Toe Walking Assessment in Autism Spectrum Disorder Subjects: A Systematic Review

Clinical gait analysis in older children with autism spectrum disorder

Individuals with autism spectrum disorder (ASD) often exhibit motor deficits that increase their risk of falls. There is a lack of understanding regarding gait biomechanics demonstrated by older children with ASD. The purpose of the study was to determine differences in gait patterns between older children with ASD and typically developing children. Eleven children with ASD and 11 age- and gender-matched typically developing children were recruited for the study. Participants walked on a force-instrumented treadmill at a constant speed (1.1 ​m/s ​- ​1.2 ​m/s) for five minutes (min). Participants performed maximal voluntary contractions to assess their knee muscular strength. Differences between individuals with ASD and matched control participants were examined through paired t-tests with a significance level of p ​≤ ​0.05. Individuals with ASD demonstrated a smaller knee extensor torque compared to controls (p ​= ​0.002). Participants with ASD exhibited a shorter stride length (p ​= ​0.04), a greater cadence (p ​= ​0.03), and a higher variation in stride width (p ​= ​0.04) compared to control participants. The individuals with ASD experienced a greater braking ground reaction force (p ​= ​0.03) during loading response. The results indicate older children with ASD develop a unique gait pattern signified by a reduced stride length, increased cadence, and an increase of variation in stride width. This unique gait pattern may represent a movement strategy used by the individuals with ASD to compensate for the weakness associated with their knee extensor muscles. Individuals with ASD who demonstrate these unique gait deviations may face reduced postural stability and an increased risk of fall-related injuries.

MRI of the Spine in Patients who Toe Walk: Is There a Role?

BACKGROUND

Little is known about the prevalence of intraspinal pathology in children who toe walk, but magnetic resonance imaging (MRI) may be part of the diagnostic workup. The purpose of this study was to examine the role of MRI for children who toe walk with a focus on the rate of positive findings and associated neurosurgical interventions performed for children with said MRI findings.

METHODS

A single-center tertiary hospital database was queried to identify a cohort of 118 subjects with a diagnosis of toe walking who underwent spinal MRI during a 5-year period. Patient and MRI characteristics were summarized and compared between subjects with a major abnormality, minor abnormality, or no abnormality on MRI using multivariable logistic regression. Major MRI abnormalities included those with a clear spinal etiology, such as fatty filum, tethered cord, syrinx, and Chiari malformation, while minor abnormalities had unclear associations with toe walking.

RESULTS

The most common primary indications for MRI were failure to improve with conservative treatment, severe contracture, and abnormal reflexes. The prevalence of major MRI abnormalities was 25% (30/118), minor MRI abnormalities was 19% (22/118), and normal MRI was 56% (66/118). Patients with delayed onset of toe walking were significantly more likely to have a major abnormality on MRI ( P =0.009). The presence of abnormal reflexes, severe contracture, back pain, bladder incontinence, and failure to improve with conservative treatment were not significantly associated with an increased likelihood of major abnormality on MRI. Twenty-nine (25%) subjects underwent tendon lengthening, and 5 (4%) underwent neurosurgical intervention, the most frequent of which was detethering and sectioning of fatty filum.

CONCLUSIONS

Spinal MRI in patients who toe walk has a high rate of major positive findings, some of which require neurosurgical intervention. The most significant predictor of intraspinal pathology was the late onset of toe walking after the child had initiated walking. MRI of the spine should be considered by pediatric orthopedic surgeons in patients with toe walking who present late with an abnormal clinical course.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

Quantitative assessment of tip-toe behavior in individuals with autism spectrum disorder and intellectual disability: A cross-sectional study

