Primary care provider decision-making when treating children with toe walking: a pilot study
Zachary Holbrook, SPT and Ali Harbaugh, SPT
19 Comments on “Primary care provider decision-making when treating children with toe walking: a pilot study”
Nice job on the poster guys! Out of curiosity, what were some of the other diagnoses responses in your survey? I would be curious to know seeing as only 53% of respondents correctly diagnosed the problem. Also, how do you two think that the results would have differed if the survey had been conducted with practicing PCPs?
Thanks Codi! Some of the other possible diagnoses options included: autism spectrum disorder, cerebral palsy, developmental discoordination disorder, and Duchenne muscular dystrophy. I believe that one of the main reasons that only 53% of respondents chose the correct diagnosis was due to the student’s lack of experience with idiopathic toe walking. With an increase in their clinical time we should expect their clinical reasoning to improve. Based on this, I believe that PCPs would have correctly diagnosed toe walking more frequently as compared to the students.
Good questions, Codi! I agree with Alli in having a higher percentage of correct diagnoses among practicing PCPs, but I’m not sure how their referral patterns would change. Idiopathic toe walking is something that many OTs and PTs recognize, but I know there are many different beliefs among other healthcare providers on whether or not kids who toe walk need treatment.
Great study and great poster Zach and Alli! I am curious as to why you think 71% of the individuals surveyed indicated that an OT referral would be necessary for Case 3 but not for either of the other cases? My immediate response would have been that OT+PT referral would be indicated for Case 2 due to the sensory origin of the ITW, but I see that I may be incorrect in that assumption. Thank you again for this educational poster!
Jerrica, the specific details in Case 3 express that the child has minor sensory deficits, whereas the child in Case 2 has significant sensory deficits so I really am not sure why OT was such a common referral for Case 3 over Case 2. Your assumption with Case 2 should be correct due to the adequate DF ROM and presence of sensory component. From my experience in my current clinical in pediatrics, a sensory component is often present in children who toe walk and a referral to OT is never a bad choice, especially if ROM gains are being made and the child continues to toe walk. Good question!
Jerrica, I would have to agree with Zach. From my own clinical and personal experience, children with sensory processing deficits who toe walk benefits from working with an occupational therapist. Thanks!
Hans, I think that it is possible that students from other schools would perform better or worse as compared to the universities we used. Some programs may have a heavier pediatric course load resulting in more clinical knowledge on how to treat toe walking. Thanks!
Interesting study! Do you think this kind of assessment paired with education could also be used for other conditions to increase referrals to PT or OT for conditions that we can have a positive impact on? I realized with some of my interprofessional experiences that many primary care providers are not sure of our areas of expertise and the patients that can be referred to us, and I would be interested to know if this type of survey learning can be used in interprofessional education. Thanks!
Elizabeth, I do believe that this type of survey with follow up education could be utilized to educate primary care providers (PCP) on PT and OT scope of practice, resulting in an increase in referrals. In fact, one of the main reasons for creating this survey is to eventually distribute to PCP so they are educated on the use of PTs and OTs for idiopathic toe walking. Thanks!
Elizabeth, one more thing to add on top of Alli’s response…I think a problem we’d run into with current PCPs is response rate and the time it takes to complete the survey. Without a reward besides education, I’m not sure PCPs would see the survey as beneficial with their current demands. I’m sure this was a significant factor in the low response rate of our study with student participants, as well. From my clinical experience I’ve learned that many PTs contact their surrounding PCPs just to create a connection and educate the PCPs on how valuable PTs can be for their patients. I think encouraging future and current PTs to make a quick phone call to PCPs nearby could have a significant impact on PT and even OT referrals. Great question!
Shantel, due to the low number of participants for each survey set, we were not able to accurately identify a theme among a specific group. Hopefully in the future the survey will be sent to licensed professionals instead of students and gain a larger number of participants. In my own opinion, I would not expect a theme among a certain group of practitioners. Since ITW does not have a well structured treatment guideline for providers to follow, I’ve found that people often develop their own treatment strategy based on theory and what has worked in the past. And this may or may not include a quick referral to OT or PT!
Great poster presentation! I have a question to build on Codi’s about the low rate of accurate diagnosis. Are there different assessment tools available to physicians/physical therapists/occupational therapists to rule in or rule out ITW compared with some of the other common diagnoses? If an assessment tool like this is missing, future research might be able to take the direction of developing a clinical prediction set for more accurate ITW diagnosis and referral recommendations.
