Decision Trees: Linking Biomechanical and Developmental Characteristics of Preschool Idiopathic Toe Walkers: A Cross-Sectional Study

Research Article

Austin Pediatr. 2016; 3(3): 1036.

Decision Trees: Linking Biomechanical and Developmental Characteristics of Preschool Idiopathic Toe Walkers: A Cross-Sectional Study

Martín-Casas P1*, Meneses-Monroy A2, Atín- Arratibel Mª Á1 and Beneit-Montesinos JV1

1Department of Physical Medicine and Rehabilitation, Medical Hydrology, School of Nursing, Physiotherapy and Pododología, Complutense University of Madrid, Spain

2Nursing School Spanish Red Cross, Madrid, Spain

*Corresponding author: Patricia Martín-Casas, Department of Physical Medicine and Rehabilitation, Medical Hydrology, School of Nursing, Physiotherapy and Pododología, Complutense University of Madrid, Spain

Received: July 21, 2016; Accepted: August 09, 2016; Published: August 11, 2016

Abstract

Background: Idiopathic Toe Walkers (ITW) show specific sensorimotor characteristics with different development, which requires foot, gait and developmental evaluation? Although algorithms facilitate their classification in clinical categories to select the best therapeutic options, decision trees would connect the diverse characteristics of preschool ITW and would help their early and comprehensive approach. The purpose of this study was to design decision trees and to propose their application in the ITW assessment and treatment.

Methods: Fifty-six ITW’s (aged 3-6 years) completed this cross-sectional study. The children underwent an orthopaedic foot evaluation and were subjects of a clinical ankle evaluation, a pedobarographic gait analysis and a developmental test - Cuestionario de Madurez Neuropsicológica Infantil (CUMANIN) -. Decision trees were developed with the studied variables, by calculating their quality value.

Results: Different decision trees showed the interrelation between biomechanical and developmental variables in the studied ITW. Predictor variables were calcaneal pronation, passive ankle dorsiflexion, percentage of impulse of the forefoot, contact time of the hind foot, peak pressure under lateral area of the right hind foot and the CUMANIN Overall Development farthing.

Conclusion: The decision trees obtained, with high values of quality, demonstrated that the older ITW had a top orthopaedic risk and an inferior level of development. Decision trees allow the integration of biomechanical and developmental variables in the assessment and treatment of the ITW, but their validation in a larger sample is necessary.

Keywords: Idiopathic toe walking; Pedobarography; Foot; Development; Gait; Algorithms

Abbreviations

ITW: Idiopathic Toe Walkers; DF: Dorsiflexion; CUMANIN: Cuestionario de Madurez Neuropsicológica Infantil; RCSP: Relaxed Calcaneal Stance Position

Introduction

Idiopathic toe walking is the condition of a tip-toe gait, considered abnormal in children older than three [1-3]. These children usually called idiopathic toe-walkers (ITW) often show alterations in other developmental areas. Their specific characteristics can lead complications such as shortened Achilles tendon, structural abnormalities, and deteriorated balance and development [1,2,4,5].

Authors evaluating ITW mainly focus on the static ankle dorsiflexion (DF) and gait [6] to determine the most appropriate clinical approach [2]. In this term, Armand et al. showed the usefulness of decision trees for the identification and classification of tiptoe gait, in both idiopathic and secondary tiptoe walking patterns [7]. The same authors associated potential causes of tiptoe gait and its clinical characteristics with the gait pattern [3].

Several authors highlighted the developmental testing of ITW [4,5,8] because of the underappreciated severity of this pathology [1]. In this sense, the pedobarographic gait analysis is widely used for its sensitivity to detect children incipient alterations and could be a useful tool in the early evaluation of the ITW [9-12].

