What is Toe Walking?

Posted on February 15, 2024January 31, 2024

Toe walking means that a child is walking and standing on tiptoes, and their heels do not make contact with the ground. Walking up on their toes can be a normal occurrence in children aged three and under as they continue to develop their ability to walk. Beyond that age, without any definitive medical reason, it is considered idiopathic toe walking (walking on toes without a known cause).

Toe Walking Causes

To understand, what’s not so simple about toe walking is the why behind it. There are many possible reasons that children might develop this pattern:

Developmental phase: A child occasionally walking on the balls of their feet can be part of normal development. When children first begin walking, usually between 12-15 months of age, they often try different foot positions including walking up on their toes. However, it is expected that typically developing children will only walk on their toes occasionally.

Neurological concern:

Sensory processing concerns: Children with sensory issues, including those on the Autism Spectrum related to the vestibular system, have a different awareness of their body position and feel stabilized during toe walking. The tactile system includes our sense of touch, pain, and temperature. Some studies conclude that children with differences in vestibular processing can also have tactile senses that exacerbate their toe walking. They may not like the feeling of the floor touching their feet, and toe walking minimizes this contact. Children seeking proprioceptive input toe walk because the gait prolongs stimulation of joint receptors and causes their muscles to tighten. The movement provides a calming input sensation for the child. (Williams 2010)
Cerebral Palsy: The most common cause of toe walking in those with cerebral palsy is spasticity, which can cause stiffness and involuntary muscle contractions in calf muscles, keeping their heels from touching the ground. Over time, without proper stretching and bracing, these muscles can become shortened, making it challenging to achieve heel contact.

Idiopathic toe walking: Toe walking can occur because of an underlying anatomic or neuromuscular condition, but in most cases, toe walking is idiopathic without a discernible underlying cause. Idiopathic toe walking occurs in children between 3 and 7 years old and is more commonly seen in males than females. Idiopathic toe walking is not related to any specific diagnosis and can presenty of reasons, due to a variet including decreased stability and sensory involvement. For some families, toe walking may be a cosmetic concern, whereas it can cause pain or functional issues in other cases. (Ruzbarsky, Scher, & Dodwell, 2016)

Treatment

You may wonder how to stop toe-walking with your child. Therapeutic treatment depends on the cause, how strong of a habit it is, how tight the calf muscles have become, and what other changes have occurred in the child’s foot and ankle due to walking this way.

Treatment can include:

Stretching: To improve muscle length, increase ankle mobility, and promote heel contact
Orthoses: Ankle-foot orthotic worn to keep the foot at a 90-degree angle and promote heel contact
*Turtle bracing: New bracing technique utilizing a removable, re-moldable, lightweight brace to achieve optimal ankle positioning, obtain and maintain ankle mobility, and promote heel contact
Serial Castings: Hard cast used to obtain and maintain a 90-degree angle at the ankle joint for extended periods (1-2 weeks at a time)
Night splints: Braces worn at night to keep the foot in a 90-degree angle and achieve prolonged stretch
Botox injections are most commonly used with those dealing with spasticity; they weaken their calf muscles and make them easier to stretch and cast.

A careful history, clinical exam, and selective diagnostic testing can be used to differentiate between different types of toe walking and determine the most appropriate treatment for each child.

How Can Carolina Therapy Connection Help with Toe Walking?

Being evaluated by a Physical or Occupational Therapist can further help determine which treatment routes are appropriate for your child. Call us today at 252-341-9944 for a free screening!

By: Taylor Saunders

What are primitive reflexes?

Posted on November 15, 2023November 7, 2023

A reflex is an automatic and instantaneous response to a sensory stimulus. Remember when you were a child at the doctor’s office and they tapped your knee with a small mallet to check if your leg kicked upwards? You didn’t decide to kick your leg, it just kicked. From infancy, reflexes are vitally important for proper development of the brain, nervous system, body and sensory systems. Some reflexes are meant to stay with us our whole lives. Others are designed to be dormant after their function is fulfilled – also called integration. Check out this awesome resource from Tools to Grow to learn more about specific reflexes and how they impact a child’s function during their daily life. Primitive reflexes are adaptive responses that develop before birth and typically integrate as the brain matures. Primitive reflexes are important for survival and development early in life; however, it is also important that they become integrated as the child grows. Retained reflexes can cause sensory issues, postural disorders, decreased motor skills, and attention/behavioral issues.

What causes retention of primitive reflexes?

Some potential causes of retention of primitive reflexes include c-sections, trauma during birth, exposure to toxins, decreased tummy time during infancy, decreased time crawling, chronic ear infections, or head injuries during infancy among many other unknown causes.

