Blog, Chirosecure Live Event December 19, 2020

Tips for Tiptoers – Dr Monika Buerger

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Now here’s today’s host Dr. Monica Buerger. Hello,

Welcome to our December. Um, ChiroSecure Look to the Children’s show. We are going to have some fun today. We’re going to keep you on your toes as we talk about Tiptoes. So why did I choose this subject? Um, first of all, let me backtrack. Thank you, ChiroSecure once again for giving us this amazing platform and opportunity to share with the world, um, the importance of chiropractic pediatric, uh, for kids and, um, to help other docs out there, um, gain some extra pearls of wisdom during this time. So tiptoes, why did I choose this subject? Because I get a lot of questions on, what does it mean? Why are they still tiptoeing? What do I do? Um, all that and more so let’s dive in and let’s have some fun and talk about it. So again, I want to thank ChiroSecure for, um, always being there for the chiropractic profession, excuse me, my froggy throat.

So tip toes, we tend to see this in little kiddos. Um, and if I slip into my endearing little, um, version of my little fiddle farts, I, I use that as an endearing expression for these kiddos that we work with. So, um, my apologies, if I slip into that, um, we tend to see tiptoes common up until about the age of two, and that is considered, um, fairly normal. But if we see this consistently and beyond that age, what might we need to want to look at what possible differential diagnosis is? What associations? So let’s dig into that a little bit. First. Certainly we want to look at muscle tone, either low tone or hyper tone, and we want to, um, rule out cerebral palsy or multiple dystrophy. So those are two top things you may want to consult. Um, outside of the chiropractic profession, have the pediatrician take a look, et cetera.

So those are two things on the top of the list that you want to make sure that isn’t involved. But what we didn’t know about neuro-development is when we have a hijacked trajectory of development, so to speak that this is one of the possible competence Atari gate mechanisms that we might see with little fiddle parts is a tip toe or altered gait pattern. So autism and ADHD happened to be on the top of that list and alter gait patterns of which one is tiptoeing can be associated with both of those labels. Um, sensory, definitely sensory processing disorder. So that’s SPD sensory processing disorder or processing dysregulation. And we’re going to see how all these kind of tend to tie together actually. So within the sensory processing world, three particular sensory systems have been associated with altered gait patterns. Tiptoe is one of them. The other gait patterns are, would be like a wide based waddle or wide based stance.

And the reason that we might see these altered gait patterns in those with processing disorders is because they’re trying to upregulate sensory input into their world so that they know where they are in space and they can modulator move about safely through space. So the three big systems within that sensory processing realm are vestibular. Um, the, the ability to maintain ourselves upright against gravity and know where we are in space proprioceptive, which we’re going to get that input from our joints and muscle spindles. Um, and actually you get some proprioceptive input from the vestibular labyrinth time and visual. So those are three big sensory systems that three big kahunas that all work together. Um, and they, they are really responsible for us being able to modulator ourselves upright against gravity and have good postural control, postural stability. So if we don’t have that, we will innately, or that the child person, child little foot apart, we’ll try to upregulate that to their CNS.

And by being on their toes, they get more bounce of the world and, and, um, more input coming up, particularly vestibular and proprioceptive. Um, so you’ll see them have that little bit more bounce in their step. Kind of like trying to be Tigger. If we look at our Winnie the Pooh characters. So, um, sensory modulation can be a reason that they are on their toes. Now, likewise, they might be, um, hyper tactile. They don’t like a lot of tactile input, so they might be up on their toes in certain environmental situations. And we’re going to talk about some history and some questions we want to ask parents, um, on the timing and the consistency of this altered gait pattern, but we’ll get there.

Um, neurogenic bladder bowel, and the world of neurology have been tied with altered gait patterns like tiptoe tiptoe in particular. So we want to look at their, um, bladder and bowel control. And in the autism world, gut dysbiosis has been associated with many neuro expressive patterns. One of them is tiptoe. So we want to look at gut dysbiosis. So if we start with, we start other than CP and MD, if we start looking at these next, um, considerations, they all kind of tie together. Okay. Because we know in the world of autism ADHD, um, we can throw in here developmental coordination disorder, a lot of labels, actually, they are often associated with processing disorders. They’re going to have, they are going to have some form, some extent of processing disorders. Those three systems are big key systems, the vestibular visual proprioceptive in regulation that we see dysregulated in this population groups.

