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The Toe Walking Tool: A novel method for assessing idiopathic toe walking children
Gait & Posture 32 (2010) 508–511
Contents lists available at ScienceDirect
Gait & Posture journal homepage: www.elsevier.com/locate/gaitpost
The Toe Walking Tool: A novel method for assessing idiopathic toe walking children Cylie M. Williams a,*, Paul Tinley b, Michael Curtin c a
Southern Health, Cardinia Casey Community Health Service, 140-155 Sladen St., Locked Bag 2500, Cranbourne, VIC 3977, Australia Charles Sturt University, PO Box 789, Thurgoona, NSW 2640, Australia c Occupational Therapy, Charles Sturt University, PO Box 789, Albury, NSW 2640, Australia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 April 2010 Received in revised form 10 July 2010 Accepted 13 July 2010
Background: The diagnosis of idiopathic toe walking (ITW) is achieved by the exclusion of all medical causes associated with toe walking. In order to identify children with this gait type, an online Toe Walking Tool questionnaire was developed that utilized questions to identify healthy idiopathic toe walkers and excluded those who toe walk as a result of a medical condition. Method: A Delphi panel process was conducted to establish the relevance and validity of the questions. A group of 10 allied health professionals assessed 12 children utilizing the Toe Walking Tool. A kappa was calculated to determine reliability. Results: Clinicians agreed the questionnaire was an appropriate and effective assessment tool. The tool proved valid in that no child tested who toe walked as a result of a medical condition was able to progress through the testing process. Testing group of practitioners had a Fleiss Kappa agreement of 0.928. Conclusion: The Toe Walking Tool is a valid and reliable method of assessing children who present to the general allied health clinician with toe walking. This tool can assist with the decision of when to refer a child for further specialist investigation of their toe walking. ß 2010 Elsevier B.V. All rights reserved.
Keywords: Gait Pediatrics Idiopathic toe walking
1. Background Toe walking has long been seen as a variant of children’s gait. This gait style is most commonly the result of disease processes, trauma or neurogenic influences. Frequently, toe walking is associated with cerebral palsy [1] or a common aspect of muscular dystrophy [2]. Toe walking has also been reported as occurring in children who have autistic spectrum disorders (ASD) [3] and global development delay (GDD) [4]. Unilateral toe walking has been primarily linked with traumatic occurrences such as injury [5] or tumors [6], causing a physical inability to get the heel to the ground. Idiopathic toe walking (ITW) is an exclusionary diagnosis given when a child toe walks in the absence of any known medical conditions. The diagnosis, appearance, prevalence and treatment of ITW has been documented, debated, and continues to feature in current literature. There is no known reason of why this gait pattern begins or continues in the absence of a medical condition when the child can walk with a heel toe gait on request. 2. Methods In a study investigating a potential link between ITW and sensory processing dysfunction, it was determined that a valid assessment and entry point should be
* Corresponding author. Tel.: +61 3 5990 6789; fax: +61 3 5990 6207. E-mail address: [email protected] (C.M. Williams). 0966-6362/$ – see front matter ß 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.gaitpost.2010.07.011
developed. It is essential to recruit children who have no medical conditions associated with toe walking to investigate this link. This is to ensure the findings are not influenced by conditions known to cause difficulties in sensory processing (e.g., ASD, GDD). A review of the literature relating to the medical conditions associated with toe walking was undertaken and ethics approval obtained. An online ‘Toe Walking Tool’ questionnaire was designed to prompt the user to identify the indicators or risk factors that may be associated with these medical conditions. The tool presented a number of exclusionary questions that progressed in a successive order. Dependent on the answer to each question, the tool would allow progression to the next question set or it would prompt the clinician to refer for further medical investigation. The tool was broken down into the following sections (Table 1):
1. 2. 3. 4.
Demographics. Indicators of trauma. Indictors of neuromuscular influence. Indicators of neurogenic influence.
