Effect of Motorized Elephant-Assisted Therapy Program on Balance Control of Children with Autism Spectrum Disorder

Postural balance control interventions in autism spectrum disorder (ASD): A systematic review

BACKGROUND

Postural control (PC) disturbances in autism spectrum disorder (ASD) are associated with its severity. Varied sensorimotor interventions have been used for the management of these symptoms. However, there is a lack of a review elucidating all the available postural control interventions in ASD.

RESEARCH QUESTION

To comprehensively present the variety of interventions targeted at improving PC in ASD and to provide future research recommendations.

METHODS

PubMed, SCOPUS, Embase, Cochrane, ScienceDirect and Web of Science databases were searched for publications examining the effects of PC targeting interventions in those with ASD. Included articles were in English, published after 2000 in the peer-reviewed journals with full text available and used intervention targeted at improving PC or balance with a predefined objective outcome measure for accessing PC or balance. Initial database search yielded 1022 studies and 21 articles were included in this review after screening.

RESULTS

We identified diverse PC interventions including animal assisted therapies, karate/martial arts, aquatic exercises, virtual reality-based training, standard and customized exercises, and physical activity programs. The effect of long- and short-term interventions on PC improvement in children and adults with ASD is mixed. Future research should focus on undertaking randomized controlled trials with large sample size and participants with varying severity of ASD to improve generalizability of the study findings. The lack of population-specific, reliable, and validated motor outcome measures including neuro-imaging techniques should be addressed.

SIGNIFICANCE

While many of the interventions improved PC in those with ASD, the sample size and methodological quality of the studies was highly variable. There are limited studies exploring the long-term effects of the interventions. Rigorous study methods with population-specific objective outcome measures are warranted to draw generalizable conclusions regarding the PC interventions in individuals with ASD.

Effects of Horseback Riding on the Postural Control of Autistic Children: A Multiple Baseline Across-subjects Design

The aim of this research was to study the effect of a horseback-riding programme on postural control in a group of autistic children (ASD). Nine children aged 9 to 12 years participated in this study through a multiple baseline across subjects design. The whole programme took place over nine months. Participants followed a previously developed specific horseback-riding programme, consisting of 45-minute sessions held twice a week for at least three months. To evaluate postural control, the average velocity of the centre of pressure displacement was measured by means of a posturographic platform. Results indicated that this intervention with horses had a positive effect on the postural control in children with ASDs.

An Overview of the Available Intervention Strategies for Postural Balance Control in Individuals with Autism Spectrum Disorder

BACKGROUND

Postural instability is a prevalent issue among individuals with autism spectrum disorder (ASD) that affects the development of their perceptual-motor skills and social functioning. Visual and somatosensory processing deficits, hypotonia, basal ganglia dysfunction, and anxiety are some of the concurrent disorders in individuals with ASD. Nevertheless, a definite management protocol for postural instability in ASD has not been introduced yet. Hence, we aim to shed light on the available intervention strategies for postural instability in individuals with ASD.

METHODS

Even though several studies have been conducted on the effects of various interventions for balance control in individuals with ASD, no study has compared their efficacy, limitations, and clinical implications.

RESULTS

This review discusses diverse proposed interventions contributing to ASD postural instability, including martial arts, water-based interventions, animal-assisted therapies, trampoline, balance training, vestibular therapy, transcranial direct current stimulation, sports, play, and active recreation for kids (SPARK), and square-stepping exercise (SSE).

CONCLUSION

Enhancing motor skills, cerebellum function, and sensory input integration were some of the main mechanisms of these interventions to improve balance control in ASD. Some interventions, such as water-based exercises and video games, were enjoyable for children with ASD and could raise their treatment adherence. In most studies, small sample sizes and the lack of a control group represented their major limitations. Therefore, future well-designed randomized controlled trials are required to assess the effects of available interventions on postural control in ASD.

Application of Quantitative Magnetic Resonance Imaging in the Diagnosis of Autism in Children

Objective

To explore the application of quantitative magnetic resonance imaging in the diagnosis of autism in children.

Methods

Sixty autistic children aged 2–3 years and 60 age- and sex-matched healthy children participated in the study. All the children were scanned using head MRI conventional sequences, 3D-T1, diffusion kurtosis imaging (DKI), enhanced T2*- weighted magnetic resonance angiography (ESWAN) and 3D-pseudo continuous Arterial Spin-Labeled (3D-pcASL) sequences. The quantitative susceptibility mapping (QSM), cerebral blood flow (CBF), and brain microstructure of each brain area were compared between the groups, and correlations were analyzed.

