development
3-5 year norms
Pelvic tilt problems
Intervention Considerations
Case Study
2 hours 15 minutes – 2 hours 20 minutes:
Early Gait characteristics (continued)
Muscle Balance Theory
Intervention to restore muscle balance
The clumsy child
Sensory issues
Posture disorders
2 hours 20 minutes – 2 hours 40 minutes:
Take 20 minutes to review and take the post test
If you enjoy studying with Liesa M. Ritchie-Persaud, you will love this NEW on-demand, online offering:
NEW! Primitive Reflexes: Strategies to Promote Integration – Strengthening Foundational Skills – Online Series
Receive access for a full year, downloadable handouts and 11 contact hours (1.1 CEUs)
$299/person
Learn at your convenience with Janine Wiskind, MS, OTR/L, CBIS. This course (recorded at a live webinar) provides therapists with a clear understanding of evaluating and treating primitive reflexes. Janine provides lots of practical interventions and a new perspective on how to look at a child’s development. Complete details and Registration here.
Continuing Education Hours for disciplines not listed below: 7 contact hours (0.7 CEUs). Intermediate level. Therapist License #______________.
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Approved by the KY Physical Therapy Association for 7 contact hours, approval #CS61-2023-APTAKY thru 3/6/25. This course meets the basic criteria of the MD Board of Physical Therapy Examiners for 0.7 CEU's. Approval #2203-78 by the NJ State Board of Physical Therapy Examiners for 7 CEC's. The Illinois Early Intervention Training Program has approved this event for 7 hours of EI credential credit in the area of Intervention. Approved sponsor by the State of IL Department of Financial and Professional Regulation for Physical Therapy for 8 contact hours. Approved provider by the NY State Board of Physical Therapy for 8 contact hours (0.8 CEUs). Education Resources is an approved agency by the PT Board of CA for 7 contact hours. This activity is provided by the TX Board of PT Examiners accredited provider #1910017TX for 7 CCUs and meets continuing competence requirements for PTs and PTAs licensure renewal in TX. Approved Provider for OK State Board of Medical Licensure & Supervision #BAP202310003. 7 hours of this course qualify toward the 20 hours requirement for NDTA re-certification.
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