2.1. Validity testing of the Toe Walking Tool To validate the content, language and flow of the questionnaire (Table 1), a Delphi panel process [7] was used. Pediatric medical and allied health professionals were invited to participate. Each expert was invited based on their profession, expertise in examination and diagnosis, and participation in recent research studies either with idiopathic toe walking or conditions associated with toe walking. Six health professionals participated: pediatric neurologist, pediatric rehabilitation physician, pediatric neuromuscular physiotherapist, pediatric orthopedic physiotherapist, pediatric occupational therapist, and a podiatrist.
C.M. Williams et al. / Gait & Posture 32 (2010) 508–511
509
Table 1 Toe Walking Tool questions and order of progression. Question
Theme
Response that may indicate a medical cause
Name Date of birth Gender Does the child toe walk Does the child have a condition that you have sought medical assistance for and/or been diagnosed with a condition causing toe walking? Does the child have a diagnosis of autism spectrum disorder? Does the child have a diagnosis of cerebral palsy? Does the child have a diagnosis of muscular dystrophy? Does the child’s family have a history of muscular dystrophy? Does the child have a diagnosis of global developmental delay? When the child was born, was their birth weight over 2500 g? When the child was born were they over 37 weeks of gestation? Was the child admitted to special needs nursery/neonatal intensive care after birth? Did the child independently walk prior to 20 months of age? Does the child have a family member that toe walks with no other medical condition? Does the child toe walk on one foot only? Is the child toe walking in response to pain? Did the child previously walk flat footed and only recently start to toe walk? When you ask the child to walk on their heels are they able to? On testing the ankle or hamstring range of motion is there a clonus and/or catch? When asking the child to get up from the floor is there a positive Gower’s sign? Is there a normal knee jerk reflex? Is there a normal babinski reflex? a. Are the hip flexors tight for the child’s age (Thomas test)? b. Are the hamstrings tight for the child’s age (Popliteal Angle)? c. Is the gastrocnemius and soleus tight for the child’s age (Lunge Test)? Does the child have more than 2 significant delayed developmental milestones? Does the child have limited eye contact, have strict rituals or ritual related behaviors, i.e., lining up toys, rocking or spinning
Demographics Demographics Demographics Demographics Demographics
Not Applicable (N/A) N/A N/A N/A N/A
Neurogenic Neuromuscular Neuromuscular Neuromuscular Neurogenic Neuromuscular Neuromuscular Neuromuscular Neuromuscular/Neurogenic Demographic Traumatic Traumatic Traumatic/Neuromuscular Traumatic/Neuromuscular Neuromuscular Neuromuscular Neuromuscular Neuromuscular Neuromuscular
Yes [3] Yes [15] Yes [2] Yes[2] Yes [4] No [1] No [1] Yes [1] No [16] N/A Yes [5,6] Yes [6] Yes [17] No [15] No [18] Yes [2] No [18] No [18] Answer of Yes for two of the questions [19]
Neurogenic Neurogenic
Yes [3] Yes [3]
2.2. Reliability testing of the Toe Walking Tool Inter-practitioner reliability of the Toe Walking Tool was determined in two stages. 2.2.1. Stage 1 Twelve children between the ages of 4 and 8 years, were recruited and evenly divided into three groups: Group 1: Children who did not toe walk. Group 2: Children who toe walked due to an identified medical condition. Group 3: Children who had been identified as idiopathic toe walkers by specialist assessment. All children were able to independently walk for 10 m without assistance from a parent or mobility aids. Consistent medical, birth history and developmental information were collected by the parent completing a standardized questionnaire [8]. A short video of a lower limb assessment and gait analysis of the children was then produced using the questions and examinations outlined in Table 1. Each video showed the child playing with the assessor, undergoing lower limb muscle length testing of the hip flexors [9], hamstrings [10], and gastrocnemius and soleus [11]. General neurological testing was also conducted. Lastly, the child was recorded walking. Where appropriate and indicated as useful by the literature, measurements were taken with a digital inclinometer and the results compared to the
norms [12,13] of this participant age group. Video assessments of each of the children included all information that the clinician would need to fully utilize the Toe Walking Tool. 2.2.2. Stage 2 The inclusion criterion for the second stage was a qualification in podiatry or physiotherapy and primarily not employed in a pediatric specific role. In the working environment of the assessor, podiatrists and physiotherapists are regularly the first allied health clinicians to assess gait difficulties in both adults and children. These criteria were set to test the tool in the general clinical domain. Six podiatrists and four physiotherapists participated in the inter-practitioner reliability testing of the Toe Walking Tool. The years of experience of this group ranged from 1 to 24 years, a mean of 11.1 years.
