How To Address Conditions That Affect Pediatric Gait
Given that toe walking and other gait disturbances are common among children, these expert panelists take a closer look at these conditions, offer keys to the diagnostic assessment and share their insights on appropriate treatment modalities and physical therapy regimens.
Q: What is your treatment plan for children with diplegia and hemiplegia?
A: Mary Keen, MD, says most children with diplegia and hemiplegia walk so she strives to facilitate independent ambulation. In order to achieve safe, efficient ambulation, Dr. Keen says children need adequate balance, adequate core strength, endurance and functional range of motion in both lower extremities. She says her treatment plan addresses these areas of function but the approach varies with each child.
Each component generally requires skilled physical therapy and a home program of exercises, which Dr. Keen and the physical therapist(s) determine. Dr. Keen says the home program may include things like wearing Lycra garments for core strengthening and using electrical stimulation for specific muscle strengthening. Dr. Keen notes that such a program always includes stretching (preferably not passive). This usually involves a variation of the “runner’s stretch” and long sitting for a prolonged and full hamstring stretch, according to Dr. Keen.
Another mainstay of her treatment plan is nighttime splinting until growth is complete. She often employs knee immobilizers with nighttime foot/ankle splints to stretch the entire length of the gastrocsoleus during sleep.
Ronald Valmassy, DPM, says the overall goal in treating these patients is establishing some stability and simultaneously preserving as much normal function and motion as possible. In most cases, Dr. Valmassy says this will involve using a functional foot orthosis or UCBL to restrict foot position and motion. He adds that this “would certainly be appropriate in milder cases in which significant compensation is occurring in the foot.” In other cases, Dr. Valmassy says a supramalleolar orthosis or an ankle foot orthosis (AFO) would be beneficial in allowing these children to ambulate with greater stability.
Initial treatment for both of these conditions depends on the adequacy of dorsiflexion of the ankle, status of the knee and status of the hip, according to Edwin Harris, DPM. He notes that most of these children have spasticity as a component of their movement disorder and are likely to have a “dynamic” contracture. As long as one can achieve 5 to 10 degrees of ankle dorsiflexion with the knee in extension, Dr. Harris says one can manage these children in AFOs. If not, he advocates trying to achieve an adequate range through physical therapy. Dr. Harris notes this physical therapy is an ongoing process and caregivers must undertake most of it at home on a daily basis.
Equinus deformity is common to both diplegia and hemiplegia, points out Dr. Harris. He says hemiplegics are more likely to have equinovarus deformity while diplegics often have equinovalgus deformity. To maintain foot correction, Dr. Harris says AFOs must have well molded foot components. In general, he initially prefers solid AFOs for children, who tend to tolerate them better.
Dr. Keen says serial casting or the combination of Botox and serial casting is sometimes necessary to achieve and/or maintain a functional range of motion in the affected hamstrings, gastrocsoleus and/or posterior tibialis muscles. Dr. Harris concurs. If dynamic contractures prevent bracing, Dr. Harris suggests administering Botox to the gastrocnemius and subsequently employing serial stretching casts to improve range. In some cases, he notes serial stretching casting alone will lead to a good result.
Fixed unyielding contracture at the ankle will probably require surgery, according to Dr. Harris. If possible, he suggests delaying this until the child is 6 to 7 years of age. Dr. Harris says surgical options include gastrocnemius recession, gastrocsoleus recession and tendo-Achilles lengthening. One would determine the procedure of choice via the physical examination. Dr. Harris cautions that diplegia and hemiplegia are four joint level pathologies that involve the hip, knee, ankle and subtalar joint complex.
“It is inappropriate to attempt to manage ankle equinus without properly addressing knee and hip flexion deformity,” notes Dr. Harris.