Toe walking, or walking on the balls of the feet, can occur during the toddler years. Some kids will grow out of this without intervention. Toe walking alone is not necessarily a cause for concern. However, if it does not resolve, it can become a habit that, if left untreated, will cause physical changes that can be difficult to treat. And while toe walking in a 2 year old girl might seem cute, in a 10 year old boy it could lead to difficulty participating in sports, teasing, and impairments of the musculoskeletal system.

Causes of Toe Walking

• Achilles tendon (heel cord) or hip flexor tightness
• Sensory system impairments – vestibular, visual, proprioceptive, tactile
• Spasticity or increased muscle tone (seen in kids with cerebral palsy)
• Abdominal/hip/knee weakness
• Increased lumbar lordosis (increased spinal curve)

Treatment For Toe Walking

• Exercises to strengthen/educate weak or underused muscles, especially the tibialis anterior
• Stretching to lengthen muscles that have become tight, including muscles of the hip, knee, and ankle
• Core stabilization to increase strength of the abdominals, hips, and improve the position of the lumbar spine
• Gait training to work on proper heel strike
• Balance training
• Bracing
• Taping
• Sensory integration interventions to provide the stimulation that the child is lacking, seeking, or avoiding
• Visual motor exercises to help the eyes work together
• Education
• In severe cases, serial casting or surgery to increase tendon/muscle length

When to See a Physical Therapist

If you have concerns regarding your child’s toe walking, a physical therapist can screen or evaluate them and recommend an individualized plan of care based on the child’s needs. In general, if your child is a toe walker, you should immediately try to address it at home. Encourage them to walk with “heels down,” “flat feet,” “not on tiptoes,” or with a “heel-toe” pattern. Do not use a jumper and avoid using a walker or an exersaucer if your child cannot touch the floor with feet flat on the ground. The sooner you notice and address toe walking, the quicker it will resolve with or without intervention from a physical therapist.

 

What is a Concussion?

A concussion is a traumatic brain injury (TBI). This occurs when the brain is damaged suddenly by an external force. A TBI can result from the skull being penetrated or pierced by an object. Likewise, it could also occur when the head is forcefully struck by or hits an object. The severity of a TBI can be mild, moderate, or severe due to the damage done to the brain.⁵ In fact, approximately 1.5-2 million people in the United States sustain a TBI each year. Of these, 75% are concussions. Therefore, concussions are the most common type of TBI.¹ Concussions are often called mild traumatic brain injury (mTBI), but concussions are serious. The term “mild” refers to the severity of the original physical trauma, but it does not indicate the severity of symptoms following the injury.

Symptoms of a Concussion

A person with a mTBI may or may not lose consciousness at the time of injury, however, mTBI is characterized by one or more of the follow symptoms:

• Loss of consciousness
• Memory loss immediately prior to or following the injury
• A change in mental status (for example: confusion, agitation, fatigue, etc.), or focal neurological deficits (such as: loss of coordination, dilated pupil or pupils, dizziness, etc.)^2,5 immediately prior to or following the injury

Recovery

Recovery from an mTBI is not always quick, for example, it can be sporadic. Additionally, some people suffer long-term impairments. This is known as post-concussive syndrome (PCS). People with PCS may demonstrate significant changes in personality and deficits in cognition.²

Impairments Following a Concussion

The cognitive/communicative impairments following mTBI can include deficits in speech, language, and social communication, as well as information processing, attention, memory, and swallowing.⁶ Moreover, it is also common to have deficits in executive functioning skills, such as planning and organizing, time management, and completing tasks, in addition to, monitoring and inhibiting behavior and emotions, and prioritizing.⁶

What Can a Speech Pathologist Do To Help?

Speech Language Pathologists (SLPs) are responsible for evaluating and treating cognitive-communicative deficits of mTMI.³ Initially, the SLP will complete a formal evaluation of speech and language skills. In addition, they will assess social communication skills, and cognitive/communicative skills. Following the evaluation the SLP will develop a treatment plan and provide strategies to target individual deficits.

Firstly, according to the American Speech Language Hearing Association (ASHA), the most effective treatment plans are individualized to the patient.⁶ These plans can include behavioral approaches and skill training. In addition, they can also include process specific training, and metacognitive approaches.^4,6 Treatment plans vary depending on the severity of the symptoms and the stage of recovery the person is in. Most importantly, treatment plans always focus on increasing the person’s independent functioning in everyday life.⁴

When Should You See a Speech Pathologist?

Contact a therapist or your doctor if you are experiencing one or more of the following symptoms after sustaining a TBI.