3. Results 3.1. Content validation Table 2 provides a summary of the feedback given by the expert panel. General comments of encouragement or administrative difficulty with online use were not included in the table. All respondents agreed with the tool content, indicating that the
Table 2 Delphi panel results.
Summary of responses from Delphi Panel
How user-friendly and appropriate did you find the questions within the tool to be (e.g., format, flow of questions)?
Were there any questions that were unclear or hard to understand? Please give the number and why?
Do you feel there is anything missing or misleading within the tool? Please comment on what and why?
Are there any questions in the tool that are unnecessary? Please give the question number and why?
How useful do you feel this tool is for intended purpose?
Appropriate format and flow Easy to understand Change in question numbering User-friendly
No Inclusion of additional information/pictures/ norms to assist in answering
No Grammar changes required Question about inclusion of generalized tone
No
Useful Looks fine Good for community-based clinicians and those in educational setting Would be good to see more results over the long term using the tool
C.M. Williams et al. / Gait & Posture 32 (2010) 508–511
510 Table 3 Collated diagnosis outcomes by number of raters. Participant and diagnosis
No toe walking
Toe walking from diagnosis
ITW
Child Child Child Child Child Child Child Child Child Child Child Child
10 10 10 10 0 1 0 0 0 0 1 0
0 0 0 0 10 9 10 10 0 0 1 0
0 0 0 0 0 0 0 0 10 10 8 10
1—Normal 5—Normal 11—Normal 12—Normal 1—TW from Diagnosis 2—TW from Diagnosis 8—TW from Diagnosis 10—TW from Diagnosis 4—ITW 6—ITW 7—ITW 9—ITW
questions were appropriate. Feedback on the order of the questions was also given. Several features were suggested to make the tool more user-friendly to the novice, including the addition of definitions, reference ranges and links to a video (e.g., a hyperlink to an online video of ankle clonus or Gower’s Sign). 3.2. Reliability of tool The results of the reliability testing of the tool are displayed in Table 3. While the majority of raters identified the risk factors that were associated with a medical condition associated with toe walking, three discrepancies were found when analyzing the data. One clinician marked a child as not toe walking despite this being present in the video. There were also two clinicians who, when provided with the history of the children, did not note that a child had been admitted to a special care nursery as a neonate. This question was designed to halt progression based on the risk that the stay was necessitated due to birth complications. Prenatal or postnatal complications may be an indication of a medical condition causing toe walking. It was noted that further questions within the tool regarding development appropriately excluded this child from the ITW group. No child who toe walked as a result of a medical condition was able to fully progress through the tool. This is of significance as it indicates the questions that identify toe walking risk factors that may be associated with a medical condition were of an appropriate level of sensitivity. The majority of clinicians progressed each of the children from Group 3—idiopathic toe walkers, through the tool. One rater believed there was a clonus present in the video and another marked a child as not toe walking despite obvious periods of toe walking on video. This was the same rater who indicated that a child from Group 2 was a non-toe walker. This rater related that they were not confident in what constitutes toe walking. As toe walking was also documented as a family concern in the questionnaire for one of these children, it is believed this discrepancy is not an error within the tool but clinician error. To measure the level of agreement between the clinicians in the tool outcomes, a Fleiss kappa [14] was calculated. This calculation is used for nominal data between multiple raters where agreement of category data is being evaluated. The clinicians’ responses were collated and documented, as shown in Table 3. The Kappa was calculated from the collated results as 0.9028, where +1 is perfect agreement and 0 is no agreement. High significance of the Kappa is also noted by the Z- and p-score calculation (Z = 29.6091; p = 0.0000). 4. Discussion and conclusion The Toe Walking Tool was found to be a valid and reliable tool for the assessment of toe walkers. The use of a systematic assessment