The term "toe walking" describes walking on the toes with a lack of heel strike upon initiation of the stance phase of gait. In individuals with autism spectrum disorder (ASD), this phenomenon, or "tip-toe behavior" (TTB), can be present in a substantial proportion of subjects even during standing. In this study, we investigated TTB in 50 persons with ASD (age range 4-26 years). We evaluated TTB through an observational/report-based assessment protocol. Subsequently, we employed a new structured video-based coding protocol based on standardized video recordings, focusing on static and dynamic conditions. Finally, the findings of the two protocols were compared. Twenty-four subjects with TTB were identified and classified according to three functional groups: TTB1, present only during running (6 subjects); TTB2, present during walking and running (11 subjects); and TTB3, present during standing, walking, and running (7 subjects). Moreover, we found that TTB3 subjects exhibited a significantly higher quantity of TTB compared with subjects in the TTB1 and TTB2 groups during both standing and walking tests. Additionally, a high quantity of TTB in the static test was found to be related to a high quantity of TTB in the dynamic test. Variables such as age, autism severity, intellectual disability, and gender were not significantly associated with the mean percent of TTB both in static and dynamic tests in multivariate analysis. This structured video-based coding approach appears feasible and useful for assessing TTB in individuals with ASD and it has the potential to provide insights into TTB trajectories and aid in designing possible interventions.

Effects of an 8-week multimodal exercise program on ground reaction forces and plantar pressure during walking in boys with autism spectrum disorder

BACKGROUND

Autism spectrum disorder is a developmental disability with first signs appearing in children aged 3 years and younger. Given that autism spectrum disorder is accompanied by a broad range of symptoms such as impaired sensory, neurological, and neuromotor functions, it appears plausible to argue that an intervention program focusing on multimodal exercise rather than single-mode exercise might be more effective in treating this wide variety of symptoms.

OBJECTIVE

The aim of this study was to evaluate the effects of a multimodal exercise program entitled Sports, Play, and Active Recreation for Kids on variables of ground reaction forces and plantar pressure during walking in boys with autism spectrum disorder.

METHODS

Twenty-four autism spectrum disorder boys aged 7-11 years were recruited and randomly allocated into an intervention or a waiting control group. Sports, Play, and Active Recreation for Kids was conducted over a period of 8 weeks with three weekly sessions. This training protocol includes aerobic dance and jump rope exercises as well as running games. Pre- and post-training, ground reaction forces and plantar pressure variables were recorded while walking at a constant walking speed of 0.9 m/s using a foot scan embedded in a 15-m walkway.

RESULTS

Significant group-by-time interactions were found for the first peak of vertical ground reaction force, loading rate, and peak pressure at the medial heel region (all p = 0.001-0.49, d = 0.89-1.40). Post-hoc analyses showed significant pre-post decreases for the first peak of vertical ground reaction force (p = 0.001, d = 1.27), loading rate (p = 0.009, d = 1.11), and peak pressure at the medial heel region (p = 0.021, d = 1.01).

CONCLUSIONS

Our results suggest that a joyful and multimodal exercise program has positive effects on kinetic walking characteristics of autism spectrum disorder boys. Accordingly, we recommend to implement this type of exercise in prepubertal autism spectrum disorder boys to improve gait kinetics.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials IRCT20170806035517N4. Registered on November 8, 2021. This study was approved by the Ethical Committee of the University of Mohaghegh Ardabili, Ardabil, Iran (IR.UMA.REC.1400.019). The study was conducted in accordance with the latest version of the Declaration of Helsinki.

Sensory Profile of Children and Adolescents with Autism Spectrum Disorder and Tip-Toe Behavior: Results of an Observational Pilot Study

Atypical sensory processing is frequently reported in persons with autism spectrum disorders (ASD), and it is one of the described diagnostic criteria for ASD. There is also mounting literature supporting the presence of motor impairments in individuals with ASD. Among these motor signs, tip-toe behavior (TTB) is a possible clinical finding, but its etiology is not clearly understood. It is suggested that TTB in ASD could be a sign of a sensory modulation impairment, but evidence is lacking and controversial. The main aim of this pilot study is to explore sensory features in a sample (4 females; 28 males) of children and adolescents with ASD (age range: 7-18). All participants also presented Intellectual Disability. Participants were divided in two groups, matched for age and gender, on the basis of the presence or absence of TTB (16 ASD TTB group vs. 16 ASD NO-TTB group) and then evaluated by using the Short Sensory Profile. We found that both ASD groups tend to significantly present sensory-related behavioral symptoms, but ASD TTB individuals more frequently showed the specific pattern of "under responsive/seeks sensation" than ASD NO-TTB individuals. These preliminary findings support that sensory-motor features might be taken into consideration when rehabilitation for TTB in children and adolescents with ASD is necessary.