• Difficulty producing speech sounds correctly
• Difficulty using or understanding  the intonation, fluctuations, and inflections of speech
• Experiencing aprosodia, the inability to understand or use the affective aspects  of speech
• Difficulty understanding or using spoken and/or written language
• Increased difficulty understanding the subtleties of language. For instance, using or identifying emotions, facial expressions, gestures, or body language.
• Difficulty carrying on conversations
• Inability or difficulty paying attention or staying on-task
• Decrease in memory function
• Increased information processing time or decreased information processing skills
• Lack of or decrease in executive functioning skills. For example, initiation and completion of tasks, self-regulation, sequencing, organizing, prioritizing, time management, or mental flexibility
• Difficulty eating or swallowing liquids or foods

References

1. Faul, M., Xu, L., Wald, M.M., Coronado, V.G. (2010). Traumatic Brain Injury in the United States:  Emergency Department Visits, Hospitalizations and Deaths 2002–2006. CDC.  Available at: http://www.cdc.gov/traumaticbraininjury/tbi_ed.html.
2. Overview of Traumatic Brain Injury.  CNS TBI Resource Guide.  Available at: http://www.neuroskills.com/tbi/injury.shtml.
3. Parrish, C., Roth, C., Roberts, B., Davie, G. (2009). Assessment of Cognitive-Communicative Disorders of Mild Traumatic Brain Injury Sustained in Combat. Available at: http://div2perspectives.asha.org/cgi/content/full/19/2/47.
4. Traumatic Brain Injury:  Benefits of Speech Language Pathology Services. ASHA. Available at: http://www.asha.org/public/speech/disorders/TBIslpBenefits.htm.
5. Traumatic Brain Injury Information Page. NINDS. April 2011. Available at: http://www.ninds.nih.gov/disorders/tbi/tbi.htm.
6. Treatment Efficacy Summary: Cognitive-communicative Disorders following Traumatic Brain Injury.  ASHA. Available at:  http://www.asha.org/uploadedFiles/public/TESCognitiveCommunicationDisordersFromTBI.pdf

Does my child have sensory processing disorder? Do you wonder why your child is an excessive risk taker who jumps and crashes into anything they can? Or why they can’t do puzzles, write well, or find the coordination for riding a bike or hitting a ball? Why does my child cry or cover their ears with every loud sound, such as vacuums, toilets, and/or hairdryers? How come they don’t like to be touched or can’t be touched enough?

I wonder why my child will only eat pizza and macaroni and cheese? Why do they only wear certain clothes or need you to cut the tags out of their shirts? Why won’t my child put their hands in anything messy or use glue, Play Doh, or play with mud? I wonder why my child fears playground equipment or going upside down? Why do crowded stores bother them so much that it leads to public meltdowns? Do you wonder why you can’t seem to calm them down or get them to sleep?

Sensory Processing

So, did you answer yes to any of those questions (or all of them)? If so, your child may be having difficulty processing the sensory information in his or her environment. But what does this mean? Sensory processing (previously referred to as sensory integration) is the way the nervous system receives messages from our sensory systems and turns those messages into appropriate motor and behavioral responses.

• Sensory processing is unconscious, which means it occurs without thinking.
• Sensory processing organizes the information brought by our senses.
• It gives meaning to our experiences by sifting through all of the information surrounding us and selecting what to focus on.
• Sensory processing allows us to act or respond to the situation we are experiencing in a purposeful manner.
• It forms the underlying foundation for academic learning and social success.

Sensory Processing Disorder (SPD)

SPD is an inability to process information received from our senses and generate an appropriate response. Therefore resulting in the decreased ability to respond to sensory information and behave in a meaningful and consistent way. This can make it difficult to use sensory information to plan and organize our body and make sense of the environment we function in. Sensory processing disorder can negatively impact your child in one or more of the following areas:

• Daily functioning
• Social and family relationships
• Emotional regulation
• Self-esteem, learning, and behavior

Also, children with difficulties in sensory processing may experience an inability to make friends or be part of a group, have poor academic performance, appear clumsy or have poor coordination, seem uncooperative, and appear disruptive and/or out of control.

Senses Affected by Sensory Processing Disorder

There are 7 senses that send messages to our nervous system that can be affected by SPD.

Hearing

Hearing – sensitivity to noises without a diagnosed hearing problem. Examples of sensitivity to hearing include:

• Distraction by sounds not normally noticed by others
• Running away, crying, or ear covering with loud or unexpected sounds
• Enjoys excessively loud music or TV
• Difficulty remembering/understanding what has been said
• Requires directions to be repeated often, or will say “what” frequently.