and history taking determined that no child with toe walking from a medical history or non-toe walking children progressed through the tool. Assessments used within the test have been described within cited literature and are validated and well used within the allied health profession. It is acknowledged that limitations of this study included the small number of participants, both children and clinicians, the varied clinician experience in assessment, and understanding how toe walking gait can present. It was noted that in most cases of outcome discrepancy, it was clinician error or misinterpretation. Each time the toe walking was missed, it was clear within the medical history that this was a parental concern. When presented with a toe walking child in every day practice, it is presumed this mistake would not occur. A definition of toe walking has also been reiterated within the Tool to ensure that potential users understand how the gait pattern may present. In all cases, the tool was sensitive enough that it did not allow any of the children who toe walk as a result of a medical condition to progress. The continued use of this tool in examination of toe walking children will allow continued data collection and further statistical analysis to be conducted on the validity. It is important to note that this tool is not a definitive means of diagnosing ITW; it primarily identifies healthy children who are toe walkers. As such, some children may be identified as having a risk factor relating to a medical condition, but further specialist investigation may still diagnose those children with ITW. A thorough and systematic history and assessment, which includes the use of the Toe Walking Tool can assist the allied health clinician to identify when children who toe walk should be referred for further medical specialist investigation. Acknowledgments Mark Ellis & Gus Waddell, Palcare, for development of the online Toe Walking Tool. Aaron Simmons for statistical support. Podiatrists and Physiotherapist of Cardinia Casey Community Health Service for their participation and support. Conflict of interest statement All authors state there is no conflict of interest that could inappropriately influence the work. There is no financial interest or funding received for this research. References [1] Green LB, Hurvitz EA. Cerebral palsy. Phys Med Rehab Clin N A 2007;18(4): 859–82. [2] Emery AE. The muscular dystrophies. Lancet 2002;359(9307):687–95. [3] Ming X, Brimacombe M, Wagner GC. Prevalence of motor impairment in autism spectrum disorders. Brain Dev 2007;29(9):565–70. [4] Accardo P, Whitman B. Toe walking. A marker for language disorders in the developmentally disabled. Clin Pediatr 1989;28(8):347–50. [5] Chudnofsky CR, Sebastian S. Special wounds. Nail bed, plantar puncture, and cartilage. Emerg Med Clin N A 1992;10(4):801–22. [6] Umehara F, Matsuura E, Kitajima S, Osame M. Unilateral toe-walking secondary to intramuscular hemangioma in the gastrocnemius. Neurology 2005;65(7):E15. [7] Kerr M. The Delphi process. In: The Delphi Process 2002, NHS, editor. 2001: remote and rural areas research initiative. Scotland: NHS; 2002. [8] O’Connor EJ, Staiger PK, McGillivray J. Research and evaluation: a multidisciplinary approach to child health. Melbourne: Deakin University; 2008. p. 1–47. [9] Glanzman AM, Swenson AE, Kim H. Intrarater range of motion reliability in cerebral palsy: a comparison of assessment methods. Pediatr Phys Ther 2008;20(4):369–72. [10] Ten Berge SR, Halbertsma JP, Maathuis PG, Verheij NP, Dijkstra PU, Maathuis KG. Reliability of popliteal angle measurement: a study in cerebral palsy patients and healthy controls. J Pediatr Orthop 2007;27(6):648–52. [11] Rose KJ, Burns J, North KN. Factors associated with foot and ankle strength in healthy preschool-age children and age-matched cases of Charcot–Marietooth disease type 1A. J Child Neurol 2009.
C.M. Williams et al. / Gait & Posture 32 (2010) 508–511 [12] Bennell K, Khan KM, Matthews B, De Gruyter M, Cook E, Holzer K, et al. Hip and ankle range of motion and hip muscle strength in young female ballet dancers and controls. Br J Sports Med 1999;33(5):340–6. [13] Katz K, Rosenthal A, Yosipovitch Z. Normal ranges of popliteal angle in children. J Pediatr Orthop 1992;12(2):229–31. [14] Fleiss JL. Measuring nominal scale agreement among many raters. Psychol Bull 1971;76:378–82. [15] Westberry DE, Davids JR, Davis RB, de Morais F, Mauro C. Idiopathic toe walking: a kinematic and kinetic profile. J Pediatr Orthop 2008;28(3):352–8.
