toe walking in children with autism

[wullie]

Hello everyone,

I am currently working with children who have autism and a lot of these children are toe walker.I am trying to do a bit more in depth reserch on this, but unfortunately I haven't found much information on the web which is a bit more specific on this matter.

I anyone has more specific information or is also working in this field I would be very grateful for any help.

Thanks

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[mavenlive]

My mother worked as a teacher for her entire career and did some great work with autistic children near the end of her career. I found this thread very informative. Thanks to all involved!

-Chris
http://www.mavenlive.com

[estherderu]

dear Mavin,

no thanks.
I hope you are not using this to promote your site?
Constructive reactions are always welcome.

Esther

[mavenlive]

Esther - I found the thread a very good read. Toe walking and autism isn't something I had made a connection between in past. But when I thought about the students my mother dealt with it seemed to be prevalent. You learn something everyday.

[SPPAWA]

I have read through the most of posts here on this page regarding toe walking being a product of sensory integration issues. This is an apparent source of controversy as there is no concrete evidence to support this. I think that we can all agree that increased output to the plantar flexor muscles of the foot and ankle would be responsible for producing the altered gait we see in "toe walkers" correct? I think we could all then agree that this may be a product of increased drive through alpha MN themselves to the plantar flexor muscles or promoted by a lack of decending cord mediated inhibition to these muscles secondary to a failure of more primitive vestibular reflexes not being damped or properly integrated from altered higher level brain centers. Such signs are again seen with "release signs" or, more specifically, in this case a "babinski response" which we all know so well. As an UMN lesion includes dysfunction in the cortex and not the cord and autism has been documented to have altered deep white matter patters (remember these are the heavily myelinated fibers) please see the following:http://www.jneurosci.org/cgi/content/full/27/43/11725 it would make sense that through the process of diaschisis descending modulation of the vestibular nuclei output would be impaired as well = increased tone to plantar flexors - similar to release signs seen in the cortically compromised ie. stroke cases. As for how to rehabilitate these, I have had some success with vestibular based rehabilitation using a swiss ball and stimulating reflexogenic eye movements, particularly those associated with output of the posterior semi circular canal system (down and to the opposite side). Building plasticity or encouraging integration with through these sensory modalities would appear to help integrate the sensory integration issue which is likely promoting these. As for whether there is a sensory integration issue at play here I feel it is imperative that we all realize the brain is a sensory driven organ. Without afferent input there is no efferent response. Thoughts are just internalized motoric behavior. Hope this helps.

SPPAWA

[illuminatidinesh]

As for whether there is a sensory integration issue at play here I feel it is imperative that we all realize the brain is a sensory driven organ. Without afferent input there is no efferent response.

Exactly my view too...... There is saying about the Nervous system" We know a lot today, understand very little".
I like to present some research evidence on this, will post as soon as possible.

[steffen-dt]

I like to present some research evidence on this, will post as soon as possible.

I would be also interested in any research results in this field. Please keep us updated.
Additional Comment I forgot:

I like to present some research evidence on this, will post as soon as possible.

I would be also interested in any research results in this field. Please keep us updated.

[steinwaymichigan]

Hi! I am involve in music and I found out that music could, in some way, help autistic child in improving their behavior. It could teach them how to communicate and to have better eye contact. As they respond well in music, it could also be used as an interface to help them do tasks that is not related to music like walking.

[estherderu]

Dear Wullie,

Thanks for that... BUT who diagnosed these children as having a SPD, a therapists or a neurologist?

I hope the neurologist.... if not, what tests and assessements does the OT use to diagnose this condition?

I am seriously interested. Do really want to know more.

kind regards

Esther

[estherderu]

Dear everyone,

Have found a number of answers to the questions regarding SPD in the following article by mrs Nancy Pollock from the canchild website.
CanChild Centre for Childhood Disability Research

Esther

[wullie]

Hi Esther,

our OT is using the Sensory Profile (www.SensoryProfile.com) by Winnie Dunn, but all the children I'm working with are also seen by other professionals. Every child has a "sensory diet"(that's the outcome of the sensory profile) which they follow every day in school.
We have seen improvements in the children who are receiving Physio and at the same time following their sensory diet. It's just very complex as the children I'm working with are on the lower end of the spectrum and most of them are non-verbal and don't follow instructions or copy/mimic any movement.
Hope this is helpful

Kind regards,
wullie

[estherderu]

Dear wullie,

Have you read Nancy Pollock's article? In it she refers to a dr heibroner and I have found the website. On it his perception of sensory processing disorders.
Why "Sensory Integration Disorder" Is a Dubious Diagnosis
Does make you think and wonder.