Oral

Oral – taste and texture. Examples of sensitivity to oral input include:

• Extreme food preferences
• Difficulty with sucking, chewing, or swallowing
• Refuses to lick envelopes, stamps, or stickers
• Excessive drooling past the teething stage
• Frequently chews on hair, shirt, or fingers
• Constantly puts objects in the mouth after the toddler years

Smell

Smell – Examples of sensitivity to smells include:

• Reacts negatively to or dislikes smells which do not usually bother or get noticed by others
• Has difficulty discriminating unpleasant odors
• Makes excessive use of smelling when introduced to objects, people, or places.

Vision

Vision – no diagnosed visual deficit. Examples of sensitivity to visual input include:

• Difficulty keeping eyes focused on task/activity they are working on for an appropriate amount of time
• Avoids eye contact
• Has a hard time seeing “the big picture”, focusing instead on details or patterns within the picture
• Difficulty locating items among other items: papers on a desk, clothes in a drawer, toys in a box.

Touch

Touch, or tactile sense, is input about touch, pressure, temperature, and pain. For example, kids with sensitivity to touch might experience fear, anxiousness, or even aggressiveness to light or unexpected touch, like to touch everything, or have an inability to identify what part of the body is touched when not looking at it.

Vestibular Sense

Vestibular sense is input from the inner ear about equilibrium, position changes, movement, and body position in space. For example, kids with vestibular sensitivity might dislike or avoid playground equipment, crave fast, spinning, or intense movement experiences, like swinging, frequent slumping, “W” sitting, or fatigue easily.

Proprioceptive Sense

Proprioceptive sense is input from the muscles and joints about body position, weight, pressure, stretch, movement, and changes in position in space. For example, kids with poor proprioception might have a preference for clothes to be as tight as possible, intentionally fall to the floor, or show difficulty understanding “heavy” and “light” movement.

What if you had Sensory Processing Disorder? Imagine If…

• You could see obstacles in your way, however, you could not make your body move to avoid them.
• The different smells in this room made you utterly nauseous.
• You felt like someone had given you a shot of Novocain in your backside, therefore you couldn’t tell if you were sitting in the middle of your chair and you fell off 3 times during this training.
• You tried to drink a cup of water from a paper cup, however, you couldn’t tell how hard to squeeze it to hold onto it. Therefore, you squeezed it too hard and the water spilled all over you. After that, the next time you did not squeeze it hard enough and it fell through your hands and onto the floor.
• Every time you tried to write with your pencil, you pushed too hard, consequently it broke repeatedly.

But Wait, There’s More

• You couldn’t focus your eyes on me because everything and everyone in the room catches your attention, therefore, your eyes just go there instead.
• Every time someone touches you, it feels like they are rubbing sandpaper on your skin.
• You could only sit here for 15 minutes and then you had to take a run around the building or do 20 jumping jacks so you could sit for another 10 minutes before your muscles felt like they were going to jump out of your skin.
• The tag in the back of your shirt makes you feel as uncomfortable as you would if a spider was crawling on you and you couldn’t get him off.
• You wanted to write something down but it took you at least 5 seconds to form each letter. You can see the letter in your head, but your hand will not go in the right direction to write it.
• The motion of the car makes you sick, subsequently you had to pull the car over three times on the way here.

How Can an Occupational Therapist Help?

These are just some of the ways that SPD can affect kids. As you go through these examples, you may think, “my child has a lot of these behaviors, he or she must have SPD” or “my child has some of these behaviors, but so do a lot of children.” What we are concerned with is how these behaviors and characteristics interfere with a child’s ability to function throughout the day and transition between activities. If you suspect your child might have SPD or if you have further questions, an occupational therapist can evaluate your child and assess how these behaviors are impacting his or her ability to function. An occupational therapist can provide activities to work on in the home to decrease behaviors and ideas on how to address the behaviors when they occur.

Sight is the ability to see, but vision is something much more encompassing. Visual perception is our ability to understand, interpret, and respond to the information that we “see” with our eyes. Commonly we think that if we have 20/20 eyesight then we have good vision. This is not necessarily true. There are many more skills that the eyes must be able to master in order for us to have appropriate vision. When a child has not properly developed his or her visual skills, it can manifest as difficulty in school. Consequently, kids with visual perception problems are labeled as lazy, being a slow learner, dyslexic, working below potential, immature, “at risk”, having a behavior problem, or having attention deficit disorder.

