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Toe Walking in Autism

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Abstract

Persistent toe walking (PTW) not due to a neurological or orthopedic disorder is often characterized as idiopathic toe walking (ITW). PTW has been associated with language disorders and autism. Toe walking accompanied by a language delay might be considered as an early sign of autism. The reason behind this association remains unknown but may relate to either the persistence of an infantile primitive reflex pattern or to sensory modulation difficulties. Persistence of the toe walking for a long time might give rise to a fixed orthopedic deformity in need of physical treatment.

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... According to the literature, about 20% of individuals with ASD walk on their tiptoes [Barrow et al., 2011;Ming et al. 2007] and this occurs in varying degrees of severity [Accardo & Barrow, 2015]. To be considered present, the duration of TW needs to be present for more than 6 months [Accardo, Monasterio, & Oswald, 2014]. Some authors describe TW as intermittent or persistent [Ming et al., 2007], while others grade TW using history and observation (e.g., as absent, present in the past, intermittently present, or persistent) [Accardo & Barrow, 2015]. ...
... This could be a pragmatic way to monitor and describe TTB during daily living activities in ASD subjects. Moreover, it is known that persistent TW in children with autism may contribute to secondary motor deformity by producing a shortening of the Achilles's tendon [Accardo et al., 2014], but it is not clear why some TTB subjects develop heel muscle shortening and others do not. A possible contributing factor could be the time the children spend in TTB during the day when they remain in a standing position. ...
... Conversely, in this study we found a directly proportional relationship between the presence of TTB and the severity of language delay in ASD children. Until recently, only a few authors suggested a possible relationship between these two elements [Accardo et al., 2014;Barrow et al., 2011], but systematic observations were never conducted, and no explanation has been provided. To our knowledge, this is the first study that analyzed, found and is able to confirm this relationship. ...
Article
We assessed presentation patterns and characteristics of tip-toe behavior (TTB), more commonly known as toe walking, in a cohort of severe autism spectrum disorder (ASD) subjects with intellectual disability in two studies. The first study included 69 consecutive ASD subjects (57 males, mean age = 14 years-3.7 SD) under observation at our institute. A therapist assessed the presence of TTB during standing, walking, and running through direct observation and an interview with the subjects main caregiver. The prevalence of TTB was 32%. We found three clinical presentation patterns of TTB: (1) present when standing, walking and running (45.5%), (2) present when walking and running (18.4%), or (3) present only when running (36.4%). TTB subjects were more frequently nonverbal than those without TTB (72.7% vs. 44.6%-P = 0.03). On the other hand, no significant difference in ASD severity according to the ADOS scale was found between TTB and non-TTB subjects. In the second study, carried out in a subgroup of 14 ASD subjects (7 TTB and 7 non-TTB), we evidenced that a soft floor surface (foam mats) made a substantial difference in reducing the TTB phenomenon. TTB is frequently present in ASD individuals and may occur in three mutually exclusive modalities, which ultimately defines what is commonly known as toe walking. The presence of TTB seems correlated to the severity of language delay. Foot contact on soft surfaces reduces TTB both during static and/or dynamic tasks. Further evaluation is needed to clarify the potential pathophysiological implications of this phenomenon
... According to the literature, about 20% of individuals with ASD walk on their tiptoes [Barrow et al., 2011;Ming et al. 2007] and this occurs in varying degrees of severity [Accardo & Barrow, 2015]. To be considered present, the duration of TW needs to be present for more than 6 months [Accardo, Monasterio, & Oswald, 2014]. Some authors describe TW as intermittent or persistent [Ming et al., 2007], while others grade TW using history and observation (e.g., as absent, present in the past, intermittently present, or persistent) [Accardo & Barrow, 2015]. ...
... This could be a pragmatic way to monitor and describe TTB during daily living activities in ASD subjects. Moreover, it is known that persistent TW in children with autism may contribute to secondary motor deformity by producing a shortening of the Achilles's tendon [Accardo et al., 2014], but it is not clear why some TTB subjects develop heel muscle shortening and others do not. A possible contributing factor could be the time the children spend in TTB during the day when they remain in a standing position. ...
... Conversely, in this study we found a directly proportional relationship between the presence of TTB and the severity of language delay in ASD children. Until recently, only a few authors suggested a possible relationship between these two elements [Accardo et al., 2014;Barrow et al., 2011], but systematic observations were never conducted, and no explanation has been provided. To our knowledge, this is the first study that analyzed, found and is able to confirm this relationship. ...