Little Evidence for Conservative Toe Walking Interventions in Autism Spectrum Disorders: a Systematic Review

This systematic review summarizes the evidence about toe walking (TW) interventions in persons with autism. Following the PRISMA guidelines, a systematic search of MEDLINE, CINAHL, PsycINFO, The Cochrane Library, Google Scholar, and Opengrey was performed. Nine articles (all case reports or case series) were included. Methodological quality was assessed using the Mayo Evidence-Based Practice Centre tool. The included studies considered 17 subjects (16 males; age range: 4–15 years). All studies reported a reduction of TW frequency, but the follow-up was lacking in seven studies. There is a lack of high-quality studies with a sufficiently large and well-characterized sample to assess the effectiveness of TW interventions in autistic persons. These findings strongly support the need for further research in this area.

Inter and intra-limb coordination variability during walking in adolescents with autism spectrum disorder

BACKGROUND

Autism spectrum disorder, a neurodevelopmental disorder, is difficult to characterize from a gait biomechanics perspective, possibly due to increased inter and intra-individual variability. Previous research illustrates increased gait variability in young children with autism, but assessments in older adolescents or at varying speeds are unavailable. The purpose of this study was to determine if adolescents with autism demonstrate increased intra-limb and inter-limb coordination variability during walking compared to age, sex, and body mass index matched controls.

METHODS

Seventeen adolescents with autism (age 13-18 years) and seventeen matched controls performed walking at two matched speeds: self-selected of adolescents with autism and at 1.3 m/s. Modified vector coding was used to determine the patterns of movement for foot-shank, left/right thigh, and contralateral thigh-arm coupling. Coordination variability, a measure of cycle-to-cycle variability, was determined across the full stride. Mixed-model analyses of variance were used to determine if group by speed interactions and/or main effects existed for coordination variability.

FINDINGS

A significant interaction existed for foot-shank variability (p = 0.039). Adolescents with autism had greater variability at self-selected speeds (p = 0.018), but not at 1.3 m/s (p = 0.593) compared to controls. Thigh-thigh coordination was greater for adolescents with ASD compared to controls at both speeds (p = 0.021). Variability was decreased at 1.3 m/s for both foot-shank (p = 0.016) and thigh-thigh (p = 0.021) coupling.

INTERPRETATION

This study illustrates that adolescents with autism perform walking with increased coordination variability at both proximal and distal segments. Thus, it is likely intra-individual variability drives the disparity of movement patterns in this population.

Relationship between tip-toe behavior and soleus - gastrocnemius muscle lengths in individuals with autism spectrum disorders

BACKGROUND

About 20% of individuals with autism spectrum disorders (ASD) showed tip-toe behavior (TTB). This behavior may be related to a decreased ankle joint range of motion (ROM) in dorsiflexion. Physiologically, gastrocnemius (GM) and soleus (SM) muscles influence ankle ROM independently. However, no studies investigated the relationship between the amount of time individuals with ASD spend in TTB and GM and SM muscle lengths.

OBJECTIVE

To evaluate the relationship between three mutually exclusive clinical patterns of TTB i.e., during standing, walking and running (TTB Class 1), or during walking and running (TTB Class 2), or only when running (TTB Class 3), and GM and SM muscle lengths.

METHODS

Sixty-nine individuals with ASD (average age: 14.1 ± 3.6 years, 56 males) were enrolled. In a clinical setting, SM and GM muscle lengths of both legs were assessed through a manual goniometer. Measurements were performed by two trained assessors blinded to TTB classifications.

RESULTS

Individuals with ASD classified as TTB Class 1 demonstrated a shortening of both GM and SM compared with NO-TTB and TTB Class 3 individuals.

CONCLUSIONS

Our results support the relationship between TTB severity and GM and SM shortening assessed by a decreased ankle joint ROM in dorsiflexion. Further studies are needed to determine the factors associated with TTB and decreased ankle ROM.