Five Commonly Retained Primitive Reflexes and their Impact on Occupations

1. Moro Reflex

The Moro Reflex is known as the “startle” reflex. This reflects is a fight or flight reaction. It is present at birth and should be integrated by four months. Common effects of retention include emotional outburst, motion sickness, and difficulties with vision, reading, and writing.

2. Asymmetric Tonic Neck Reflex (ATNR)

The Asymmetric Tonic Neck Reflex (ATNR) is known as the “Fencer’s pose”. It assists in the birthing process. It appears at birth and should be integrated by nine months. Common effects of retention include decreased eye-hand coordination, poor handwriting, poor balance, difficulty with reading and math, and difficulty focusing.

3. Symmetric Tonic Neck Reflex (STNR)

The Symmetric Tonic Neck Reflex (STNR) is an essential foundation for crawling. It appears at six to eight months and should be integrated by nine to eleven months. Common effects of retention include poor posture, W sitting position, poor eye-hand coordination, messy eater, and low muscle tone.

4. Tonic Labyrinthine Reflex (TLR)

The Tonic Labyrinthine Reflex (TLR) is commonly seen in children with ADHD diagnoses. It appears before birth and should be integrated by three and a half years of age. Common effects of retention include decreased balance, poor spatial awareness, toe walking, weak muscles, poor posture, and difficulty with climbing.

5. Spinal Galant

The Spinal Galant Reflex also assists in the birthing process. It appears at birth and should be integrated by three to nine months. Common effects of retention include bed wetting after potty training, hyperactivity, postural issues including scoliosis, attention issues, and decreased endurance.

What are integrated reflexes?

Integrated reflexes are important for developing motor control. A child needs motor control to maintain proper posture at a desk in school, ride a bike, read a book, cross midline, write, and get dressed. A child with integrated reflexes has normal movement patterns to complete these functional tasks at home and at school. A child with unintegrated reflexes could benefit from skilled reflex integration therapy which will essentially train a child’s brain by establishing an efficient movement pattern that supports higher level motor skills or cognitive tasks.

How do you know whether or not your child has integrated these reflexes?

There are many common areas of difficulty that may suggest a retained reflex including the following:

“Bouncing” Child: Constantly moving, can’t sit still on a chair, hyperactive
“Noodle” Child: Leans on everything, rests head on table
“Shirt Chewers”: Constantly chewing on shirts or pencils, and touches everything
“Emotional Child”: Challenges with regulating emotions, easily frustrated or upset, difficulty with utilizing age appropriate coping strategies to calm body
School Performance Challenges: difficulty with reading, handwriting, language/speech, poor sitting balance and immature grasp on writing utensils
Coordination Challenges: Chronic body aches, poor endurance, fatigue, muscle weakness, poor concentration, fidgeting, disorganization

How do I know If My Child Has Retained Primitive Reflexes and What Can I Do?

Once your Occupational Therapist suspects a retained reflex, he/she will educate the caregiver on the importance of carryover for treatment recommendations. Caregivers play an important role in seeing progression in their child’s everyday activities. It is typically recommended that the child completes a set of tailored exercises to meet your child’s needs, 5-10 minutes per day, for 30 consecutive days in order to see any progress. Your therapist may recommended a reward or sticker chart in order to keep your child motivated towards an end goal. Progress can be noted short term and over 9-12 months. In addition to exercises, your Occupational Therapist will make recommendations for modifications in the school and home environments which may include changing positioning during school work, movement breaks, sensory techniques, relaxation techniques, decreasing auditory and visual stimulation, and organizational skills, just to name a few!

In order to determine whether your child would benefit from direct treatment for Reflex Integration, it is recommended that your child be evaluated or screened by an Occupational Therapist at Carolina Therapy Connection. Give us a call at 252-341-9944 today to schedule your FREE occupational therapy screening with one of our experienced and knowledgable OT’s.

The Vestibular System in Pediatrics

Posted on October 3, 2022October 4, 2023

What is the Vestibular System?

Vesti-what?!? The vestibular system is made up of the inner ear, vestibulocochlear nerve that communicates between the inner ear and brain, parts of the brainstem, and cortical areas in the brain. The vestibular system responds to head movements like when you nod your head “yes”, shake your head “no”, or tip your head to shake the water out of your ears. It also responds to movements like when you move forward or backwards when you’re sledding, move up and down like when you’re jumping, or when you spin around in circles. Overall the vestibular system helps you figure out where you are in space as you move around your environment so that you can…

Maintain your gaze on a target while moving your head (vestibulo-ocular reflex)
Maintain postural control or balance
Orient yourself to your environment
React appropriately to your surroundings
Avoid falls

Check out this helpful resource from Integrated Learning Strategies, who breaks down the vestibular system as an internal GPS system for the body!