And... in the process, getting back to trying to our subject namely what to do about the toewalking... maybe we should rethink our treatment goals.

Esther

[julhay]

Hi Everyone,

I thought I'd add my bit. I'm an occupational therapist working with children with autism, some of whom toe walk. For starters, SPD is not yet a recognised diagnosis so while we may describe a child as having SPD, we do not diagnose them with it. A child's sensory processing and sensory integration is assessed by using the Sensory Integration Praxis Test (SIPT) or more commonly the Clinical Observations (a non standardised ax originally developed by A Jean Ayres). This information is collated with the results of the sensory profile mentioned previously and general observations of the child's function in different settings (school, clinic, home etc.).

I have been working on the hypothesis that toe walking is a sensory seeking behaviour, with the child seeking deep pressure, proprioceptive or vestibular stimulation (or all three). All of the children I see have significant sensory processing dysfunction and this hypothesis is in line with their overall sensory profile. In terms of treatment, I use a sensory diet along with the Wilbarger Brushing Protocol and I have also been using Kinesio Tex Tape to inhibit gastroc/soleus and facilitate tib. anterior. The sensory diet and Wilbarger Protocol improve a child's sensory integration and decrease sensory seeking behaviours. The Kinesio tape increases proprioception to the muscles as well as utilising the specific muscle application. Within treatment sessions we frequently use vestibular, proprioceptive and deep pressure stimulation.

I realise that there is no significant scientific research to support this, as I said this is just a hypothesis. I have however, seen a decrease in toe walking and improvement in gait stability in the children I have been treating.

Julia

[estherderu]

Dear Julia,
thank you so much for your imput.
I have been researching the (kinesio) elastic therapeutic tape for a while now. Have come to believe that it doesn't always matter in which direction the tape is applied.
Have you tried different directions or just kept to the (kinesio) protocol?
I have been wondering if taping either only the tibialis or the triceps would make the same difference.

Have also thought about using other/nieuw tape applications. have done so and so far the results have been meager.
Could you tell me a little more about the number of patients you have used tape on and your success rate?
If you are interested in the "new" applicaties, please leave me you email address and I will send them to you.

kind regards

Esther

[julhay]

Hi Esther,

I'm relatively new to kinesio taping, I did the training in October so I tend to stick to the protocol when doing inhibition/facilitation taping. The taping I have done is with a very small number of children, about half a dozen although all showed a decrease in toe walking behaviour in some form. With some of the boys it was only immediately after the tape was applied and as the elasticity wore off, so did the effect of the tape.
One particular success was a boy (8yrs) with very severe toe walking who had been recommended for achilles tendon release surgery in 6 months due to limited ankle ROM and pain. For him I alternated between lower leg and upper leg applications (inhibit gastroc/soleous or hamstring, facilitate tib ant or quads). Through a combination of taping, sensory diet and the brushing programme we restored his ankle ROM to 90 degrees and he is no longer having tendon release surgery. He had a two week break from taping over the christmas period and mum noticed that his gait stability deteriorated over this time.
As I said, I've only done this with a handful of kids, it's more out of personal interest than anything else. If you could send me the details of the other taping methods that would be great, thanks. My email is [email protected]

Julia

[Bobby Nabeyama]

Hi Bobby,

Have you got any comments or thoughts about my pondering...
" The thought has crossed my mind that the reason why children (not only those with autisme) toewalk could possibly be because of a need to "stimulate" their own sensory systems. ?

Esther

Hope all is well, Esther.

I have heard all too frequently the theories and hypotheses for needing or wanting proprioceptive or vestibular input. There is no evidence to suggest toe walking is due to children's need to stimulate their own sensory systems. Therapists do way too much theorizing without much validity to them.

Kind of scary if our objectives are to help children. Very scary, actually.

[Bobby Nabeyama]

Hi Everyone,

I thought I'd add my bit. I'm an occupational therapist working with children with autism, some of whom toe walk. For starters, SPD is not yet a recognised diagnosis so while we may describe a child as having SPD, we do not diagnose them with it.

Unfortunately, therapists including OTs diaganose SPD as if it is recognized.

