Pediatrics Study Guide #2
Lecture #1: Upright Mobility: Steps to independent Walking
Steps to independent walking
· What are toddlers learning
o Weight through heel and lateral edge of foot
§ Naturally bow legged
o Control upright tibia position
o Balance flexion and extension against gravity
o Lateral weight shifts
o use gastroc to eccentrically control their tibia
· how do toddlers learn to walk independently
o sports stance play (spine and pelvis one block, tibia vertical) 100’s hours small movements and shifts (10-12 months)
o 2000 walking steps-7 football fields-fell 15 times in one hour of play (14 months)
o practice does not make perfect, Practice makes permanent
Effgen Gait References
Preparation for gravity and Gait
· Supine play
o Hands to mouth
o Feet to hands play
o kicking
· Prone play
o Neck and spine extension
o Prone on elbows
o Weight to pelvis
· Sitting play
o Control upright trunk
o Shift weight
o Rotation and disassociation
o Equilibrium reactions
Crawling, creeping, and moving in Prone (pg. 75 of Efgen)
· Crawling
o Move in prone (on stomach)
o Combat/amphibian crawl (flexing and extending all 4)
o Homolateral crawling pattern both UE and LE on the same side flexion or extended
o Contralateral/reciprocal crawling opposite arm and leg flexion and extension together
· Creeping on all 4’s
o quadruped
o One limb at a time
o Homolateral creep arm and leg on the same side
o Reciprocal creeping/diagonal or contralateral pattern opposite arm and leg flexion and extended together
Pulling up, cruising, standing, and walking
· Once infant learns to creep, they attempt to pull to stand
· When lift leg start of weight shift
· Cruise along a supporting surface
o Unilateral weight bearing, weight shifting, balance and synergistic hip abduction/adduction
· Creep and cruise before
o Attempting to stand independently
o Walking with support and taking independent steps
· GOAL: internal control of automatic and efficient walking
· Development of walking table (pg. 77)
· Initial walking—immature walking---mature walking
Idiopathic toe walking
· Children who ambulate with bilateral toe-toe pattern without any known reason or pathology
· Toe walking may have an underlying neurological cause
· Toe walking can be the first sign of a neurological or developmental condition such as CP or autism spectrum disorder
· Toe walking tool and screening and intervention and treatment algorithm are excellent guidelines
Toe walking
· Walk on toes is considered atypical
· CNS is not mature, check for spasticity
· Preterm increased incidence of toe walking
· 5mos-1 year olds no toe walkers need to develop anterior tibialis
o develop less anterior tibialis and incorporate gastrocnemius in walkers
o causes a decrease time in jumpers and walkers
· never normal to walk on your toes at 1 year
How to assess and treat for toe walking
· in toe walking normal loading and midstance transfer of body weight are absent
· early identification to prevent adaptive shortening of gastrocnemius and development of persistent gait and balance issues
· heel-toe progression requires at least 10 degrees of ankle DF
o serial casting, night splints, or AFO may be needed to decrease contracture
· more aggressive treatment can include botox injections and if significant ankle equinas
o surgery is a consideration
· PT intervention includes:
o Stretching gastroc
o Balance (SLS)
o Posture
o Floor to stand
o Squatting
o Hopping, jumping
o Coordination
· Positive correlation between language delays, toe walking and learning disabilities
Gait analysis tools
· Rancho Los Amigos Gait analysis: full body
· Observational Gait Scale
· Functional assessment Questionnaire
· Toe walking tool
· Biomechanical assessment summary chart
Key determinates and growth to age 7
· Single leg stance (% cycle)
o Time on one leg during stance
o Increases with age
· Step length (cm)
o Relationships to limb length
o Increases with age
· Velocity (m/min): increases with age
· Cadence (steps/min): decreases with age
One-year-old Characteristics
· Wide base of support
· High arm guard position- shoulders abducted, elbows flexed)
· Absent reciprocal arm swing
· Flat foot initial contact
· Exaggerated hip rotation
18 months characteristics
· Heel strike
· High guard arm position
· Reciprocal arm swing in 65%
· Average cadence 171 steps/min
· Exaggerated hip rotation
Two year old characteristics
· 100% heel strike
· narrowing base of support
· decreased hip rotations
· increasing step length
30 months characteristics
· Reciprocal arm swing in nearly all (96%)
