Marcha na ponta dos pés idiopática: desenvolvimento de vídeo educativo e protocolo das trocas gessadas na prevenção nas alteraçōes musculoesqueléticas

Abstract

Introduction: Idiopathic toe walking (ITW) is a term that includes an abnormal gait pattern in which the child walks by unloading weight bearing on the front of the feet, skipping or decreasing the initial stance phase of heel strike on the ground. When associated with restricted ankle range of motion, it is characterized as “congenital contracture of the Achilles tendon”, walking on toes is part of normal development, and can occur up to two to three years of age and should resolve spontaneously. When it persists for more than five years, it must be investigated. Most individuals are healthy children; structural or neuromuscular pathological conditions may be associated and may be an early identifier of some other etiology. It is a diagnosis of exclusion, with no signs of a neurological, orthopedic, or psychological condition. Intervention for this situation should be performed to improve the restriction in ankle range of motion (ROM). There are few references in the world literature on natural history and the best time for intervention. Better understanding this condition will help in understanding the natural history, allowing the identification of variables that may associate the equinus structure of the ankle or spontaneous remission. This way, we can create educational videos to instruct families when it is necessary to seek treatment, preventing physical deformities and psychosocial changes in the individual in childhood, adolescence and adulthood. Objective: Describe the natural evolution of ITW, plaster replacement protocol and its effectiveness in preventing musculoskeletal changes in adults. Develop an educational video and scientific articles with results and treatment protocols found in the study. Method: Prospective analysis of medical records of 10.119 individuals treated over 12 years, at the pediatric orthopedics outpatient clinic from Sarah Rehabilitation Hospitals Network, Brasília - DF, Brazil. 367 individuals were included, with at least one gait analysis in the movement laboratory, aged between 4 and 18 years old with ITW pattern, with clinical and laboratory examinations within normal limits. Those with changes in the neurological examination or complementary tests were excluded: laboratory; neurophysiological; and imaging, or with other diagnoses. The three-dimensional gait kinematics movement analysis technique was performed in a standard way, using the VICON VANTAGE system. The clinical evolution of 367 individuals divided into three groups was studied, by the following ages, 4 to 6 years, 7 and 8 years and over 9 years and compared with each other, analyzing their characteristics in the different age groups, called the control group. 101 had gait analyzes at two moments and were classified into two groups: Control group - they were kept under observation, without intervention. Plaster group - underwent intervention with serial plaster changes (service protocol). Results: 543 had ITW, with a prevalence of 5%, admitted with an average age of 6.6 years, 63% were male, 494 (91%) from Distrito Federal. Analysis of clinical evolution was carried out in 367 individuals (mean follow-up of 3.1 years, SD = 2.8 years). Assessment by age group, individuals over 9 years of age showed evolutionary improvement in gait and physical examination variables with reduced plantar flexion (maximum, medium, and minimum) and increased GDI, when compared to individuals aged between 4 to 6 years. 101 underwent evaluations after follow-up or after intervention with serial plaster changes. An increase in GDI of around 10% and an approximate reduction of 10° in mean, maximum and minimum plantar flexion to the median were quantified, with an average follow-up of 1.5 years (SD = 1.4) demonstrating the effect of plaster casts on reduction of the structuring of ankle plantar flexion. The chance of spontaneous improvement is 0.21 and with plaster replacements it increases by a factor of 3.67. Developed Products: Three products were developed: animated and ducational video, with the purpose of educating and raising awareness about ITW. Protocol for treatment with serial plaster changes proved to be safe and effective. Scientific article demonstrating the results of treatment with serial plaster changes. Conclusion: The importance of studying ITW, to better understand its evolution, is fundamental to understanding its natural evolution and knowing when to intervene to minimize the impact of emotional problems and possible orthopedic changes. The evaluation by age group in individuals over 9 years of age showed evolutionary improvement in gait and physical examination variables with reduction in plantar flexion, when compared to those aged between 4 and 6 years. For the first time, it was found that ITW treatment led to a 3.67 times greater change or normalization of gait compared to the control group (without intervention) and with no complication reports. Plaster exchanges can be indicated as an accelerator of spontaneous evolution, managing to correct the plantar flexion structure, or postponing a surgical procedure, if necessary, in cases that do not evolve with spontaneous evolution.