Visual Perception Skills

• Eye Tracking and Fixation: This is the ability to use fine eye movements to follow objects such as a line of print when reading and fixate on each object, letter, or word.
• Eye Focusing: The ability of the eyes to focus on objects/words close to our face for extended periods of time and jump from close to far away and close again such as looking from the board to the desk during school activities.
• Eye-Teaming: Ability of our eyes to work together to prevent double vision, visual fatigue, and poor attention.

Assumptions regarding vision can result in visual perception impairments being overlooked. These assumptions include¹:

• Parents assume their child has perfect vision if they passed a vision screen or test or if they have 20/20 vision.
• Teachers assume that if a student can see letters on the board easily then they should be able to read letters in a book for extended periods of time without difficulty.

Currently it is estimated that 1 in 4 kids have vision problems that interfere with learning.¹ Complaints may include:

• Seeing double
• Loss of place when reading
• Highlighted words are easier to read
• Words go in and out of focus on a page
• Words and letters disappear when reading so I have a to blink a lot and I lose my place

Symptoms of Poor Eye Tracking ¹

• Easily distracted/poor attention during work times
• Avoids near-point work
• Poor reading posture
• Head tilting during reading/writing
• Holds book too close to eyes
• Reading homework takes a long time
• Loses place when reading and/or uses a marker to keep place
• Moves head when reading
• Omits or re-reads words/letters/lines
• Repeats letters within words
• Reads big words, but misreads/misses small words
• Difficulty copying from chalkboard
• Avoids reading out loud or enjoys being read to but avoids self-reading
• Poor reading comprehension and/or comprehension worsens as reading continues
• Misaligns numbers in math

Symptoms of Poor Visual Perception ¹

• Letter reversal (b, d, q, p), number reversals, word reversals
• Repeatedly confuses left and right
• Grips pencil too tightly/poor grip
• Poor handwriting or writes uphill or downhill
• Deficient orientation of handwriting/drawings on the page
• Poor shape recognition or difficulty copying shapes
• Confuses similar words or fails to recognize the same words multiple times
• Difficulty with sports/poor motor skills

Social Observations ¹ 

• Difficulty with sports/poor motor skills
• Short attention span, frequent day dreaming
• Low self-esteem, poor self-image
• Temper tantrums
• Class clown or extremely shy
• Frequent crying or behaviors when tasks are hard
• Frustration or angry emotions come on quickly
• Clumsy or has difficulty with sports
• Often appears confused
• Mixed dominance or lack of hand preference
• Developmentally delayed

References

1. Remick, K.M, Stroud, C.A.,& Bedes, V. (2000). Eyes on track: A missing link to successful learning. Folsom, CA.  JF’s Publishing.

School sports are exciting events for the millions of children who are beginning or returning to a sport. Unfortunately, it also brings the potential for injuries. As many as  20% of children who participate in sports activities will be injured each year. As a parent, there are things you can do to help minimize your child’s risk of a sports injury.

Ways to Minimize Your Child’s Risk of a Sports Injury

• Choose sports that are sponsored by your child’s school, community center, or other club. This ensures supervision by qualified adults.
• Choose sports based on the skills, size, and maturity level of your child. He or she should be able to understand the rules and recognize potential risks. A child who is much smaller than his peers has a greater chance of injury playing a sport like pee-wee football versus tee ball. A child who is unable to consistently catch a ball is more likely to get hit by a ball while playing baseball or basketball.
• Choose gear that is sport specific and appropriate. Properly maintained shoes, pads, mouth guards, gender specific clothing, and protective eye wear is the first line of defense.

Make Sure You Prepare Your Child

• Practice safe. The majority of sports related injuries occur during practice. Make sure there is adequate warm-up and cool-down time. This includes activities that are low intensity and slowly increase. Ensure that your child has access to water. Also make sure he or she is rests if needed, and wears sunscreen outside.
• Prepare your child. Make sure he or she is healthy, in shape, flexible, and strong. Encourage your child to play outdoors, on playgrounds, and with friends. Practice sports skills with your child before he or she starts playing. Relay races, throwing, catching, dribbling, shooting baskets, and obstacle courses can improve coordination, speed, and reaction time. These skills are essential  to  success. Activities like hula hooping and jumping rope can improve strength, coordination, and endurance. Try yoga that is specifically for kids to improve flexibility.
• Finally, if your child does sustain an injury, proper medical attention and rehabilitation can decrease the risk of recurring injuries or development of a chronic condition. A physical therapist can develop a program specific to your child’s needs.

For additional information about how to minimize your child’s risk of a sports injury, check out our article on how to Prevent ACL Injuries in Female Athletes.