Article
Background and objectives Till now there is no standardized clinical method of assessment of Toe walking (TW) in autism. Moreover, it seems that the persistence of toe walking can be related to language impairment1 even if systematic observations in the literature are poor. The aims of this cross-sectional study are: 1) to assess the prevalence of toe walking in an ASD cohort; 2) to describe the clinical patterns of presentation of TW; 3) to evaluate the relationship between TW presentation patterns and the severity of autism with particular regard to language delay. Materials and methods The study includes 73 consecutive children (60 males, 13 females; mean age = 14,7 years) diagnosed with autism according to the DSM V criteria and under observation at our institute. A therapist assessed the presence of Tiptoe behavior (TTB) during standing, walking and running using direct observation and interview of the main caregiver living with the children. The severity of autism and the language delay severity was established using the ADOS (2nd version) assessment test. Results Overall: 23 children (31,51%) presented TTB. Ten children (13,70%) exhibited it while standing, walking and running (class 1), six (8,22%) only during walking and running (class 2) and seven children (9,59%) only during running (class 3). The ADOS mean scores of non TTB children (20.32 (5.39 SD)) and of TTB children (23.39 (5.35)) were not significantly different. Otherwise there were no significant differences in the mean overall ADOS score of the TTB children according to the three TTB classes. Instead we found that language delay severity was correlated with the presence of TTB (p <0.05). Discussion At our knowledge, this is the first study that shows the presence of three different pattern of presentation of TW in ASD patients and that analyzes and finds a relationship between TTB and severity of language delay. Conclusions TTB frequently manifests itself in individuals with Autism. It may occur in three mutually exclusive modalities, which include what is commonly defined toe walking. The presence of TTB is correlated to language delay severity.
... In a cohort study, using a qualitative assessment, Valagussa et al. (2017) described three mutually exclusive TTB clinical functional classes of increasing severity: (1) TTB present only during running, (2) TTB present during walking and running, and (3) TTB present during standing, walking, and running. Furthermore, it was suggested that the persistence and severity of TTB can impact the length of the Achilles tendon (Accardo et al., 2014;Valagussa et al., 2020). This, in turn, can influence motor behavior in terms of calf discomfort/pain during daily life activities, such as jogging or a higher risk of falling (Caselli et al., 1988), affecting the child's functional capabilities and quality of life (Calhoun et al., 2011). ...
... As of now, various etiological hypotheses of TTB have been suggested. Weber (1978) proposed that "toe walking arises from the fixation of a normal transient stage of development"; later, Accardo et al. (2014) suggested TTB as a "residual of a primitive reflex (i.e., positive support reflex or tonic labyrinthine reflex)" or as a result of a vestibular issue. It was also hypothesized that TTB could be a sign of a sensory modulation or processing impairment. ...
Article
Full-text available
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.
... A wide range of motor impairments is reported among individuals with ASD as alterations in motor milestone development 4 such as disturbances in reach-to-grasp movements, deficits in gross and fine motor movements and praxis, impaired postural capacity and gait impairment. 5 Toe walking (TW) is a possible finding during the gait assessment of individuals with ASD. Clinically, TW refers to walking on the toes without heel strike upon initiation of the stance phase of gait. ...
Article
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) muscle 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 NON-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.
... In the medical literature, the causes of toe walking are thought to be storage diseases leading to neuromuscular involvement, mitochondrial diseases and urea cycle disorders (1). Furthermore, toe walking is also reported as an early symptom of autism (2,3). According to the literature on cases of toe walking, neural tube defects generally refer to orthopedic and neurologic case reports affiliated with spinal deformities or case series considered as atypical due to the lack of definition in such reports (1,(4)(5)(6)(7)(8)(9). ...
... Some researchers described TW as intermittent or persistent (Ming et al., 2007), while others graded TW using history and observation (e.g., as absent, present in the past, intermittently present, or persistent) (Accardo & Barrow, 2015). As it is known that persistent TW in people with autism may contribute to secondary motor deformity by producing a shortening of the Achilles's tendon (Accardo, Monasterio, & Oswald, 2014) it becomes important to have an assessment tool and/or outcome measure for both the clinical and rehabilitative setting. Moreover, in a recent cohort study we observed that the condition is not necessarily related only to walking, since these children often also stand and run on their tiptoes. ...