Results

The iron content and cerebral blood flow in the frontal lobe, temporal lobe, hippocampus, caudate nucleus, substantia nigra, and red nucleus of the study group were lower than those in the corresponding brain areas of the control group (P < 0.05). The mean kurtosis (MK), radial kurtosis (RK), and axial kurtosis (AK) values of the frontal lobe, temporal lobe, putamen, hippocampus, caudate nucleus, substantia nigra, and red nucleus in the study group were lower than those of the corresponding brain areas in the control group (P < 0.05). The mean diffusivity (MD) and fractional anisotropy of kurtosis (FAK) values of the frontal lobe, temporal lobe and hippocampus in the control group were lower than those in the corresponding brain areas in the study group (P < 0.05). The values of CBF, QSM, and DKI in frontal lobe, temporal lobe and hippocampus could distinguish ASD children (AUC > 0.5, P < 0.05), among which multimodal technology (QSM, CBF, DKI) had the highest AUC (0.917) and DKI had the lowest AUC (0.642).

Conclusion

Quantitative magnetic resonance imaging (including QSM, 3D-pcASL, and DKI) can detect abnormalities in the iron content, cerebral blood flow and brain microstructure in young autistic children, multimodal technology (QSM, CBF, DKI) could be considered as the first choice of imaging diagnostic technology.

Clinical Trial Registration

[http://www.chictr.org.cn/searchprojen.aspx], identifier [ChiCTR2000029699].

Application of Three-Dimensional Pseudocontinuous Arterial Spin Labeling Perfusion Imaging in the Brains of Children With Autism

Objective

To explore the application of three-dimensional pseudocontinuous arterial spin labeling (3D-PCASL) perfusion imaging in the brains of children with autism and to understand the characteristics of cerebral blood perfusion in children with autism.

Methods

A total of 320 children with autism (160 men and 160 women) aged between 2 and 18 years and 320 age- and sex-matched healthy children participated in the study. All children were scanned by 3.0 T magnetic resonance axial T1 fluid-attenuated inversion recovery (FLAIR), T2 FLAIR, 3D-T1, and 3D-PCASL sequences. After postprocessing, cerebral blood flow (CBF) values in each brain region of children with autism and healthy children at the same age were compared and analyzed. Furthermore, CBF characteristics in each brain region of autistic children at various ages were determined.

Results

The CBF values of the frontal lobe, hippocampus, temporal lobe, and caudate nucleus of children with autism are lower than those of healthy children (P < 0.05). Additionally, as the ages of children with autism increase, the number of brain regions with decreased CBF values gradually increases. A receiver operating characteristic (ROC) analysis results show that the CBF values of the frontal lobe, hippocampus, temporal lobe, and caudate nucleus can distinguish children with autism [area under the ROC curve (AUC) > 0.05, P < 0.05].

Conclusion

The 3D-PCASL shows lower brain CBF values in children with autism.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier: ChiCTR2000034356.

Quantitative susceptibility mapping shows lower brain iron content in children with autism

OBJECTIVE

To explore the application of quantitative susceptibility mapping (QSM) of brain iron content in children with autism.

METHODS

For the control group, 40 normal children aged 2-3, 3-4, 4-5, and 5-6 years were prospectively selected from June 2018 to December 2018, with equal numbers of males and females in each age group. For the study group, 40 children with autism aged 2-3, 3-4, 4-5, and 5-6 years were prospectively selected from January 2019 to October 2019; once again, there were equal numbers of males and females in each age group. All children received routine head MRI scans and enhanced T2*-weighted angiography (ESWAN) sequence scans, and the ESWAN sequence images were processed by software to obtain magnetic susceptibility maps. The regions of interest (ROIs) of the frontal white matter, frontal gray matter, thalamus, red nucleus, substantia nigra, dentate nucleus, globus pallidus, putamen nucleus, caudate nucleus, pons, and splenium of the corpus callosum were selected, and the magnetic susceptibility values were measured. The differences in magnetic susceptibility between the two groups were compared in children at the same age.

RESULTS

For the children aged 2-3 years, the magnetic susceptibility values in the caudate nucleus, dentate nucleus, and splenium of the corpus callosum in the study group were lower than those in the control group (p < 0.05). For the children aged 3-4, 4-5, and 5-6 years, the magnetic susceptibility values in the frontal white matter, caudate nucleus, red nucleus, substantia nigra, dentate nucleus, and splenium of the corpus callosum in the study group were lower than those in the control group (p < 0.05).

CONCLUSION

The brain iron content of children with autism is lower than that of normal children.

TRIAL REGISTRATION

This study protocol was registered at the Chinese clinical trial registry (registration number: ChiCTR2000029699; http://www.chictr.org.cn/searchprojen.aspx ).

KEY POINTS

• In this study, the brain iron content of normal children and children with autism was compared to identify the differences, which provided a new objective basis for the early diagnosis of children with autism. • This study examined the iron content values in various brain regions of normal children aged 2-6 years in this region and established a reference range for iron content in various brain regions of normal children in one geographical area, providing a reliable and objective standard for the diagnosis and treatment of some brain diseases in children. • The results of this study indicate that the brain iron content of preschool children with autism is lower than that of normal preschool children.