Then we often see bladder bowel and dysbiosis issues with these population groups. So you see how I’m just kind of taking you through a journey of looking at the big picture, all those things that might be involved. It’s really not as simple as saying they tip toe because of one thing, it’s usually a systems wide approach. And that’s what I’m trying to walk you through. So in the world of autism, um, tiptoe walking is often associated with gut dysbiosis. Um, and it can lean a little bit more towards reflux because they’re trying to, um, in fact, there is a maneuver that many talk teach to adults about reflux and in the morning, first thing in the morning is drink some water and then kind of bounce on your toes, kind of jump up and down and bounce on your toes to try to pull that. Um, if you especially like have like a hiatal hernia or something, so think gut dysbiosis, but lean towards the side of maybe reflux and GERD issues. So now if we take that next thing in line, when we talk about primitive reflexes, a couple of primitive reflexes in particular have been associated with tiptoe.

And if we look again, if we take you through the journey, say, okay, with developmental considerations, they, these individuals, these little fiddle farts in the autism or ADHD or development or coordination, any label we want to get them oftentimes have processing issues about issues and retain primitive reflexes. A couple in particular, you want to look at, um, tonic. Labyrinthine is one of them that is associated with tiptoe walking. Now, the tonic labyrinthine is kind of considered a, um, a, a dural tube or cranial sacral rhythm associated with cranial sacral rhythm abnormalities. So for us in the chiropractic world, we definitely want to look at, um, the upper cervical, especially the occiput and the sacral areas and looking at neural tube tension and, and addressing, um, not just with adjustments, but maybe some cranial sacral therapy as well, trying to get that dural tube, the tension off the dural tube, the tonic labyrinthine reflex is one of those associated with the craniosacral rhythm as is the symmetrical tonic neck reflex or the STNR.

Um, so I just want you to keep a couple of those things in mind. You also might find it ASA occiput with these kiddos. Um, and when they’re have the ASA occiput and their eyes are looking above the horizon for brain compatibility, for us to be able to process our world and be in sync with our world, all these sensory systems are imperative. Um, and that visual system is, is key. And we want to have our eyes on the horizon. Our eyes want to be parallel to the horizon if we have an occiput, or if we have dural trench in causing that ASR occiput, our eyes are going to be, um, we might have what we call midline shift superior midline shift. Our vision is our eyes are paid attention to above the horizon. And so we want to, we’re not sure where we are in space.

They might not be sure where they are in space or having to navigate through space because of that visual security. And so you might see the tip toe from a biomechanical reason, as well as a visual compensatory reason or processing compensatory reason. So keep that in mind as well. So look at the occiput in particular, the moral reflex can play a role in tip towers because Mara reflex it. Um, Maura is associated with a hyper defensive sensory mode, and when we’re on sensory defensive mode, that is going to shift us to a sympathetic dominant state and, um, keep our cortisol kicking, keep those adrenals pork butt cranking. And when that happens, we might not, we might have trouble with, um, the onboarding, the development, um, of pastoral reflexes and one called the tendon guard reflex. Essentially what happens is the postage courier muscles, especially the posterior leg muscles, um, contract because of all this cortisol kick.

And so that’s, we’re getting shortening of the posterior calf muscles and Achilles tendon. And so they really can’t elongate those ones. This is where this is one thing we have to be mindful of this whole picture, because so many of these kiddos can get scheduled for an Achilles tendon release, which is a huge major sure. Or ordeal, and that may or may not mitigate the problem, but the core, the roots of the problem it’d be a systemic wide approach. So, um, that’s another reason why I wanted to bring you this information. And then the Ben scheme, you do want to look at a retain Babinski, but Bensky, it can be, can be active, um, through the first couple of years of life. And that’s, that’s why maybe toe walking can be seen for the first couple of years of life. The bisky gets integrated by, um, it’s helped to get integrated by a, um, the belly crawling by belly crawling.