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[16] Hicks R, Durinick N, Gage J. Differentiation of idiopathic toe-walking and cerebral palsy. J Pediatr Orthop 1988;8(2):16–163. [17] Bachli H, Wasner M, Hefti F. Intraspinal malformations. Tethered cord syndrome. Orthopade 2002;31(1):44–50. [18] Russman BS, Ashwal S. Evaluation of the child with cerebral palsy. Semin Pediatr Neurol 2004;11(1):47–57. [19] Davids JR, Foti T, Dabelstein J, Bagley A. Voluntary (normal) versus obligatory (cerebral palsy) toe-walking in children: a kinematic, kinetic, and electromyographic analysis. J Pediatr Orthop 1999;19(4):461–9.
Contents lists available at ScienceDirect
Gait & Posture journal homepage: www.elsevier.com/locate/gaitpost
The Toe Walking Tool: A novel method for assessing idiopathic toe walking children Cylie M. Williams a,*, Paul Tinley b, Michael Curtin c a
Southern Health, Cardinia Casey Community Health Service, 140-155 Sladen St., Locked Bag 2500, Cranbourne, VIC 3977, Australia Charles Sturt University, PO Box 789, Thurgoona, NSW 2640, Australia c Occupational Therapy, Charles Sturt University, PO Box 789, Albury, NSW 2640, Australia b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 April 2010 Received in revised form 10 July 2010 Accepted 13 July 2010
Background: The diagnosis of idiopathic toe walking (ITW) is achieved by the exclusion of all medical causes associated with toe walking. In order to identify children with this gait type, an online Toe Walking Tool questionnaire was developed that utilized questions to identify healthy idiopathic toe walkers and excluded those who toe walk as a result of a medical condition. Method: A Delphi panel process was conducted to establish the relevance and validity of the questions. A group of 10 allied health professionals assessed 12 children utilizing the Toe Walking Tool. A kappa was calculated to determine reliability. Results: Clinicians agreed the questionnaire was an appropriate and effective assessment tool. The tool proved valid in that no child tested who toe walked as a result of a medical condition was able to progress through the testing process. Testing group of practitioners had a Fleiss Kappa agreement of 0.928. Conclusion: The Toe Walking Tool is a valid and reliable method of assessing children who present to the general allied health clinician with toe walking. This tool can assist with the decision of when to refer a child for further specialist investigation of their toe walking. ß 2010 Elsevier B.V. All rights reserved.
Keywords: Gait Pediatrics Idiopathic toe walking
1. Background Toe walking has long been seen as a variant of children’s gait. This gait style is most commonly the result of disease processes, trauma or neurogenic influences. Frequently, toe walking is associated with cerebral palsy [1] or a common aspect of muscular dystrophy [2]. Toe walking has also been reported as occurring in children who have autistic spectrum disorders (ASD) [3] and global development delay (GDD) [4]. Unilateral toe walking has been primarily linked with traumatic occurrences such as injury [5] or tumors [6], causing a physical inability to get the heel to the ground. Idiopathic toe walking (ITW) is an exclusionary diagnosis given when a child toe walks in the absence of any known medical conditions. The diagnosis, appearance, prevalence and treatment of ITW has been documented, debated, and continues to feature in current literature. There is no known reason of why this gait pattern begins or continues in the absence of a medical condition when the child can walk with a heel toe gait on request. 2. Methods In a study investigating a potential link between ITW and sensory processing dysfunction, it was determined that a valid assessment and entry point should be
* Corresponding author. Tel.: +61 3 5990 6789; fax: +61 3 5990 6207. E-mail address: [email protected] (C.M. Williams). 0966-6362/$ – see front matter ß 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.gaitpost.2010.07.011
developed. It is essential to recruit children who have no medical conditions associated with toe walking to investigate this link. This is to ensure the findings are not influenced by conditions known to cause difficulties in sensory processing (e.g., ASD, GDD). A review of the literature relating to the medical conditions associated with toe walking was undertaken and ethics approval obtained. An online ‘Toe Walking Tool’ questionnaire was designed to prompt the user to identify the indicators or risk factors that may be associated with these medical conditions. The tool presented a number of exclusionary questions that progressed in a successive order. Dependent on the answer to each question, the tool would allow progression to the next question set or it would prompt the clinician to refer for further medical investigation. The tool was broken down into the following sections (Table 1):
1. 2. 3. 4.