Article
There is increasing evidence that autism spectrum disorder (ASD) subjects have also motor impairments. Toe walking (TW) is a phenomenon that can be found in ASD subjects during gait, even if this condition was found not to be necessarily related only to walking, since these children often also stand and run on their tiptoes. Since persistent TW in ASD subjects may contribute to secondary shortening of the Achilles's tendon, it becomes important to have an assessment tool and/or outcome measure for both the clinical and rehabilitative settings. The aim of this systematic review is to critically evaluate and describe the methods employed to assess toe walking in ASD subjects. The systematic review protocol was previously registered on PROSPERO. We conducted an extensive literature search in PubMed, CINAHL, PsycINFO, The Cochrane Library, and Scopus databases. There were no restrictions on the types of study design eligible for inclusion. Ten studies were included in the systematic review. Risk of bias of the included studies was conducted using the following instruments depending on the study types: STROBE Statement, Cochrane risk of bias tool, and CARE checklist. Almost all the included studies (8/10) proposed a tip‐toe behavior (TTB) assessment only during walking. Nine out of ten of the included studies assessed TTB using a qualitative methodology. The results evidenced the heterogeneity of qualitative methods and a lack of a structured quantitative test to assess toe walking in ASD subjects. Autism Res 2018. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. Lay Abstract Toe walking (TW) is a phenomenon that can be found during ASD subject's gait. The persistence of this behavior may contribute to secondary Achilles's tendon shortening. In this perspective it becomes important to have an assessment tool and/or outcome measure for both the clinical and rehabilitative settings. The current systematic review aimed to describe the methods employed to assess TW. The results evidenced the lack and the need of a structured quantitative test to assess TW in ASD subjects.
... with Postural control (PC), coordination and motor planning. [5,[14][15][16][17] are only a part of the motor challenges known to be common in ASD. ...
Article
Background: Tailored interventions. One potential novel intervention is orthotic under-garments (OUG Autism spectrum disorder (ASD) is a prevalent neuro-developmental disorder frequently presenting sensory-motor impairments. The complexity and diversity of ASD typically calls for individualized).Aim: To explore the feasibility and effect of OUG as a supplementary therapeutic modality on motor, sensory capabilities and behavior of a child with ASD. Participant: A five years and eight months old child with ASD that presents hypotonia, poor postural control and coordination, a significant motor delay, severe sensory modulation problems, and unusual behaviors.Procedure: Motor, sensory and behavioral evaluations were performed pre (Pre-I) and after (Post-I) a four months intervention: Peabody Developmental Motor Scales-2 (PDMS-2), The Short Sensory Profile (SSP), therapists’ reports and parental interviews served as a behavior and emotion evaluation.Results: Motor function has improved (PDMS-2 percentile <1 Pre-I vs. Post-I 3). Sensory function has improved (Total SSP score 136 Pre-I vs. Post-I 102). Therapeutic and parental reports indicated a decrease of atypical behaviors, improvement in self-confidence and better social participation.Conclusion: According to the current case report, the OUG was found to be useful in improving sensory-motor functions and emotional behaviors of a child with ASD. Our findings provide a possible support to the introduction of orthotic undergarment as a part of individually tailored physical therapy interventions for the child with ASD.
... 1. toe walking is a reflection of sensory integration dysfunction, and 2. toe walking is the remnant of an earlier tonic labyrinthine in supine reflex. 2 Sensory integration disorder symptoms do not occur in all children with autism and when present exhibit different degrees of severity. Hyper-or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment are now included as diagnostic criteria for autism spectrum disorders. ...
Article
Toe walking has been associated with language disorders and autism. To better understand the association between persistent toe walking and sensory and motor variables in children with autism, the degree of toe walking was compared with an estimate of the severity of sensory integration dysfunction symptoms and the presence of residual components of the tonic labyrinthine in supine reflex pattern in 61 children younger than 37 months of age with newly diagnosed autism. There was no association between the presence of toe walking and sensory symptoms (P = .5298) or language age (P = .6142), but there was an association between toe walking and the presence of components of the tonic labyrinthine reflex (P = .04222). These preliminary results support the contribution of subtle motor deficits to the evolution of some behaviors associated with autism.