And I call it the toe dig when we’re learning to belly crawl, you take, as you’re pushing off on that, back on the, on the leg, that’s propelling you forward that toe digs into the ground. That’s I call it a toe dig and that helps to integrate that, but Minsky reflex. So if they skip belly crawling, um, that can be a factor as well. So keep that in mind. So if you see a little fiddle fart, that’s not going through their motor milestones, um, they’re not rolling. They’re not tummy time rolling. And then belly crawling and doing that toe, dig propelling off their toe, pushing forward. You know, that’s the thing that you want to try to help, um, navigate and employ that they’re doing that. But later on, they may present with this, um, compensatory gait mechanism of toe walking tots, tethered oral tissues, tongue tie.

Again, this is such a complex issue. It’s much more than breastfeeding and speech. So way beyond that, the tongue is considered the, um, Rutter of the city. Okay. It says it’s a tethered restriction, it’s a fascia restriction. And if we have this restriction, it can, it can go from cranium to toes and it can constantly be this anchor pulling us down and it can cause neural tube tension. So we’re right back down to dural tube tension. Um, so you might see a compensatory mechanism and, and by the way, with tots, it’s very much associated with various learning and neurodevelopmental struggles. Um, and with that dysbiosis, neurogenic bladder and bowel and retained primitive reflexes. So once again, you kind of see the whole global picture that we’re talking about here. And definitely we want to look at subluxations again, look at those, look at the cranial sacral regions in particular and that creating neural tube and, um, that ASMR occiput. Okay. Hang on a second. I just have a question here.


And absolutely they can be locked in a flection type pattern because the brain, because of dysregulation of, uh, circuitry due to poor processing problems, they can’t, the brain might not be able to inhibit those Fletcher, the flexor muscles. And so they’re locked down. Um, the vestibular systems big in this whole role-play and the vestibular system is going to activate your extensor muscles. So this is a great question because they can be locked down in a flexor based position because, um, of distortion of sensory input, especially the stipular sensory input that they can’t get there, that they don’t go to the extensive patterns. So it is a very systems wide approach. So thank you for that question. Hopefully I answered that question, um, to your liking. Okay. So we want to look at history because we want to look at the whole picture here. So we’ll go back to that question on step into flux, into flexor pattern.

Tommy, time’s a big issue here. Not only do we want to see Bailey climb, but oftentimes the precursor to that is going to be our tummy time. And if they don’t like tummy time, they might not go to these progressive milestone patterns and thus belly crawling, tell me, time is going to help us, um, activate those extensor muscles and that mystical division. And oftentimes we see kiddos that have labels autism, ADHD in particular. They didn’t like tummy time kiddos with tots, with tether or restrictions. Um, oftentimes don’t like tummy time. Lack of getting through these milestones will pro um, prevent these primitive reflexes from integrating. So again, look at the systems wide approach. Oftentimes those little fiddle parts that don’t like tummy time also have gut dysbiosis reflex is a big one. Okay. So hopefully this shows you that systems wide approach.

So we want to dig into deep history, lots of times with these little kiddo kiddos, our observation and our detailed history is going to give us a lot of the red flags and give us a pathway in which to dive into first. So we do want to look at, um, gestation, what was mom’s stress, stress level right now, this is a big one. Um, and we’ve talked about, we’ve talked, um, I can’t remember which month we did it, but we did talk about prenatal stress. So you can go back and scroll through either, um, our intersect for like educational seminars, Facebook page, or Cairo Securus, Facebook page, and look back a few months when we talked about prenatal stress. Cause this is a huge one. So we want to look at gestation. We want to look at mom’s stress level. Did she have trouble conceiving? Did she need help conceiving, um, what was that birth experience? What was the mechanism of birth? Was it C-section, were there assisted devices such as forceps or section cup assisted devices are associated with things like plagiocephaly and torticollis, which if we add that into the mix and the history, we can see, we can see why there might be a number of these previous associated, um, issues, because we know that with those types of birth experiences and with those assistive devices, there’s a predisposition to pleasure separately and toward a call us and thus developmental considerations.