Demographics. Indicators of trauma. Indictors of neuromuscular influence. Indicators of neurogenic influence.
2.1. Validity testing of the Toe Walking Tool To validate the content, language and flow of the questionnaire (Table 1), a Delphi panel process [7] was used. Pediatric medical and allied health professionals were invited to participate. Each expert was invited based on their profession, expertise in examination and diagnosis, and participation in recent research studies either with idiopathic toe walking or conditions associated with toe walking. Six health professionals participated: pediatric neurologist, pediatric rehabilitation physician, pediatric neuromuscular physiotherapist, pediatric orthopedic physiotherapist, pediatric occupational therapist, and a podiatrist.
C.M. Williams et al. / Gait & Posture 32 (2010) 508–511
509
Table 1 Toe Walking Tool questions and order of progression. Question
Theme
Response that may indicate a medical cause
Name Date of birth Gender Does the child toe walk Does the child have a condition that you have sought medical assistance for and/or been diagnosed with a condition causing toe walking? Does the child have a diagnosis of autism spectrum disorder? Does the child have a diagnosis of cerebral palsy? Does the child have a diagnosis of muscular dystrophy? Does the child’s family have a history of muscular dystrophy? Does the child have a diagnosis of global developmental delay? When the child was born, was their birth weight over 2500 g? When the child was born were they over 37 weeks of gestation? Was the child admitted to special needs nursery/neonatal intensive care after birth? Did the child independently walk prior to 20 months of age? Does the child have a family member that toe walks with no other medical condition? Does the child toe walk on one foot only? Is the child toe walking in response to pain? Did the child previously walk flat footed and only recently start to toe walk? When you ask the child to walk on their heels are they able to? On testing the ankle or hamstring range of motion is there a clonus and/or catch? When asking the child to get up from the floor is there a positive Gower’s sign? Is there a normal knee jerk reflex? Is there a normal babinski reflex? a. Are the hip flexors tight for the child’s age (Thomas test)? b. Are the hamstrings tight for the child’s age (Popliteal Angle)? c. Is the gastrocnemius and soleus tight for the child’s age (Lunge Test)? Does the child have more than 2 significant delayed developmental milestones? Does the child have limited eye contact, have strict rituals or ritual related behaviors, i.e., lining up toys, rocking or spinning
Demographics Demographics Demographics Demographics Demographics
Not Applicable (N/A) N/A N/A N/A N/A
Neurogenic Neuromuscular Neuromuscular Neuromuscular Neurogenic Neuromuscular Neuromuscular Neuromuscular Neuromuscular/Neurogenic Demographic Traumatic Traumatic Traumatic/Neuromuscular Traumatic/Neuromuscular Neuromuscular Neuromuscular Neuromuscular Neuromuscular Neuromuscular
Yes [3] Yes [15] Yes [2] Yes[2] Yes [4] No [1] No [1] Yes [1] No [16] N/A Yes [5,6] Yes [6] Yes [17] No [15] No [18] Yes [2] No [18] No [18] Answer of Yes for two of the questions [19]
Neurogenic Neurogenic
Yes [3] Yes [3]
2.2. Reliability testing of the Toe Walking Tool Inter-practitioner reliability of the Toe Walking Tool was determined in two stages. 2.2.1. Stage 1 Twelve children between the ages of 4 and 8 years, were recruited and evenly divided into three groups: Group 1: Children who did not toe walk. Group 2: Children who toe walked due to an identified medical condition. Group 3: Children who had been identified as idiopathic toe walkers by specialist assessment. All children were able to independently walk for 10 m without assistance from a parent or mobility aids. Consistent medical, birth history and developmental information were collected by the parent completing a standardized questionnaire [8]. A short video of a lower limb assessment and gait analysis of the children was then produced using the questions and examinations outlined in Table 1. Each video showed the child playing with the assessor, undergoing lower limb muscle length testing of the hip flexors [9], hamstrings [10], and gastrocnemius and soleus [11]. General neurological testing was also conducted. Lastly, the child was recorded walking. Where appropriate and indicated as useful by the literature, measurements were taken with a digital inclinometer and the results compared to the
norms [12,13] of this participant age group. Video assessments of each of the children included all information that the clinician would need to fully utilize the Toe Walking Tool. 2.2.2. Stage 2 The inclusion criterion for the second stage was a qualification in podiatry or physiotherapy and primarily not employed in a pediatric specific role. In the working environment of the assessor, podiatrists and physiotherapists are regularly the first allied health clinicians to assess gait difficulties in both adults and children. These criteria were set to test the tool in the general clinical domain. Six podiatrists and four physiotherapists participated in the inter-practitioner reliability testing of the Toe Walking Tool. The years of experience of this group ranged from 1 to 24 years, a mean of 11.1 years.