· Mature control of hip abduction and adduction
· Average cadence now reduced to 156 steps/min
Three years old characteristics
· Adult-like base of support
· All joint rotation smooth and look “adult-like”
· Reciprocal arm swing 100%
Four year old characteristics
· Reciprocal arm swing
· All joint rotations look adult-like
· Adult-like BOS
Five year old characteristics
· Reciprocal arm swing
· All joint rotations look adult like
· Adult like BOS
· Increasing stride length and gait velocity (1.08m/sec)
· Cadence now 154 steps/min
Six year old characteristics
· Reciprocal arm swing
· All joint rotations look adult like
· Adult like BOS
· Cadence now 146 steps/min
Seven year old characteristics
· Reciprocal arm swing
· All joint rotations look adult like
· Adult like BOS
· Increasing stride length and gait velocity (1.14m/sec)
· Cadence now 143 steps/min
Observational Gait of the Stance Leg: Ankle foot rocker
· According to Perry, progression of gait over the supporting foot depends on 3 functional rockers
o Heel rocker
§ Rocker I
§ Heel strike to flat foot
§ function is to translate the vertical component of the ground reaction force to forward progression
o ankle rocker
§ Rocker II
§ Flat foot to heel rise
§ Function is to control the rate of forward progression of the body
o forefoot rocker
§ Rocker III
§ Heel rise to the end of stance
§ Function is to extend the period of ground contact via the gastrocnemius before initiating swing
· Summary
o Most gait maturity is achieved by 3.4 to 4 years of age
o Age 7: adult gait pattern is present
o clinical indicators of maturity
§ ratio of pelvic span to inter-ankle distance
§ duration of single limb support increases
§ dynamic joint ankle measurement are adult like
§ time distance parameters scaled for leg length are adult like
§ GRF curves, moments and powers are adult like
o Changes in gait after age 4 related to stride characteristics
§ Increases in stride length, step length
§ Decreases in cadence
§ Increases in walking velocity
o Temporal spatial parameters appear to be associated with leg length (growth)
Introduction to pediatric pathological Gait
Common Gait deviations in CP
· Hip
o Adduction second to spasticity/contracture of adductors and hip flexors combined with weak hip abductors
o Increased hip flexion second to spasticity iliopsoas, rectus, Sartorius
o Femoral anteversion (Due to hip flexion contracture limited de-rotation of FNA----tibia ext torsion and genu valgum
Key points to pathological gait analysis
· What gait deviations are apparent?
· Components?
o Foot, ankle, rockers
o Knee
o Hip/pelvis
o Trunk/neck
o UE
· Overall gait pattern
o Efficiency and quality?
Functional gait deviations at the ankle
· Equinus: second to spasticity/contracture of gastroc-soleus
o toe walker
· Hyperdorsiflexion: calcaneus gait during stance
o Often as a result of surgery for equinus
· Varus deformity: overactivity of posterior tibialis and or anterior tibialis
o Often equinovarus
· Valgus deformity: equinus, hind foot valgus, and mid foot collapse
Functional Gait deviations at the knee
· Jump gait: increased stance phase hip and knee flexion with ankle equinus
o Most common deviation
· Crouch gait: increased stance phase hip and knee flexion with increase PF
· Stiff knee gait: decrease knee ROM throughout the entire gait cycle
o Largest problem is in swing
o Compensations
· Recurvatum knee: mostly from PF spasticity or contracture, also hamstring weakness
Spasticity Management
· Children who have spasticity, need multidisciplinary spasticity evaluations to determine the best course of treatment
· Treatments might include:
o Oral medications
§ Botulinum toxin and phenol (injected spasticity medicines)
§ Intrathecal baclofen pump
o Surgical procedure
§ Selective dorsal rhizotomy (SDR) surgery
Crouch Gait
· Common in diplegic CP
· Most often associated with hamstring contracture
· End result: combination of excessive hip flexion, knee flexion, and ankle equinus
· Treatment: often multiple simultaneous surgical soft tissue releases (hip, knee, ankle)
Stiff knee
· Common in spastic diplegic CP
· Characterized by limited knee flexion in swing
· Phase 2 rectus femoris firing out of phase
· Evaluation: gait analysis shows quadriceps activity from terminal stance throughout swing phase
· Treatment: surgical transfer of distal rectus femoris tendon
Duchenne’s Muscular Dystrophy
· Pathology
o Progressive degeneration of the muscle fibers and variation in fiber size
· Body structure/function: progressive muscle weakness proximal>distal
