Abstract

Introduction

Older school-aged children with autism-spectrum disorder (ASD) can continue to present with idiopathic toe-walking (ITW), even after years of continued orthotic intervention. Children with ASD who continue to exhibit sensory-seeking (or sensory-avoidant) toe-walking are frequently treated with orthotic intervention from early toddler age, into adulthood. Orthotic compliance can be challenging for both the child and the parents, as traditional rigid orthotic intervention interferes with the sensory-seeking tactile input, or exacerbates sensory-avoidant behaviors due to increased stimuli from orthotic contact with the lower extremities. It is known that toe-walking can cause other postural compensations including equinovarus deformities, excessive genu recurvatum, and hip flexion tightness with increased lumbar lordosis.

Mots Clés

autism spectrum disorder, idiopathic toe-walking, orthotic compliance, sensory processing, pediatric gait, postural stability, functional mobility, dynamic ankle-foot orthosis

Corps du résumé / Matériels et méthodes

Aim: To assess children with ASD and toe-walking clinical outcomes in dynamic assistant-resistant orthotic designs, acceptance and rejection rates, social perceptions, and impacts on gait.

Methods: Twelve subjects diagnosed with ASD and toe-walking, between the ages of 8-12 years old, were recruited for the study. Inclusion criteria included an orthotic history of daily use of bilateral articulated ankle-foot orthoses (AFOs) with plantar-flexion stops since preschool age. Exclusionary criteria included plantarflexion contractures greater than 5 degrees or known additional diagnosis known to cause toe-walking. Outcome measures were taken barefoot, with current orthotic intervention, and with dynamic strut intervention at various time periods.

Résultats

Subjects' overall wearing refusal decreased by 42% with the dynamic strut AFOs. Subjects chose to wear the dynamic AFOs 83% of the time. Barefoot was able to perform the TUG and TUDS test at faster speeds than with the articulated or dynamic strut AFO designs. At the 1 month and 3-month assessment, the dynamic strut AFO demonstrated longer distances ambulated during the Pediatric 30-Second Walk Test (30sWT) than both barefoot and articulated AFO assessments. There was no difference between the 1-month dynamic strut AFO assessment and baseline articulated AFO assessment of the Pediatric Reach Test. The 3-month dynamic strut assessment demonstrated an improvement in the Pediatric Reach Test. No significant difference in outcome measures found when assessing barefoot walking at the beginning versus end of assessment.

Discussion

Overall, these findings support the clinical viability of dynamic strut orthoses as a more acceptable and functionally beneficial option for managing ITW in children with ASD. Further research with larger sample sizes and long-term follow-up is warranted to better understand their impact on musculoskeletal development and participation in daily activities.

Conclusion

The introduction of dynamic strut AFO designs appears to offer a promising alternative to traditional rigid orthotic interventions for school-aged children with autism spectrum disorder (ASD) and idiopathic toe-walking (ITW). The significant reduction in orthotic refusal (42%) and high user preference (83%) suggest increased comfort, acceptance, and wearability, which are critical for long-term therapeutic success in this population.

Although barefoot performance remained superior for certain mobility measures like the Timed Up and Go (TUG) and Timed Up and Down Stairs (TUDS) tests, dynamic strut AFOs demonstrated notable functional gains in endurance and postural stability over time. Specifically, improvements in the 30-Second Walk Test and Pediatric Reach Test at the three-month mark indicate enhanced gait efficiency and balance compared to both baseline and traditional AFO designs.

Importantly, the consistent barefoot results from baseline to study completion imply that the dynamic orthotic intervention did not negatively affect intrinsic gait or balance abilities, a concern often raised with long-term orthotic use. The improved tolerance and function seen with dynamic strut AFOs may stem from a more adaptive sensory interface, potentially mitigating overstimulation or under-stimulation commonly experienced with rigid devices in children with sensory sensitivities.

Bibliographie / Références

Engelbert R Idiopathic toe-walking in children, adolescents BMC Musculoskelet Disord. 2011;12:61

Williams CM, Exploring health professionals’ understanding of evidence-based treatment for idiopathic toe walking. Child Care Health Dev. 2020;46(3):310–9.

Ruzbarsky, J. Toe walking: causes, epidemiology, Current Op in Pediatrics, 28(1), 40–46.