3. Results 3.1. Content validation Table 2 provides a summary of the feedback given by the expert panel. General comments of encouragement or administrative difficulty with online use were not included in the table. All respondents agreed with the tool content, indicating that the
Table 2 Delphi panel results.
Summary of responses from Delphi Panel
How user-friendly and appropriate did you find the questions within the tool to be (e.g., format, flow of questions)?
Were there any questions that were unclear or hard to understand? Please give the number and why?
Do you feel there is anything missing or misleading within the tool? Please comment on what and why?
Are there any questions in the tool that are unnecessary? Please give the question number and why?
How useful do you feel this tool is for intended purpose?
Appropriate format and flow Easy to understand Change in question numbering User-friendly
No Inclusion of additional information/pictures/ norms to assist in answering
No Grammar changes required Question about inclusion of generalized tone
No
Useful Looks fine Good for community-based clinicians and those in educational setting Would be good to see more results over the long term using the tool
C.M. Williams et al. / Gait & Posture 32 (2010) 508–511
510 Table 3 Collated diagnosis outcomes by number of raters. Participant and diagnosis
No toe walking
Toe walking from diagnosis
ITW
Child Child Child Child Child Child Child Child Child Child Child Child
10 10 10 10 0 1 0 0 0 0 1 0
0 0 0 0 10 9 10 10 0 0 1 0
0 0 0 0 0 0 0 0 10 10 8 10
1—Normal 5—Normal 11—Normal 12—Normal 1—TW from Diagnosis 2—TW from Diagnosis 8—TW from Diagnosis 10—TW from Diagnosis 4—ITW 6—ITW 7—ITW 9—ITW
questions were appropriate. Feedback on the order of the questions was also given. Several features were suggested to make the tool more user-friendly to the novice, including the addition of definitions, reference ranges and links to a video (e.g., a hyperlink to an online video of ankle clonus or Gower’s Sign). 3.2. Reliability of tool The results of the reliability testing of the tool are displayed in Table 3. While the majority of raters identified the risk factors that were associated with a medical condition associated with toe walking, three discrepancies were found when analyzing the data. One clinician marked a child as not toe walking despite this being present in the video. There were also two clinicians who, when provided with the history of the children, did not note that a child had been admitted to a special care nursery as a neonate. This question was designed to halt progression based on the risk that the stay was necessitated due to birth complications. Prenatal or postnatal complications may be an indication of a medical condition causing toe walking. It was noted that further questions within the tool regarding development appropriately excluded this child from the ITW group. No child who toe walked as a result of a medical condition was able to fully progress through the tool. This is of significance as it indicates the questions that identify toe walking risk factors that may be associated with a medical condition were of an appropriate level of sensitivity. The majority of clinicians progressed each of the children from Group 3—idiopathic toe walkers, through the tool. One rater believed there was a clonus present in the video and another marked a child as not toe walking despite obvious periods of toe walking on video. This was the same rater who indicated that a child from Group 2 was a non-toe walker. This rater related that they were not confident in what constitutes toe walking. As toe walking was also documented as a family concern in the questionnaire for one of these children, it is believed this discrepancy is not an error within the tool but clinician error. To measure the level of agreement between the clinicians in the tool outcomes, a Fleiss kappa [14] was calculated. This calculation is used for nominal data between multiple raters where agreement of category data is being evaluated. The clinicians’ responses were collated and documented, as shown in Table 3. The Kappa was calculated from the collated results as 0.9028, where +1 is perfect agreement and 0 is no agreement. High significance of the Kappa is also noted by the Z- and p-score calculation (Z = 29.6091; p = 0.0000). 4. Discussion and conclusion The Toe Walking Tool was found to be a valid and reliable tool for the assessment of toe walkers. The use of a systematic assessment