A child's sensory processing and sensory integration is assessed by using the Sensory Integration Praxis Test (SIPT) or more commonly the Clinical Observations (a non standardised ax originally developed by A Jean Ayres). This information is collated with the results of the sensory profile mentioned previously and general observations of the child's function in different settings (school, clinic, home etc.).

Unfortunately, the SIPT is not used much nor is it validated for what is currently looked upon as SPD, there are no clinical observations to validate SPD, and the Sensory Profile merely provides subjective measures to hypothesize SPD even if the child may not have SPD.

I have been working on the hypothesis that toe walking is a sensory seeking behaviour, with the child seeking deep pressure, proprioceptive or vestibular stimulation (or all three). All of the children I see have significant sensory processing dysfunction and this hypothesis is in line with their overall sensory profile.

This hypothesis does not have the empirical backing by way of literature, scientific, and theoretical support to suggest any validity.

In terms of treatment, I use a sensory diet along with the Wilbarger Brushing Protocol and I have also been using Kinesio Tex Tape to inhibit gastroc/soleus and facilitate tib. anterior. The sensory diet and Wilbarger Protocol improve a child's sensory integration and decrease sensory seeking behaviours. The Kinesio tape increases proprioception to the muscles as well as utilising the specific muscle application. Within treatment sessions we frequently use vestibular, proprioceptive and deep pressure stimulation.

That protocol is antiquated without any validity and should not even be mentioned in therapy anymore.

I realise that there is no significant scientific research to support this, as I said this is just a hypothesis. I have however, seen a decrease in toe walking and improvement in gait stability in the children I have been treating.

Julia

You should be commended to at least know and admit that there is no significant research to back such mentioned hypotheses.

However, to suggest that practicing protocols based on admitted unfounded hypotheses are purely rationalizations. Therapists need to move away from rationalizations. We can rationalize anything to make something sound good, make sense, appear acceptable and intuitive.

[Bobby Nabeyama]

I'll have to review this:

Pediatric Physical Therapy: Winter 2010 - Volume 22 - Issue 4 - p 417–426 doi: 10.1097/PEP.0b013e3181f9d5b8 Case Study

Effects of Motor Control Intervention for Children With Idiopathic Toe Walking: A 5-Case Series

Clark, Elaine PT, DSc, PCS; Sweeney, Jane K. PT, PhD, PCS, FAPTA; Yocum, Allison PT, DSc, PCS; McCoy, Sarah W. PT, PhD

[estherderu]

Hi Bobby,

Thank you for letting us know about this article. Will look it up as well.
Looking forward to a fruitfull discussion. Toewalkers are very HOT in the Netherlands at the moment and I hope to get other colleagues to comment here as well.

Esther

[zisuer]

Hi Esther,

sorry about that, I ment SPD-sensory processing dysfunction.

Ilka

I was just suggested that a hinged AFO can helped a lot. And a few theory behind and related treatments as below:
Toe walking and autism:
Why: a few theories
· A sign of tactile hypersensitivity, the person is trying avoid the contact with the surface. --- Treatment based on this theory---aim at reducing sensory hypersensitivity by therapeutic brushing and graded desensitization to tactile input.
· Is an attempt to self provide propriceptive input, and calm themselves. ---treatment based on this theory---provide the person with propriceptive input in other ways, such as jumping on a trampoline, stomping feet, walking in sand, providing traction and other activities involving compression/traction
· Due to the tunnel vision--- treatment: prism lenses and vision training

[estherderu]

dear colleague to be...

And where did you get this information?
If you have read this thread carefully you will have seen that there is a lot of controversy about this issue.
Please enlighten us to where your theories come from. I hope it comes from various sources and that you can share these with us.

kind regards Esther

[Bobby Nabeyama]

I was just suggested that a hinged AFO can helped a lot. And a few theory behind and related treatments as below:
Toe walking and autism:
Why: a few theories
· A sign of tactile hypersensitivity, the person is trying avoid the contact with the surface. --- Treatment based on this theory---aim at reducing sensory hypersensitivity by therapeutic brushing and graded desensitization to tactile input.
· Is an attempt to self provide propriceptive input, and calm themselves. ---treatment based on this theory---provide the person with propriceptive input in other ways, such as jumping on a trampoline, stomping feet, walking in sand, providing traction and other activities involving compression/traction
· Due to the tunnel vision--- treatment: prism lenses and vision training

Unfortunately, these dubious theories and treatments are practiced among PTs.