PHYSIOTHERAPY IN NEUROLOGY ILecturer in charge: Pn. Fadia Binti Razali

NO. NAME MATRIX NUMBER1 Adlin Hani Bt. Mazlan Hanafi 20114452522 Farah Syahirah Binti Jamil 20118594823 Laila Nabihah Binti Abdul Wahab 20118271564 Nazatul Aina Binti Azizlan 20114467865 Naziha Binti Zainal 20114820926 Nur Aimi Binti Ismon 20116756967 Nur Alia Nabilah Binti Rashid 20114753328 Nur Isney Bt. Ibrahim 20114222629 Nur Najwan Bt. Shahidan 2011273233

10 Nur Sakinah Binti Ishak 201140663411 Umi Kaltsom Binti Suhari 2011898108

WALKING WITH TIP TOES• Tip-toe walking describes the human body

posture and locomotion which using the balls of the feet and removing the heel(s) of one or both feet from the ground during walking.

• Normal for most kids between 10 and 18 months but if tip-toe walking last longer there will be a symptom.

CAUSE : Idiophatic Toe Walking(ITW) • Also known as ‘habitual’ toe walking. • ITW is the habit of tiptoe walking with no clear reason for it.• A diagnosis of ITW is made after assessing the child to rule out any neuromuscular or orthopaedic problems. (cerebral palsy, autism, muscular distrophy)• Usually a child with ITW can stand and walk normally with the feet flat on the floor.

• 40 % of children who idiopathic have family history of tiptoe walkers.

• Persistent equinus positioning will result in contractures and permanent shortening of the calf muscle and Achilles tendon.

• Early identification and treatment of children with ITW is needed.

TREATMENT: Idiophatic• Passive/active Stretching Exercises .– Ankle plantar-flexor (gastrocnemius)– Achilles tendon stretch

• Use squeak shoes/ special shoes• Braces - to stretch Achilles tendons– night braces ,day braces

• Serial Casting – to gain ankle DF ROM• Strengthening Exercises– Anterior Tibialis - improve dorsiflexion

• Surgical – worst cases

CAUSE : Tightness of Archilles Tendon/Equinus

Equinus: involuntary plantarflexion due to a tight or overactive heelcord.

Factors that contribute :• It is often due to tightness in the Achilles tendon.• In some individuals, this tightness is congenital and

sometimes it is an inherited trait.• Severe Achilles Tendonitis or Calcaneal Apophysitis - might

tip toe to take some of the tension off their Achilles tendon.• A deep muscular calf Hemangioma –

This is a vascular neoplasm which causes swelling of the calf muscle.

TREATMENT : Tightness of Archilles Tendon

Surgery• In cases of severe, chronic (long term) Achilles

tendonitis the sheath may become thick and fibrous.

• Surgery aims to remove the fibrous tissue and repair any tears in the tendon.

• A cast or splint will be required post operatively and a recovery program including physiotherapy, specific exercises and a gradual return to activity will be planned.

Casting/Splinting• For initial treatment, casting or splinting of the affected foot

may be recommended to allow it to rest completely.

Technique Achilles tendon stretch • Have your child lie on his back on a comfortable surface such

as a firm bed.• With his knee bent, bring your child’s foot upwards, toward

his head, bending his ankle.• Hold the stretch at the end of the movement (that is, as far

as your child’s range of motion will permit) for 15 to 30 seconds. This should not be painful for your child.

• Bring your child’s foot back to a normal postion. Repeat the exercise 10 times on each leg, daily.

CAUSE : Autism

• Autistic children have an acute sensory sensitivity to tactile sensations

• Problem with proprioception which feel disconnected from one’s own limbs and how to move in space

• Short Achilles tendon that prevents the children from standing flat-footed and limits the ROM in the ankle

TREATMENT : Autism• Massage -Help to desensitize feet• Sensory modulation outdoor path

Example: 1) walk on mulch 2) walk on cypress bark 3) walk on sand 4) walk on smooth river crock 5) walk on pebbles beach• Proprioceptive Activities

- jump on a trampoline- marching

• Therapeutic brushing -Decrease fear and discomfort of being touched.• Botox

-temporarily paralyzes part of the heel cord muscle is less tight, the child can walk with the heels down.

• Stretching-Active stretches tend to be more effective.

-passive ones may be easier to carry out

• Casting-put a cast on the child’s leg to help stretch the muscle.

• Surgery -to increase the flexibility of their heel cords. -involves cutting the muscle to make it longer, then putting the child in a cast for a few weeks.

TIPTOE WALKING DUE TO TACTILE HYPERSENSITIVITY FEET

• Very common in Autism Spectrum Disorder(ASD).• Tactile sensation is unpleasant, the person tries to

react by trying to avoid contact with walking surface as much as possible (very ticklish)

• More often observed when the person is barefoot. • Pain and discomfort may be stimulated by even light

touch. • It can greatly interfere with activities of daily living as

putting on shoes or walking causes pain.• Treatment should be focused on reduce the

sensitivity of the feet.

Kaplan OD, Melvin. Visual Management : A Physiological Approach to Rehabiliting Autism Spectrum Disorder

CAUSE : Cerebral Palsy (CP)

Cerebral palsy will cause individual to walk ontip toes because :• Calf muscles and Achilles tendon contract• Due to abnormal nerve supply and

consequent abnormal growth.

TREATMENT : Cerebral Palsy (CP)

• Use bracing• Botox (still experimental treatment)• Gait analysis• Lengthening procedure (strengthening

exercise)• Surgery

REFERENCES• Stillman, W. (2011). Why does my autistic toddler nearly

always walk on tiptoes? . Retrieved August 9, 2012, from http://www.sharecare.com/question/why-autistic-toddler-walks-tiptoes

• Your child is walking on her toes . (2012). Retrieved August 9, 2012, from http://www.babycenter.com/0_your-child-is-walking-on-her-toes_12580.bc

• Jake Lawson, J. (2011). Retrieved August 9, 2012, from http://www.livestrong.com/article/14754-sensory-modulation-training/

• Brody, J. (2005). Spastic Diplegia Cerebral Palsy. Retrieved August 9, 2012, from http://www.cerebralpalsysource.com

/Types_of_CP/diplegia_cp/index.html

• Roberta, (June, 2011). Idiopathic toe walking in children. Physio questions. Retrieved August 10, 2012 from http://www.physioquestions. com /2011/06/09/idiopathic-toe-walking/

• Wendy. (March 2,2012), Faq about tip toe walking, A couple more hours, retrieved on 8 August 2012, http://www.couplemorehours.com/2012/03/ faq-about-tip-toe-walking.html

• Children Tip Toeing. Retrieved August 9, 2012, from http://www.drfoot.co.uk/tip_toe_child

.html