View source for Early Development of Toddler Walking and Other Locomotor Tasks

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== Introduction to Toddler Gait ==
Toddlerhood is an amazing time of rapid skill development, and independent ambulation<ref name=":0">Liu W, Mei Q, Yu P, Gao Z, Hu Q, Fekete G, et al. [https://www.mdpi.com/2227-9067/9/3/406 Biomechanical Characteristics of the Typically Developing Toddler Gait: A Narrative Review]. Children (Basel, Switzerland). 2022;9(3):406.</ref> is one of the most important and exciting milestones for children and their care providers.  

Children are typically considered to be infants when they are aged less than or equal to 12 months and toddlers when they are aged between 13 and 36 months.<ref>Islam, G.M.R. [https://www.sciencedirect.com/science/article/pii/S221210991930617X Association of socioeconomic status with childhood anemia among infant, toddler, and preschool children in bangladesh]. Value Health Reg. Issues 2020;21:141-8.</ref> Skilled clinical examination and knowledge of locomotor milestones are the most common methods to identify potential motor impairments in toddlers. The initiation of independent gait is generally considered to begin around 12 months of age. However, Liu et al.<ref name=":0" /> note that approximately 10% of typically developing toddlers may not achieve independent walking until 14.4 months or later. Furthermore, a 2006 study by the World Health Organization reported that independent ambulation (without support) could occur between 8 and 18 months of age.<ref>Martorell R. de Onis M. Martines J. Black M. Onyango A. Dewey K. WHO Motor Development Study: Windows of achievement for six gross motor development milestones WHO MULTICENTRE GROWTH REFERENCE STUDY GROUP1,2 1. Acta Pediatrica. 2006. Suppl 450:86-95.</ref>

Please read this article if you would like to learn more about [[Gait Development in the Growing Child|gait development in children]].

== Understanding Toddler Gait Development ==
<blockquote>Liu et al. define gait as “a movement pattern of limbs, especially lower limbs on a substrate, which can fulfill the primary need of locomotion and provide propulsion and support for the body.”<ref name=":0" /></blockquote>Toddler gait development occurs during a time of rapid skill development where the child is undergoing many dynamic and ongoing physical and mental changes. These can include (1) the rapid growth and development of the neuromuscular and sensory systems, (2) the ossification of bones, and (3) the appearance of foot arch structure. In addition, toddler gait can also be influenced by age, body dimensions (including the muscle-fat ratio), maturation of the central nervous system, and head-trunk postural stability.<ref name=":0" />

=== Development of Walking Skills ===
Toddlers must first [[Learning To Stand - Development and Training|learn to stand]] independently before taking their first steps, often beginning by standing with hand support and gradually transitioning to standing without assistance.

Initial steps are characterised by (1) a wide base of support, (2) short stride length, (3) high stepping gait pattern, and (4) foot strike with a flat foot or forefoot, and arms held in high guard position (shoulders in abduction and elbows flexed)

With practice and exposure, the toddler gait pattern begins to resemble the more mature pattern seen in young children. These changes include:

* decrease in the base of support
* decrease in the time spent in double limb support during the gait cycle
* increase in step (stride) length and cadence 
* heel strike starts to emerge around the age of two years
* arm swing emerges

=== Propulsive Forces in Toddler Gait ===

* Research by Bril et al.<ref name=":1">Bril B, Dupuy L, Dietrich G, Corbetta D. [https://www.researchgate.net/profile/Gilles-Dietrich/publication/280911335_Learning_to_tune_the_antero-posterior_propulsive_forces_during_walking_a_necessary_skill_for_mastering_upright_locomotion_in_toddlers/links/561deca408ae50795afd85f2/Learning-to-tune-the-antero-posterior-propulsive-forces-during-walking-a-necessary-skill-for-mastering-upright-locomotion-in-toddlers.pdf Learning to tune the antero-posterior propulsive forces during walking: a necessary skill for mastering upright locomotion in toddlers]. Experimental Brain Research. 2015 Oct;233:2903-12.</ref> investigated the anteroposterior forces generated during toddler walking, emphasising the need to control propulsive forces by adjusting the distance between the centre of mass (CoM) and the centre of pressure (CoP).
* Todders' walking patterns and propelling forces were measured, showing a rapid increase in CoM-CoP distance with increasing velocity during the early walking phases.<ref name=":1" />

=== Learning to Navigate Different Terrains ===
Toddlers observe and adapt to navigating steps and various terrains. This requires experience and occasional falls as they learn to negotiate stairs / steps and other obstacles of various heights.
* Adolph et al. highlight the natural practice regimen of toddlers, which involves variable and time-distributed practice.<ref>Adolph KE, Cole WG, Komati M, Garciaguirre JS, Badaly D, Lingeman JM, Chan GL, Sotsky RB. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3591461/ How do you learn to walk? Thousands of steps and dozens of falls per day]. Psychological science. 2012 Nov;23(11):1387-94.</ref>
** This study reveals that toddlers engage in variable practice, taking short bursts of steps followed by resting periods, exploring diverse movements, surfaces, and directions during locomotion.
** This variability in practice helps toddlers develop a perceptual-motor system that is adept at change, allowing them to adapt and learn how to walk in ever-changing environments.
** '''Time-distributed practice''' is more effective than massed practice because intermittent rest periods allow learning to be consolidated, relieve fatigue, and renew motivation.
** '''Variable practice''' leads to greater flexibility and broader transfer than blocked practice because executing a variety of movements in various contexts helps learners to identify the relevant aspects of the environment that need attention.