Jenifer, through our research, we found a developed screening algorithm that can be used to determine the correct referral option for toe walking based on the cause whether that be neurological (i.e. Spinal Muscular Atrophy, cerebral palsy), orthopedic, or idiopathic. The article also has an algorithm for intervention/treatment based on the patient’s toe walking symptoms and age. Thanks!
Nice work! I was curious if you found any specific interventions while completing your lit review that you think would be beneficial to address in the future research? I was specifically curious if there was anything about AFO usage or specific exercises and on their impact on the child’s gait? Is there anything about interventions at a particular age of the child that may make the most impact?
Kristen, due to the guidelines for idiopathic toe walking (ITW) being unclear, there are currently inconsistencies on the best treatment options for patients based on their symptoms and age. We did find that in general, children under the age of five or who have periodic episodes of ITW should be under observation by a physical therapist and physician as ITW has shown to improve with age. This is partially thought to be due to children gaining weight as they age resulting in them ‘sinking’ downwards onto their heels during ambulation. If toe walking persists in children younger than five, physical therapy and serial casting are typically the next step. If these children continue to toe walk, Botox and/or surgery are likely the next steps. A newer ankle foot orthoses has been utilized for ITW patients called the thee-step pyramid insole. The insole has shown to be effective for 60-70% of ITW in their study. Thanks!
Pomarino D, Ramírez-llamas J, Martin S, Pomarino A. The 3-step pyramid insole treatment concept for idiopathic toe walking. Foot Ankle Spec. 2016; 20(10):1-7.
Great poster, guys! Although a majority of your respondents were correct with their referrals to PT and OT, nearly 30% chose inappropriate referrals in cases 2 and 3. I’m wondering what the most common alternative referrals were for your respondents?
USD PT Research 
Nice job on the poster guys! Out of curiosity, what were some of the other diagnoses responses in your survey? I would be curious to know seeing as only 53% of respondents correctly diagnosed the problem. Also, how do you two think that the results would have differed if the survey had been conducted with practicing PCPs?
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Thanks Codi! Some of the other possible diagnoses options included: autism spectrum disorder, cerebral palsy, developmental discoordination disorder, and Duchenne muscular dystrophy. I believe that one of the main reasons that only 53% of respondents chose the correct diagnosis was due to the student’s lack of experience with idiopathic toe walking. With an increase in their clinical time we should expect their clinical reasoning to improve. Based on this, I believe that PCPs would have correctly diagnosed toe walking more frequently as compared to the students.
LikeLike
Good questions, Codi! I agree with Alli in having a higher percentage of correct diagnoses among practicing PCPs, but I’m not sure how their referral patterns would change. Idiopathic toe walking is something that many OTs and PTs recognize, but I know there are many different beliefs among other healthcare providers on whether or not kids who toe walk need treatment.
LikeLike
Great study and great poster Zach and Alli! I am curious as to why you think 71% of the individuals surveyed indicated that an OT referral would be necessary for Case 3 but not for either of the other cases? My immediate response would have been that OT+PT referral would be indicated for Case 2 due to the sensory origin of the ITW, but I see that I may be incorrect in that assumption. Thank you again for this educational poster!
LikeLike
Jerrica, the specific details in Case 3 express that the child has minor sensory deficits, whereas the child in Case 2 has significant sensory deficits so I really am not sure why OT was such a common referral for Case 3 over Case 2. Your assumption with Case 2 should be correct due to the adequate DF ROM and presence of sensory component. From my experience in my current clinical in pediatrics, a sensory component is often present in children who toe walk and a referral to OT is never a bad choice, especially if ROM gains are being made and the child continues to toe walk. Good question!
LikeLike
Jerrica, I would have to agree with Zach. From my own clinical and personal experience, children with sensory processing deficits who toe walk benefits from working with an occupational therapist. Thanks!
LikeLike
Do you think that the results would differ if this study was replicated using a population outside of local universities in the Midwest?
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Hans, I think that it is possible that students from other schools would perform better or worse as compared to the universities we used. Some programs may have a heavier pediatric course load resulting in more clinical knowledge on how to treat toe walking. Thanks!