Um, we know that prenatal stress is associated with dysmaturation of the autonomic nervous system, which is going to go play right into the role of that question of, is there maybe dysregulation in the brain? Can the brain not turn off those flexors because of poor processing and poor neural circuitry? So we know that prenatal stress is, is definitely an issue here. So we want that good history. What is mom’s current stress level? That’s a big one as well, where they, um, preterm. We know that preterm, we know that prenatal stress is also not just associated with dysmaturation of the nervous system, but, um, um, neuromuscular development. So there might be competence, compensatory mechanisms there. What were there, depending on the age of the little fiddle fart. I mean, if they’re coming into you at age five, eight, whatever, and they’re still having this tip toe pattern, what were their early developmental years like?

Did they like tummy time? Did they roll in a corkscrew fashion at the appropriate times? Did they, um, did they belly crawl? Did they creep on all fours? Did they have an injury? Did they fall off a change, a table down the stairs, all those things we need to look at early development and then a past medical history and family history in the ADH literature, they look at idiopathic toe walking. They don’t, there’s no known reason for this toe walking pattern, but they do see it with ADHD that if a family, a family member, um, especially the dad, excuse me, had a history of idiopathic toe walking, excuse me. Um, the little, the little foot apart, the offspring may also have a history of idiopathic idiopathic toe walking. But what we have to take into consideration is oftentimes our ancestors, the way they process their world and respond to the stress in their world gets hammy, doubted it, it goes, it actually kind of, it follows the DNA pattern.

So those stress responses follow, uh, we call it inter intergenerational inheritance. So it would stand to reason that if we have a family history of ADHD and toe walking, that the offspring is inheriting their parents load and the response to their processing, the way they process their environment and their stress mechanisms. So that would could potentially to this altered gait pattern as well. So we want to dive in and get a good history. Um, at what age of the toe walking begin, has it been there from when they started to learn how to walk it, did it, um, all of a sudden become an issue? Is it both feet want to get into that, into that gait pattern? Was there an injury? Was there a tipping point? No pun intended. I didn’t, I just did that one in there. Was there a tipping point of Tictail? Um, do they get an infectious load? Did they, um, have an accident? Was there a time point that, that, that, that pattern started? Is it variability of toe walking on certain surfaces only under stressful conditions, only when they’re more tired when they, um, are sick. Is there a pattern to this? Again, if they’re on different surfaces, like grass or sand, they may have a hypersensitivity to tactile input. And so it’s just, it’s not a biomechanical issue. It’s a compensatory issue to that particular environment. So they may be hyper sensory in that tactile system.

Is it going on uneven surfaces up and down stairs where they might have a display of what we call gravitational insecurity, not being self-aware and comfortable in those environmental conditions that may tip you off. I’ve got another, I’m just, I’m just full of them today. Um, that may tip you off that this tip toeing is compensatory to particularly gravitational measurements because of lack of distibular integration processing. So we want to, you know, we want to dig in a little bit, um, how much time are they spending on the tiptoeing? Uh, are they able to get into a flat position? And sometimes that may be when they’re more comfortable, calm environment. Okay. So again, look at these patterns. Are there any associations of, uh, pain? Okay. Is it maybe a biomechanical issue, um, that is resulting in this walking pattern?

So on your examination, we definitely look at muscle tone, hyper or hypo. You want to not only asking your history, but the observe this little fiddle fart, or depending what age are coming in. Do they have language delays? Do they have speech delays? So this is, this is important for a couple of reasons. Are, are, if you have the, uh, are, are they, um, have they been in speech therapy a lot, are kids with tongue ties, oftentimes have ongoing language delays and speech delays. We also know that speech delays are very much associated with, um, poor, fine motor development.

So is this altered gait pattern dune due to number three on here, fine and gross motor delays, which is also associated with poor link with language delays. So you want to look at tethered oral tissue. You want to look at muscle tone. You want to look, what is their fine and gross motor skills, observe them in your office, have them do various finding most finding gross motor tasks. Can they do sequential finger touching? Do they have the pencil grip that should be there by one year of age? Um, what is their gross core control? Can they balance on one leg? And they tandem walk some very simple screening procedures. Can they hold their core stability on a unstable surface? Um, like a, um, a balance pad or something, get a sense of what their finding gross motor skills are. Visual tracking is going to be give you a sense of their fine motor control.