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The Pre-Linguistic Autism Diagnostic Observation Schedule (PL-ADOS) is a semistructured observation scale designed for use as a diagnostic tool for children less than 6 years old who are not yet using phrase speech and are suspected of having autism. The PL-ADOS takes approximately 30 minutes to administer and is appropriate for use with this population because of its emphasis on playful interactions and the use of toys designed for young children. Reliability studies indicated that both individual activity ratings and summary ratings could be reliably scored from videotaped assessments by naive raters. Additionally, PL-ADOS scores of nonverbal preschool-aged children referred for clinical diagnosis and classified on the basis of a diagnostic team's clinical judgment, clearly discriminated between autistic and nonautistic developmentally disabled children. The resulting diagnostic algorithm is theoretically linked to diagnostic constructs associated with ICD-10 and DSM-IV criteria for autism.
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The above evaluation for minor dysmorphic features might perhaps be referred to as medical or scientific physiognomy. Physiognomy was never supposed to be limited to the study of the face, but in its better versions includes the face, the palms, the somatotype, as well as the gait and other movement patterns. Medical physiognomy therefore approximates the modern approach to syndrome identification but remains somewhat broader. The above and similar dysmorphic features may contribute to the identification of a specific chromosomal, genetic, or teratogenic syndrome diagnosis. However, the presence of several (usually taken as more than 3 or 4) of these minor malformations in the absence of a specific syndrome still suggests either a genetic influence (perhaps a constellation of familial features) or some adverse impact on the developing fetus occurring in the first trimester. The absence of a syndrome and the presence of a familial pattern of dysmorphology does not rule out an association with developmental disorders; rather they recommend a more in-depth review of the family history for the presence of subtle developmental abnormalities. In the presence of a developmental diagnosis, dysmorphic features support the need for a more detailed genetic investigation and strongly favor a prenatal as opposed to postnatal cause for the disorder. With a suspicious but nondiagnostic developmental delay, the presence of dysmorphic features favors increasing the seriousness with which an otherwise mild degree of delay is interpreted.
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To determine whether children with persistent toe walking, without suspected developmental problems, and with normal results after neurologic examination, who were seen in an orthopedic clinic demonstrate delays in language development, gross or fine motor skills, visuomotor development, sensory integration function, or evidence of behavioral problems through a comprehensive multidisciplinary evaluation. A prospective, descriptive study of 13 children (mean age = 3.9 years) referred for idiopathic toe walking. Each child was evaluated by a pediatric neurologist, developmental pediatrician, speech/language pathologist, occupational therapist, and physical therapist. On developmental screening, 7 of 13 children demonstrated delays and 3 were questionably delayed; all 10 had speech/language deficits. Speech/language evaluation showed that 10 of 13 (77%) had receptive or expressive language delays or both. Occupational and physical therapy evaluations found 4 of 12 (33%) had fine motor delays, 4 of 10 (40%) had visuomotor delays, and 3 of 11 (27%) had gross motor delays. Idiopathic toe walking was most often associated with speech/language delays, but delays in other areas were also present. We suggest that idiopathic toe walking should be viewed as a marker for developmental problems and recommend that any child with this condition should be referred for a developmental assessment.
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All of the 17 autistic children studied in the present paper showed disturbances of movement that with our methods could be detected clearly at the age of 4-6 months, and sometimes even at birth. We used the Eshkol-Wachman Movement Analysis System in combination with still-frame videodisc analysis to study videos obtained from parents of children who had been diagnosed as autistic by conventional methods, usually around 3 years old. The videos showed their behaviors when they were infants, long before they had been diagnosed as autistic. The movement disorders varied from child to child. Disturbances were revealed in the shape of the mouth and in some or all of the milestones of development, including, lying, righting, sitting, crawling, and walking. Our findings support the view that movement disturbances play an intrinsic part in the phenomenon of autism, that they are present at birth, and that they can be used to diagnose the presence of autism in the first few months of life. They indicate the need for the development of methods of therapy to be applied from the first few months of life in autism.