LikeLike
Interesting study! Do you think this kind of assessment paired with education could also be used for other conditions to increase referrals to PT or OT for conditions that we can have a positive impact on? I realized with some of my interprofessional experiences that many primary care providers are not sure of our areas of expertise and the patients that can be referred to us, and I would be interested to know if this type of survey learning can be used in interprofessional education. Thanks!
LikeLike
Elizabeth, I do believe that this type of survey with follow up education could be utilized to educate primary care providers (PCP) on PT and OT scope of practice, resulting in an increase in referrals. In fact, one of the main reasons for creating this survey is to eventually distribute to PCP so they are educated on the use of PTs and OTs for idiopathic toe walking. Thanks!
LikeLike
Elizabeth, one more thing to add on top of Alli’s response…I think a problem we’d run into with current PCPs is response rate and the time it takes to complete the survey. Without a reward besides education, I’m not sure PCPs would see the survey as beneficial with their current demands. I’m sure this was a significant factor in the low response rate of our study with student participants, as well. From my clinical experience I’ve learned that many PTs contact their surrounding PCPs just to create a connection and educate the PCPs on how valuable PTs can be for their patients. I think encouraging future and current PTs to make a quick phone call to PCPs nearby could have a significant impact on PT and even OT referrals. Great question!
LikeLike
Great poster! Do you guys know how the different groups of practitioners answered? and if you do, did they choose similarly?
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Shantel, due to the low number of participants for each survey set, we were not able to accurately identify a theme among a specific group. Hopefully in the future the survey will be sent to licensed professionals instead of students and gain a larger number of participants. In my own opinion, I would not expect a theme among a certain group of practitioners. Since ITW does not have a well structured treatment guideline for providers to follow, I’ve found that people often develop their own treatment strategy based on theory and what has worked in the past. And this may or may not include a quick referral to OT or PT!
LikeLike
Great poster presentation! I have a question to build on Codi’s about the low rate of accurate diagnosis. Are there different assessment tools available to physicians/physical therapists/occupational therapists to rule in or rule out ITW compared with some of the other common diagnoses? If an assessment tool like this is missing, future research might be able to take the direction of developing a clinical prediction set for more accurate ITW diagnosis and referral recommendations.
LikeLike
Jenifer, through our research, we found a developed screening algorithm that can be used to determine the correct referral option for toe walking based on the cause whether that be neurological (i.e. Spinal Muscular Atrophy, cerebral palsy), orthopedic, or idiopathic. The article also has an algorithm for intervention/treatment based on the patient’s toe walking symptoms and age. Thanks!
Here is the link to the article: https://www.cincinnatichildrens.org/-/media/cincinnati%20childrens/home/service/j/anderson-center/evidence-based-care/recommendations/type/idiopathic-toe-walking-pdf-new
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Nice work! I was curious if you found any specific interventions while completing your lit review that you think would be beneficial to address in the future research? I was specifically curious if there was anything about AFO usage or specific exercises and on their impact on the child’s gait? Is there anything about interventions at a particular age of the child that may make the most impact?
LikeLike
Kristen, due to the guidelines for idiopathic toe walking (ITW) being unclear, there are currently inconsistencies on the best treatment options for patients based on their symptoms and age. We did find that in general, children under the age of five or who have periodic episodes of ITW should be under observation by a physical therapist and physician as ITW has shown to improve with age. This is partially thought to be due to children gaining weight as they age resulting in them ‘sinking’ downwards onto their heels during ambulation. If toe walking persists in children younger than five, physical therapy and serial casting are typically the next step. If these children continue to toe walk, Botox and/or surgery are likely the next steps. A newer ankle foot orthoses has been utilized for ITW patients called the thee-step pyramid insole. The insole has shown to be effective for 60-70% of ITW in their study. Thanks!
LikeLike
Here is a link and the citation for the three-step pyramid insole: https://www.ncbi.nlm.nih.gov/pubmed/27650108
Pomarino D, Ramírez-llamas J, Martin S, Pomarino A. The 3-step pyramid insole treatment concept for idiopathic toe walking. Foot Ankle Spec. 2016; 20(10):1-7.
LikeLike
Great poster, guys! Although a majority of your respondents were correct with their referrals to PT and OT, nearly 30% chose inappropriate referrals in cases 2 and 3. I’m wondering what the most common alternative referrals were for your respondents?
LikeLike