Um, so these are some things we can tie together into the whole picture. Again, again, we want to look at processing dysregulation. You may want to screen for your primitive and postural reflexes. Again, those reflexes in particular that we want to look at, if they’re integrated would be more on tannic labyrinth by and the Bensky depending on the age of the child coming into, have they developed their postural reflexes, posture, reflexes don’t fully develop, um, until that age three or three and a half, but those would be the Oculus head writing when you lean them in one direction, do they does their head right to the midline? Because again, our eyes want to be on the horizontal on horizon. So when we put them in these positions, do their eyes, do their, their eyes compensate right to the midline. Um, do they not, do they have good postural control?

Do they have a tongue tie? Here’s a little caveat. Sometimes it’s hard to, if you’re not, especially if you’re not well versed or are used to that, please be mindful that if you’re in a state where you cannot enter the oral surface or a cavity, keep that in mind. Um, but here’s a general rule of thumb. It’s easy to find a lip tie, just having them lift their lip up and see if they have a lip tie. They’ll have a tongue tie. And so often if you’re not seeing that tongue type, um, visually it’s because it’s a posterior tie and it’s hard to distinguish. So look at the lip tie. Do they have a lip tie that’ll kind of tip you off that, um, look at the range of motion, of course, spine and pelvis. One thing I want you to also think about in your cranial work is look at the speed annoyed as well because the speed annoyed, um, represents, uh, it’s counterpart is the pelvis. So addressing, um, the Spino and can be huge in this cranial sacral rhythm and this dural tube tension. It’s also going to very much help you with, um, the visual system. You’ll find that kiddos with visual processing and especially fine motor visual scanning. If you work that sphenoid, you can get a lot of bang for your buck out of that. So you want to look at the range of motion and hips, knees, ankles the spine.


I’ll get this question just in a minute here. Um, and spine and pelvis leg, leg, discrepancies, foot deformities, et cetera. So I have a question here. Um,


Are there any challenges you can do to better, um, insight into treatments?

Um, let me try to, I don’t have my glasses on here. So, um,

I would say I’m thinking the question is any challenges, any tests

We can look at? Um, okay.

So, um, with regard to Babinski in particular or anything in particular,


In particular. Okay. So let’s look at, um, let’s look at tonic labyrinthine reflex, tonic, labyrinthine reflex. We’ll go through a few of the reflexes. Tonic labyrinthine reflex is a flection extension reflex of the head. So with you can either have them stand with their feet together and have them close their eyes,

Look down,

Have them hold for 10 seconds and then keep their eyes closed and look up. So you go into flection extension, you can see how well they can hold their core postural control. You can, um, see whether they dig their toes into the, they do this barefoot idealistically. If they dig their toes into the ground to try to maintain their core stability, do they sway? Do they sweat ADP? Do they sway laterally? This gives you an idea of how the integrity, if that tonic labyrinthine reflex is still too active, the other way, if they can’t do that, um, one of the exercises we will do for the little kiddos, the younger population is I call them, um, the, the bird nest and the flying bird. So the bird nest would have be have them supine rolling up and grabbing their knees and wholly with their head flexed and holding that position, rolling up into a ball.

Essentially, I call that the bird nest, um, and hold for 10 to 20 seconds. See if they can hold that position, then flip them over, um, prone and kind of do a modified Superman. I have them put their hands on their shoulders. So these are the bird wings, their feet, their legs are zipped together, they’re together. Um, and so they hold their legs together. There’s zipped together, arms are appear, and they come up into an extension position Superman. So you can use that as another test to test the integrity of the tonic lab and find can they do those? So flying like a bird arms on shoulders, feet zipped together, come up into extension. Can they hold that for 10 to 20 seconds? And then supine, they roll into the ball into the bird’s nest. Now I also do that as an exercise. Okay. So if they have a, I might do the tonic labyrinthine test standing, okay.