=== Fundamental Locomotor Skill Development ===
In addition to learning to ambulate over different terrains, toddlers learn a range of fundamental locomotor skills that allow them to negotiate different obstacles they encounter. These skills can include (1) negotiating different terrain textures (slippery surfaces or rough ground), (2) negotiating grades or slopes and stairs, (3) stepping up and over obstacles, (4) running,<ref>Bach MM, Zandvoort CS, Cappellini G, Ivanenko Y, Lacquaniti F, Daffertshofer A, Dominici N. [https://www.frontiersin.org/articles/10.3389/fnhum.2023.1101432/full Development of running is not related to time since onset of independent walking, a longitudinal case study]. Frontiers in Human Neuroscience. 2023 Feb 16;17:1101432.</ref> (5) quick stops and directional changes, (6) jumping, and (7) carrying and manoeuvring large or heavy objects.<ref>Cole WG, Adolph KE. Learning to move in a changing body in a changing world. Integrative and Comparative Biology. 2023 Sep;63(3):653-63.</ref><ref>Elodie H, Barbu-Roth M, Manh-Cuong D, Bastien B, Caroline T. Generating variability from motor primitives during infant locomotor development. eLife. 2023;12.</ref> 

== Rehabilitation Considerations for Non-ambulatory Children ==
[[File:Supported stepping device CP shutterstock 95429680.jpg|thumb|306x306px]]
The use of [[standers]] and over-ground [[walkers]] is beneficial for non-ambulatory children with cerebral palsy, providing opportunities for standing and promoting mobility.<ref>McLean LJ, Paleg GS, Livingstone RW. Supported‐standing interventions for children and young adults with non‐ambulant cerebral palsy: A scoping review. Developmental Medicine & Child Neurology. 2023 Jun;65(6):754-72.</ref> 

* '''Supported-standing interventions''' are recommended, starting from as early as 9 to 12 months for children with higher [[Gross Motor Function Classification System - Expanded and Revised (GMFCS-ER)|Gross Motor Function Classification System (GMFCS)]] levels to enhance function and reduce sedentary behaviour. 
* '''Over-ground supported stepping devices''' aid in active movement, emotional development, and communication. However, adequate support and safety measures are necessary, with contraindications including pain and flexor withdrawal during weight-bearing.<ref>Livingstone RW, Paleg GS. [https://www.mdpi.com/2673-7272/3/2/12 Use of overground supported-stepping devices for non-ambulant children, adolescents, and adults with cerebral palsy: A scoping review]. Disabilities. 2023 Mar 28;3(2):165-95.</ref>

=== Influence of Muscle Hypotonia and Joint Hypermobility ===
Muscle hypotonia and joint hypermobility, which are common in developmental motor disorders, can impact ankle stability and standing. Assessment for tibial torsion is crucial for understanding lower limb alignment issues.<ref>Van Aswegen M, Czyż SH, Moss SJ. [https://www.mdpi.com/1660-4601/17/9/3245 The Profile and Development of the Lower limb in Setswana-speaking children between the ages of 2 and 9 years.] International Journal of Environmental Research and Public Health. 2020 May;17(9):3245.</ref> 

* The use of orthotics, such as '''supra malleolar orthotics''' (SMOS), is recommended for stabilising foot position, but the balance between orthotic use and barefoot exploration for sensory experiences is essential. Evidence supports the effectiveness of orthoses in improving function, stability, and independence in children with hypotonia and joint hypermobility.<ref>Weber A, Martin K. [https://www.researchgate.net/profile/Kathy-Martin-3/publication/259394561_Efficacy_of_Orthoses_for_Children_With_Hypotonia_A_Systematic_Review/links/5a62588c4585158bca4c536f/Efficacy-of-Orthoses-for-Children-With-Hypotonia-A-Systematic-Review.pdf Efficacy of orthoses for children with hypotonia: a systematic review]. Pediatric Physical Therapy. 2014 Apr 1;26(1):38-47.</ref><ref>Paleg G, Romness M, Livingstone R. Interventions to improve sensory and motor outcomes for young children with central hypotonia: A systematic review. Journal of pediatric rehabilitation medicine. 2018 Jan 1;11(1):57-70.</ref>

== Conclusion ==
Toddler gait development involves a progression from standing independently to taking steps, adapting to different terrains, and continuously learning and adjusting locomotor skills through variable practice and exploration. Studies emphasise the importance of natural, variable practice regimes in enabling toddlers to learn adaptive locomotor behaviours and develop a perceptual-motor system capable of responding to changing environments.

Interventions such as standers, over-ground walkers, and orthotics play a vital role in improving mobility, stability, and overall quality of life for children with developmental motor disorders. Assessment and individualised treatment plans are crucial to address a child's specific needs. 

== Additional Resources  ==
*[https://www.health.act.gov.au/about-our-health-system/healthy-living/kids-play-active-play/early-childhood-educators/fundamental Fundamental Movement Skills]
*[https://tomt.skillsforaction.com/tomt/toddler/locomotor-agility-tasks Task Oriented Movement Therapy]
== References  ==

<references />
[[Category:ReLAB-HS Course Page]]
[[Category:Course Pages]]
[[Category:Rehabilitation]]
[[Category:Paediatrics]]