· Activity participation
o Monitor skill regression, loss ambulation, fatal
§ Inability to hop and jump
§ Difficulty getting up from floor (Gower’s maneuver)
§ Difficulty with stairs
§ Frequent falls
· Vignos functional Scale
o Test classifies the decline, the significant factors are:
§ stair climbing decline
§ walking independent then AD and assistance
§ unable to get out of chair
§ braces for ambulation
o consider these factors in assessing ambulation decline
o Rating Scale
§ Walks and climbs stairs without assistance
§ Walks and climbs stairs with aid of railing
§ Walks and climbs stairs slowly with aid of railing (over 25 second for eight standard steps)
§ Walks, but cannot climb stairs
§ Walks assisted but cannot climb stairs or get out of chair
§ Walks only with assistance or with braces
§ In a WC: sits erect and can roll chair and perform bed and WC ADL
§ In a WC: sits erect and is unable to perform bed and WC ADL without assistance
§ In WC sits erect only with support and is able to do only minimal ADL
§ In bed: can do ADL without assistance
· Stages of duchenne’s
o Infancy to preschool: no significant impairments
o Early school-age period
§ Initial disability typically occurs by 5 years of age, clumsiness, falling, and inability to keep up with peers while playing
§ Stair climbing and standing from the floor become progressively more difficult (see first functional limitation by 6-8 years, toe walking)
o Adolescent period
§ Significant disability progression as a result of muscle weakness and development of contractures
§ Walking is lost as means of mobility and increase difficulty in general mobility with transfers
§ Manual or power WC
o Transition to adulthood
§ Continued progression of disability with greater reliance on AD
§ Power EC for mobility
§ Dependent for transfers and ADL
· Upper limb movements
o High guard elbows flexed, hands up present at initiation of walking
o No reciprocal arm leg movements at 1 year
o Reciprocal arm leg movements with hands down in 70% of 18 month old subjects 100% by 3-5 years
· Physical therapy goals
o Care should be anticipatory and preventative
o PT may include evaluation, education and or direct treatment
o Prevention of contractures
o Preservation of independent mobility
o Prolongation of ambulation, use of surgery and orthotics remains controversial and use is decreasing
o AT to maintain functional independence as long as possible
o Promote self advocacy
· Atypical locomotor behavior (describe each gait pattern)
o Fetal dyskinesia/akinesia
o Asymmetric or chronic pivot prone rotation
o Commando crawling
o Bunny hopping
o Bottom scooting
o Out toeing
o In toeing
o Genu valgus gait
o Genu varus gait
o Idiopathic toe walking
o Equines gait
o Calcaneal gait
o Trendelenburg gait
· Review: Development of mature Gait
o Free spared walking velocity increases rapidly from independent walking by 3.5 to 4 years of age
o Increased velocity is due to increase step length (leg length)
o Percent time of single limb support increase to mature level by 3.4 to 4 years of age
o 7 year olds are considered the standard for the development of mature gait
Learning to walk walking to learn get on your feet
· immobility
o leading to contractures, scoliosis and hip subluxation
o causing poor CP function
o giving kids metabolic syndromes
o compounding intellectual disability
o shortening their lives
· Research reviews: moving makes you smarter
o Exploration through early years, facilitates development
o Infants and children with limited exploration are at risk for global developmental impairments
o Gait trainers use will target exploratory behaviors
o Children need to move in space to promote intellectual development
o Over age 50 evidence that exercise improves brain function, memory, and decrease the onset and severity of dementia
o Is using a gait trainer or other mobility device exercise? Exploration? Or both?
Benefits of early standing and upright mobility
· Promotes joint and bone development
· Prevents contractures and increase motion
· Improves lung function
· Better B and B function
· Better circulation
· Decrease constipation
· Decreased spasticity
· Lower risk of pressure sores
· Improved cognition growth with environmental exploration
· Improved visual awareness
· Improved socio-emotional and psychological aspects
· Promotes a more active lifestyle
Research indicates we need to provide ways for our children to be upright and move
· Two studies supported the impact on walking distance and number of steps taken