Eyes closed. Like we talked about flection extension. They don’t do that. Well, then I have them do the flying bird and the bird nest as an exercise to help integrate that tonic lab with line. The other thing you want to check is you want to check, um, the integrity that the, the, um, other gas drops and the soil is how tight they are. So do a straight leg raise and Dorsey, flex their foot to see if they can, if, how tight they are. Um, so you might also have them doing stretching, have parents do stretching or the kiddo do stretching themselves and try to elongate, um, the gastroc and soleus and stretch those out a little bit. Um, for Morrow, again, we want to look at moral reflex. You can do that standing and do that trust fall gate and see if they have a retain Morrow.

The closer a primitive reflex mimics the infant tile reflux. So the closer that they have that display of impetus more reflects the more engaged it is, the more active it’s staying more cortisol’s kicking out. So if that’s positive, I’m going to look at a couple, again, depending on the age, I am going to look a couple, maybe nutritional Def deficiencies that keep us hypertonic iron zinc, magnesium big ones. And because when they had, when you were on this Morrow kick and in sympathetic shift, we burned through these nutrients faster. So check those out as well. And if they have a positive Morrow, I may have them be, um, doing the, um, I call them and Venus fly traps. I think I’ve heard them also called starfish exercises where they cross the same arm and same foot. So if my right arm’s on top, my right foot would be on top and roll up into a ball and then unroll and uncross.

So that can be good for the Morrow. Um, uh, definitely you can strike the Hill, look at Babinski if they’re older than two, two and a half, um, and to mitigate Babinski, you can do that same kind of brushing. The other thing you can do, I’m going to do this using my hand, cause I can not, I’m not flexible to tip my toes up to the screens to show you what my toes, but if these are my toes, you can put one foot, one finger underneath and have the toes curled over kind of toes latched on here and try to have them keep their toes flexed while you put resistance against them. So that’s another way you can help mitigate Babinski. Okay. Um, does that help with that question? Let me know. So those are some things we can check. Those are things we can do to help mitigate.

If they’re, if they’re there again, you’re going to check your spine, your pelvis, check your speed annoyed, cause that spheroid will mimic the pelvic, um, the, the pelvic alignment. So that’s why craniosacral work is, can be so important. I would check also, um, look at doing, because of that mustard division’s off. I would also look at doing maybe ear poles and seeing if, um, add that with the speed annoyed. And then of course the palate, the hard and soft palate, especially heads, they have tethered oral tissues. Those are going to be really, really important there. Okay. So those are some things I’d like you to look at on examination. And I think we’ve covered any more questions that I’ve got out there. Please bring them on a, wait a second or two. Nope, no more questions. Okay. Well hopefully you enjoy this information. Hopefully it helps you again, looking at the big picture from a neurological standpoint, from a neuro developmental standpoint and from a neuro nutritional standpoint, big things that are deficient in the prenatal period, um, are going to also affect neuro development.

And again, magnesium zinc iron are really, and, uh, chronic muscle contracture, um, and Coleen Coleen is a fun one. Coleen deficiency in a prenatal period is said to, um, is known to disrupt sensory processing development processing, especially processing speed. About 70% of mamas are said to be low on Choline, and this will translate into the neuro-development of the offspring. And, um, so that’s a big one to look at, look at as well as calling you get Coleen from egg yolks and it is essential for a cell wall, membrane, integrity and synthesis. So that’s another big one. That’s a hand-me down during the prenatal period that I would look at, um, possibly as an issue as well. So I’m going to wrap it up and leave it there. And I want to wish all of you an incredible holiday season and thank you again, Kyra secure for, um, always being there and having our backs and those of you out there enjoy may you have a lot of peace and some downtime, some time to regenerate and rejuvenate and, um, take on 2021, like, uh, in a totally different way than we’ve taken on 2020, hopefully.

So until next year I will see you in the new year. So Merry Christmas, happy Hanukkah, happy Kwanza, happy new year, um, and may peace and many blessings be your way. I’ll see you in January the third, Thursday in January and Dr. Erik Kowalke will see the first, the first Thursday in January and, um, blessings to all of you, we’ll see you then

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