Article
To determine the long-term results after conservative treatment (physiotherapy, casting, orthoses, or a combination of these) of idiopathic toe-walking (ITW). Tiptoe-walking is diagnosed as idiopathic (habitual) if no signs of neurological, orthopaedic, or psychiatric disease are detected. The diagnosis is one of exclusion. Sixteen former patients with ITW, all now at least 13 y old, were asked to participate in a follow-up investigation 7-21 y after being first diagnosed. Two cases were excluded because heel-cord lengthening had been performed later on in other hospitals. The remaining 14 patients completed a questionnaire. Eleven patients consented to a clinical examination, during which they were videotaped and their active and passive ankle-joint dorsiflexion measured. These data were compared with the assessment at the initial evaluation. In one instance, the toe-walking ceased after conservative treatment (plaster cast). In all other cases the toe-walking pattern recurred. At follow-up three patients showed some toe-walking when they were unobtrusively observed. When videotaped, they did not toe-walk, although a distinct heel-strike was missing. The remaining eight patients all walked with a heel-strike. Two patients had slight symptoms possibly related to toe-walking. No fixed contracture was present at the first evaluation, and none was found at follow-up. There was no systematic change in ankle-joint dorsiflexion from initial assessment to follow-up examination. Non-surgical treatment of ITW does not have a lasting effect and the long-term results in this study are considered to reflect the natural history, i.e. the toe-walking pattern eventually resolves spontaneously in the majority of children. Surgical treatment of ITW should be reserved for the few cases with a fixed ankle-joint contracture.
Article
As the literature that pertains to botulinum toxin expands, the scope of treatment options broadens. Although initial uses of botulinum toxin focused around the head and neck, there are many uses for the toxin in the area of the foot and ankle; more possibilities are under investigation every day. We review the uses and techniques for botulinum toxin in the foot and ankle and present results of botulinum toxin treatment in 10 idiopathic toe walkers.
Article
The purpose of this study was to determine the effects of botulinum toxin type A treatment on ankle muscle activity during gait of children who are idiopathic toe-walkers. Five children who were idiopathic toe-walkers with a mean age was 4.34 years participated. Gait of the subjects was evaluated prior to, 20 days following, and 12 months following bilateral botulinum toxin type A injection of the gastrocnemius and soleus muscles. Subjects received physical therapy following the 20-day evaluation. Dependent variables were type of foot contact pattern and duration of swing-phase tibialis anterior activity and onset of stance-phase gastrocnemius relative to ground contact. Prior to treatment 51% of foot contacts were with the toe (heel just off the ground) or were digitigrade, while the remaining contacts were flat foot or heel strike. At approximately 20 days following treatment, only 8% of foot contacts were toe contact or digitigrade. Prior to treatment, mean gastrocnemius onset was 30 ms prior to foot contact and the duration of swing-phase tibialis anterior was only 345 ms. Following treatment (and a more normal foot contact pattern), mean gastrocnemius onset followed ground contact by 36 ms and tibialis anterior duration increased through terminal swing and into the loading response. The posttreatment improvement was maintained at 12-month follow-up. It appears that botulinum toxin type A treatment normalizes the ankle EMG pattern during gait and a more normal foot-strike pattern is obtained. These data are discussed in terms of a neuromotor rationale for the rehabilitation of children who are idiopathic toe-walkers to maintain posttreatment improvements.
Article
We used kinematic, kinetic and EMG analysis to compare the spontaneous heel-contact gait patterns of 13 children classified as habitual toe walkers (HTWs) and age-matched controls. In the HTWs, the incidence of spontaneous heel-contact strides during a single recording session ranged from 15% to 92%, with no correlation with age, passive ankle joint excursion, walking speed and trial order. Hallmarks of the heel-contact strides were premature heel-rise, reversal of the second rocker, relative shortening of the loading response and anticipation and enhancement of the electromyographic (EMG) activity normally observed in the triceps surae (TS) during the first half of the stance phase. This variant of the locomotor program is different from the walking patterns observed in normally developing toddlers and children with cerebral palsy (CP). It does not necessarily reflect a functional adaptation to changes in the rheological properties of the muscle-tendon complex.
Article
While many studies of motor control in autism have focused on specific motor signs, there has been a lack of research examining the complete range of subtle neuromotor signs. This study compared performance on a neurologic examination standardized for children (PANESS, Physical and Neurological Exam for Subtle Signs, Denckla [1974 Developmental Medicine and Child Neurology, 16(6), 729–741]) between a group of 40 boys aged 6–17 with autism and average range IQs and a group of 55 typically developing boys. The Autism group was shown to have significant impairment on several measures of motor control compared to the Control group. Regression analyses revealed that a model including four PANESS variables offered a high level of discrimination in distinguishing boys with high-functioning autism from controls.