What is vestibular dysfunction?

Vestibular dysfunction may be attributed to deficits or impairments of the inner ear, vestibulocochlear nerve, brain, or brainstem. As adults we may notice difficulties with our vestibular system due to symptoms like dizziness, vertigo, trouble keeping objects in focus while moving our head, or changes in our balance. Children who have vestibular concerns may not realize that they are dizzy or that movement of letters when reading is atypical if they have always experienced these symptoms. This can make diagnosing vestibular concerns hard and can often times be mistaken for other issues (learning disabilities, behavior problems etc.) due to a child’s inability to explain the symptoms they are experiencing.

Migraines, Benign Paroxysmal Vertigo of Childhood (BPVC), and Traumatic Brain Injuries are the most common causes of childhood vertigo. Ocular disorders, inner ear malformations, labyrinthitis (inflammation of the inner ear), and neuritis (inflammation of the vestibulocochlear nerve) are also common causes.

As a parent, here are a few signs and symptoms to watch for regarding vestibular dysfunction:

Head tilted to the side
Easily stressed, anxious, or upset with quick changes in movement or being on unstable, uneven, or taller surfaces
Nausea and vomiting
Imbalance or frequent falls
Vertigo or dizziness
Reduced cognitive performance
Decreased consciousness or arousal
Poor spatial awareness, navigation, or orientation
Ringing in ears
Spontaneous and involuntary eye movements
Motion/car sickness
Constant need for movement or taking unsafe risks for various positional changes or movement patterns

What should you do if your child is experiencing vestibular dysfuntion?

First and foremost, consult your child’s pediatrician to discuss your concerns. You may be referred to a neurologist for further evaluation and recommendations. If your child’s pediatrician or neurologist determines that your child would benefit from Physical or Occupational Therapy treatment, your child may be referred for an initial OT and/or PT evaluation.

How can a pediatric occupational therapist or physical therapist help with vestibular concerns?

During the initial evaluation your therapist may…
- Assess how your child’s eye move in a variety of situations
- Screen for abnormal eye movements
- Assess your child’s visual acuity
- Test your child’s balance while static or standing still, as well as their dynamic balance while on a variety of surfaces, while they are moving, or while they are performing a task
- Assess how your child responds to various positional changes and movement patterns
- Assess for seeking or avoidance behaviors of various positional changes or movements
During treatment your therapist may…
- Use balance beams, obstacle courses, balance boards, single leg stance activities, etc. to challenge and improve your child’s balance.
- Use stair training, climbing a rockwall or ladder, standing on a platform swing, etc. to address gravitational sensitivities and challenge balance at various heights.
- Use swinging, spinning, rolling in a foam cylinder, sliding down slide, riding on a scooter board, etc. to help strengthen your child’s vestibular system. These activities will also potentially help delay the onset or reduce the severity of your child’s dizziness.
- Use specific activities involving movement of their eyes and head to strengthen their vestibular system.

If you have concerns about your child’s vestibular function, motor development, sensory difficulties or anything else, call Carolina Therapy Connection at 252-341-9944 or email us at info@carolinatherapyconnection.com to get started today! We accept all major insurances and would love to help your family and kiddo maximize their independence and potential to grow healthy and strong!

Blog Written By: Joann Flaherty, PT, DPT and Jessica Reynalds OTD, OTR/L

References:

Casselbrant ML, Villardo RJ, Mandel EM. Balance and otitis media with effusion. Int J Audiol. 2008;47(9):584-589.
Christy, J., Beam, M., Mueller, G., & Rine, R. (2019). Just Screen It!! (Part 2): Developmental Disability, Vestibular Deficit, or Both?. Presentation, APTA Combined Sections Meeting.
Christy, J., & Rine, R. (2019). Just Screen It!! (Part 1): Developmental Disability, Vestibular Deficit, or Both?. Presentation, APTA Combined Sections Meeting.
Lin, C. (2019). Vestibular Rehabilitation Intervention. Presentation, East Carolina University.
Salami, A., Dellepiane, M., Mora, R., Taborelli, G., & Jankowska, B. (2006). Electronystagmography finding in children with peripheral and central vestibular disorders.International Journal of Pediatric Otorhinolaryngology, 70(1), 13-18. doi:10.1016/j.ijporl.2005.05.001
Wiener-Vacher, S. R. (2008). Vestibular disorders in children. International Journal of Audiology, 47(9), 578-583. doi:10.1080/14992020802334358