Indlæg nr. 1 om tågængere.

Posted on 09. mar, 2017 by in Ikke kategoriseret

Tågængere – definition.

En tågænger er et barn med en ganganomali uden normalt hælisæt ved starten på et skridt samt manglende fuld fodkontakt senere i standfasen. Det gælder begge fødder og barnet går på tæerne eller på forfoden i størstedelen af kontakten med underlaget.

Det normale.

Det er normalt at et barn begynder at gå, når det er 12 – 14 måneder gammelt, og før det er 18 måneder. De fleste begynder at gå på deres flade fødder, men nogle begynder at gå på tæerne. De fleste vokser fra det i løbet af 3 – 6 måneder, når de har lært at gå, og det er normalt helt ovre, når barnet bliver 3 år. Når barnet står og hviler, er det oftest på flade fødder. Lige så snart det bevæger sig, løfter det sig op på tå og går med strakte knæ.

Det kan være uden betydning hos børn, der ellers udvikler sig normalt indtil 2 års alderen. Normal gangafvikling fra hælisæt til afvikling over tæerne er normalt veludviklet, når barnet er 22 måneder. Nogle af de børn, der stadig går på tæerne efter 2 års alderen, gør det ofte pga. vane men bør undersøges nærmere.

Den mest almindelige type tågang hos børn er idiopatisk (= optræder uden påviselig årsag). Det sande antal børn med idiopatisk tågang er ukendt, da alle ikke er registrerede hos egen læge.

Barnet går og løber på tæerne – symmetrisk på begge underekstremiteter, især når det ikke iagttages. Når barnet bliver bedt om det, kan det som regel gå på flade fødder.

Lidt fra forskningen.

Flere mindre studier viser, at der er mellem 7 og 24% tågængere hos børn. Et større studie fra Holland i 2011 fandt prævalens på 12% i den almindelige befolkning. Et andet stort studie i Sverige i 2012 fandt prævalens for idiopatisk tågang på 4,9% hos børn på 5½ år.

Idiopatisk tågang blev første gang beskrevet af Hall i 1967 som vane-tågang, og medfødt kort achillessene er en udelukkelsesdiagnose. Idiopatisk tågang defineres bedst som bilateral tågang med eller uden achilleskontraktur hos et barn over 2 år uden andre ætiologier. (Andre steder i litteraturen er det, når barnet fortsætter med at gå på tæerne, efter det er 3 år).

Andre studier viser en større frekvens af tågængere hos patienter med autisme, sen udvikling og sprogproblemer. Et nyere studie har vist forekomst på 20,1% hvis autisme, mens historiske optegnelser anslår det til at være helt optil 63%.

Symptomer.

Synlig gang på tæer eller på forfod. Hvis barnet stadig er tågænger efter 2 år, bør der gøres noget. Måske også tidligere hvis der er stramme muskler i benene, stram achillessene eller manglende muskelkoordination.

Årsager.

Mange børn vedbliver at gå på tæerne pga. vanen, fra da de lærte at gå.

Tågang kan skyldes en dyberegående neuromuskulær sygdom (både central- og perifere neurologiske forstyrrelser), muskulære forstyrrelser og anatomiske forstyrrelser, som benlængdeforskel. Der findes en enkelt rapport i litteraturen om et sjældent tilfælde af akut tågang sekundært til myositis hos en ellers sund 4 årig. Det er kritisk for behandling, at ekskludere neurologiske og muskulære sygdomme som årsag til ganganomalien.

De mest sete årsager til ikke-idiopatisk tågang:

  • Kort achillessene, så hælen forhindres i at nå jorden
  • Cerebral parese (den mest almindelige sygdomsårsag, der rammer 1-7 ud af 1000 børn), som er en forstyrrelse i bevægelse, muskeltonus eller positur forårsaget af skade elle anormal udvikling i dele af den umodne del af hjernen, der styrer muskelfunktion. Det er uvist hvor mange børn, der er tågængere, da der er stor variation i rapporterne, fordi sygdommen har et bredt spænd. Men det er noteret, at under 50% er tågængere.
  • Muskulær dystrofi eller en anden generaliseret nerve- eller muskelsygdom. Tågang kan ses ved Duchennes muskelatrofi – en genetisk sygdom hvor muskelfibre usædvanligt er modtagelige for skade og bliver svage over tid. Denne diagnose er mest sandsynlig hvis barnet startede med at gå normalt, før det blev tågænger. Gangen udvikler sig til tågang pga. den progressive svaghed i knæets ekstensorer.
  • Børn med autisme kan gå på tæerne eller forfoden, men mange gør det ikke.
  • Tågang kan være forårsaget at en knogleblokering i talocruralleddet, der hindrer antagonist bevægelsen: dorsalfleksion. Dette er ofte i forbindelse med traume eller arthritis.

Modsat siges det, at børn med idiopatisk tågang giver øget prævalens for andre pædiatriske forstyrrelser som koncentrationsbesvær, hyperaktivitet, tics, Tourettes syndrom og OCD.

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