Article
The treatment of idiopathic toe walking in children can include surgical lengthening of the gastrocnemius/soleus complex after conservative options have been ineffective. Previous outcome reports of surgery for idiopathic toe walkers have largely been limited to assessing the sagittal plane motion of dorsiflexion/plantar flexion with minimal quantitative preoperative and postoperative analysis. The purpose of this study was to comprehensively assess the outcome of idiopathic toe walkers that had been treated surgically. Fourteen children seen in our motion analysis laboratory that underwent gastrocnemius or tendo-Achilles lengthening for idiopathic toe walking were retrospectively reviewed. Preoperatively, this group had significantly greater anterior pelvic tilt than normal, decreased peak knee flexion in swing, greater external foot progression, and the expected increased plantar flexion (P < 0.01). Postoperatively, anterior pelvic tilt decreased by a mean of about 4 degrees (P < 0.01), only for the group that had tendo-Achilles lengthening because the gastrocnemius group was close to normal preoperatively, and peak knee flexion normalized. The foot progression angle of this group did not change from preoperative values and remained significantly more external than normal, although dorsiflexion in stance significantly improved after surgery (indicating the goal of the surgery was achieved). Increased external foot progression in idiopathic toe walkers is apparently due to increased external tibial torsion and/or external hip rotation but was unaffected by gastrocnemius/soleus surgical lengthening. Significant improvement occurred on an overall index of gait variables, indicating surgery can be an effective treatment of idiopathic toe walkers.
Article
Autism spectrum disorders (ASD) are manifest as impairments in social interaction, language and speech development, and the appearance of repetitive behaviors with restricted interests. Motor impairments in individuals with ASD have been categorized as "associated symptoms". The objective of this study was to describe the prevalence of motor deficits in ASD. Specifically, using retrospective clinical record review, we report the prevalence of hypotonia, motor apraxia, reduced ankle mobility, history of gross motor delay, and toe-walking, as well as the improvement of these symptoms with age, in a cohort of 154 children with ASD. The possible association of motor deficits with epilepsy or developmental regression was also assessed. To address whether the motor deficits in children with ASD were properly identified and treated, we evaluated whether the children with the motor deficits were more likely to receive physical and/or occupational therapies as compared to the children with ASD who did not show motor deficits. Hypotonia was the most common motor symptom in our ASD cohort (51%) and this appeared to improve over time, as suggested by the significant reduction in prevalence in older children (p=0.002). Likewise, motor apraxia (34%) showed a tendency to be more prevalent among younger children as compared with older children (p=0.06). Historical intermittent toe-walking was found in 19% of children while reduced ankle mobility was a rare occurrence. Gross motor delay was reported in 9% of children, all of whom gained motor independence by the time of examination. Except for gross motor delay, ASD children with fine motor deficits were not more likely to receive interventional services, as compared with ASD children without the motor deficits. The results suggest that fine motor control and programming deficits are common co-occurrence of children with ASD in this cohort. The reduced prevalence of these motor deficits in older children suggests improvement over time, whether through natural progression, results of interventional therapy, or the combination of the two. However, ASD children with the motor deficits were not more likely to receive service than those without the motor deficits.
Autistic spectrum disorders Autism frontiers: clinical issues and innovations
  • Pj Accardo
The capute scales: cognitive adaptive test/clinical linguistic & auditory milestone scale
  • P J Accardo
  • A J Capute
  • PJ Accardo
Gillaim autism rating scale. Austin: Pro-Ed
  • J E Gilliam
  • JE Gilliam
Autistic sociopathy in childhood In: Firth, editor. Autism and asperger syndrome
  • H Asperger
Gillaim Asperger’s disorder scale. Austin: Pro-Ed
  • J E Gilliam
  • JE Gilliam
Autism diagnostic observation schedule (ADOS) Los Angeles: Western Psychological Services
  • C Lord
  • M Rutter
  • P Dilavore
  • S Risi
Does your baby have autism? Detecting the earliest signs of autism. Garden City: Square One Publishers
  • O Teitelbaum
  • P Teitelbaum
Krug Asperger’s disorder index. Austin: Pro-Ed
  • D A Krug
  • J Arick
  • DA Krug
Asperger syndrome diagnostic scale (ASDS) Austin: Pro-Ed
  • Bs Myles
  • Sj Bock
  • Rl Simpson
Diagnostic checklist form E-2 San Diego: Autism Research Institute
  • B Rimland
Manual for the social communication questionnaire. Los Angeles: Western Psychological Services
  • M Rutter
  • A Bailey
  • C Lord
Autism diagnostic interview – revised (ADI-R) Los Angeles: Western Psychological Services
  • M Rutter
  • Le Couteur
  • A Lord
Reflexes gone astray
  • P Teitelbaum
  • Ob Teitelbaum
  • J Fryman
  • R Maurer