and history taking determined that no child with toe walking from a medical history or non-toe walking children progressed through the tool. Assessments used within the test have been described within cited literature and are validated and well used within the allied health profession. It is acknowledged that limitations of this study included the small number of participants, both children and clinicians, the varied clinician experience in assessment, and understanding how toe walking gait can present. It was noted that in most cases of outcome discrepancy, it was clinician error or misinterpretation. Each time the toe walking was missed, it was clear within the medical history that this was a parental concern. When presented with a toe walking child in every day practice, it is presumed this mistake would not occur. A definition of toe walking has also been reiterated within the Tool to ensure that potential users understand how the gait pattern may present. In all cases, the tool was sensitive enough that it did not allow any of the children who toe walk as a result of a medical condition to progress. The continued use of this tool in examination of toe walking children will allow continued data collection and further statistical analysis to be conducted on the validity. It is important to note that this tool is not a definitive means of diagnosing ITW; it primarily identifies healthy children who are toe walkers. As such, some children may be identified as having a risk factor relating to a medical condition, but further specialist investigation may still diagnose those children with ITW. A thorough and systematic history and assessment, which includes the use of the Toe Walking Tool can assist the allied health clinician to identify when children who toe walk should be referred for further medical specialist investigation. Acknowledgments Mark Ellis & Gus Waddell, Palcare, for development of the online Toe Walking Tool. Aaron Simmons for statistical support. Podiatrists and Physiotherapist of Cardinia Casey Community Health Service for their participation and support. Conflict of interest statement All authors state there is no conflict of interest that could inappropriately influence the work. There is no financial interest or funding received for this research. References [1] Green LB, Hurvitz EA. Cerebral palsy. Phys Med Rehab Clin N A 2007;18(4): 859–82. [2] Emery AE. The muscular dystrophies. Lancet 2002;359(9307):687–95. [3] Ming X, Brimacombe M, Wagner GC. Prevalence of motor impairment in autism spectrum disorders. Brain Dev 2007;29(9):565–70. [4] Accardo P, Whitman B. Toe walking. A marker for language disorders in the developmentally disabled. Clin Pediatr 1989;28(8):347–50. [5] Chudnofsky CR, Sebastian S. Special wounds. Nail bed, plantar puncture, and cartilage. Emerg Med Clin N A 1992;10(4):801–22. [6] Umehara F, Matsuura E, Kitajima S, Osame M. Unilateral toe-walking secondary to intramuscular hemangioma in the gastrocnemius. Neurology 2005;65(7):E15. [7] Kerr M. The Delphi process. In: The Delphi Process 2002, NHS, editor. 2001: remote and rural areas research initiative. Scotland: NHS; 2002. [8] O’Connor EJ, Staiger PK, McGillivray J. Research and evaluation: a multidisciplinary approach to child health. Melbourne: Deakin University; 2008. p. 1–47. [9] Glanzman AM, Swenson AE, Kim H. Intrarater range of motion reliability in cerebral palsy: a comparison of assessment methods. Pediatr Phys Ther 2008;20(4):369–72. [10] Ten Berge SR, Halbertsma JP, Maathuis PG, Verheij NP, Dijkstra PU, Maathuis KG. Reliability of popliteal angle measurement: a study in cerebral palsy patients and healthy controls. J Pediatr Orthop 2007;27(6):648–52. [11] Rose KJ, Burns J, North KN. Factors associated with foot and ankle strength in healthy preschool-age children and age-matched cases of Charcot–Marietooth disease type 1A. J Child Neurol 2009.
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