The combination of the clinical, gait analysis and developmental evaluation could offer a better characterization and therapeutic indication of the ITW [3]. To our knowledge, the exceptional attempts to provide links between ITW biomechanical and developmental characteristics have just described the symptoms without demonstrating a relationship between these characteristics or the impact of planning a treatment, other than the recommendation of a global approach [2,4,5,13]. Thus, the purpose of this paper was to link clinical, developmental and pedobarographic gait pattern characteristics of preschool ITW, in order to aid clinical practitioners when choosing the best ITW evaluation and treatment plan.

Materials and Methods

One hundred and fifty-one ITW (3 – 6 years old) were evaluated for this prospective investigation (via specific advertising) from February to July 2010. Both clinical and developmental examination and the pedobarographic gait analysis were performed by the same two experts and experienced Physiotherapists in the Physical Therapy Unit of the Clinic of Chiropody of the local university. The inclusion criteria were to have: toe-walking since the gait beginning; current toe-walking; absence of heel rocker assessed by observational gait analysis; and ability to heel contact on request [5,6,14]. The exclusion criteria included trauma, neurological or developmental disorders, unilaterally tiptoe gait, and previous treatment for tiptoe gait. According to these criteria, we finally selected 56 children.

Parents signed the informed consent before beginning the study according the Declaration of Helsinki (De Helsinki, 2008). This crosssectional study was approved by the Clinical Investigation Ethics Committee of the local university, with registration number F (EFP)- 001/2010.

Pedobarographic gait analysis

Pedobarographic gait analysis was performed using Foot scan USB Gait Clinical System® (2 m x 0.4 m x 0.02 m, 16384 sensors, 500 Hz, and 3 sensors per cm2), embedded in a 9 meters experimental walkway. Children were asked to walk onto the gait track looking at the front and at a comfortable speed, after they had being walking in the room for a minute. At least 10 whole footprints of both feet were recorded and their average was used for the analysis. Analyzed variables were calculated directly by the system by means of the automatic division in foot zones [9-12,15,16]. Studied variables were maximum and peak pressure, percentage of impulse and contact time of the hindfoot, midfoot and forefoot, and gait angle of both feet.

Clinical assessment

Clinical examination including the measure of the popliteal angle, the passive ankle DF, both with extended and flexed knee and the relaxed calcaneal stance position (RCSP) [17,18]. Angular measurements were obtained using a handheld goniometer, with modalities which have demonstrated to go from moderate to high reliability. Position and methodology of measurement were respected, avoiding compensations and following the main recommendations to increase reliability measurement [17,19].

Developmental evaluation

Developmental evaluation was performed by Cuestionario de Madurez Neuropsicológica Infantil (CUMANIN), test validated in Spain that evaluate cognitive functions, language, motor, perceptive and laterality aspects 20. Global and specific scales results can be expressed as farthings with respect to the reference population. For this study, Motor Skill Scale and Overall Development farthing and foot laterality was used. Overall Development farthing results from the addition of Articulatory, Expressive and Comprehensive Language scales and Motor Skills, Spatial Structuring, Visopercepcion, Memory and Rhythm Scales. CUMANIN has been described as a useful tool for developmental evaluation in some Spanish researches studying different samples of children, both with and without disorders [20- 22].

Sample characteristics

Fifty-six children (age: 54.7 + 12.17 months; Weight: 19.56 + 3.49 kg; Height 1.09 + 0.08 m; Body Mass Index: 16.46 + 1.49) were recruited for this study corresponding to 112 lower limbs.

Pedobarographical values could not be shared with studies with the same analysis system, but they appear to be similar to other studies [9,11,12,15]. All orthopaedic and developmental variables were within normal range for similar population, with 64.8% of the ITW showing a right foot laterality [13,23,24].

Statistical analysis

Decision trees were elaborated and their quality value (R2 coefficients) was calculated throughout SPSS v.19.0 Software for Windows. For all tests p-values < 0.05 (IC 95 %) and < 0.001 (IC 99 %) were considered statistically significant.

Results

Decision trees showed a relationship between some of the studied variables, because some of them could be predicted by others. In this way, left ankle DF with extended knee predicted left RCSP (Figure 1). Right RCSP could not be predicted by any studied variable.