Physical Therapy for Treatment of Toe-Walking in Children with Autism Spectrum Disorder

In this third installment of articles providing insight into the benefits of physical therapy for individuals with Autism Spectrum Disorder (ASD), I will elucidate how physical therapy can reduce toe-walking, a common presenting symptom of the disorder. Toe-walking is a common phenomenon in children under age three, but it typically fades by age five. In individuals with ASD, this behavior often persists. There is concern that this can perpetuate gross motor delays and widen the gap with typically developing peers as children age. 

Toe-walking is exactly what it sounds like; walking or running in a tip-toe position. It typically manifests due to abnormal sensory input in individuals with ASD, and in this specific case, the vestibular system has been implicated. The vestibular system provides feedback to the brain regarding body position and motion using structures in the inner ear. It creates a sense of the body’s movement and need for stability (balance) relative to its surroundings. In the case of a dysfunctional vestibular system, walking on the toes creates a position of stability and increases sensory input to the joints.

An altered kinesthetic sense, created by the proprioceptive system, can also cause toe-walking in individuals with ASD. In the proprioceptive system, sensory receptors in the joints provide feedback to the brain regarding limb and joint position relative to the rest of the body. This is required for coordinating multi-joint movements, such as walking and running. Each joint has to articulate with another, i.e.: the hip and the knee, to create motion. If this sensory information cannot be accurately relayed to the brain, the child will again seek a position of increased sensory input and joint stability, which results in a toe-walking pattern.

Finally, the tactile system is responsible for relaying sensory information from touch to the brain. In the case of children with ASD, this can cause heightened input from physical touch, which may be perceived as aversive. In the case of toe-walking, the floor may create aversive input, and walking on the toes minimizes contact with the floor.

The compensations that are created for this abnormal sensory input can lead to worsened gross motor delays and musculoskeletal impairments. Prolonged toe-walking causes shortening of the Achilles’ tendon, which leads to tight calf muscles and a physical barrier to lowering the heels to the ground. If toe-walking persists to the point that the muscles restrict ankle range of motion, this creates another limitation to creating a typical gait pattern. Children who reach this point may need casting or bracing to correct the muscular restrictions before sensory reintegration and gait training can be undertaken.

A physical therapist will perform an evaluation to determine which factors are causing a child’s abnormal gait pattern. This is done by watching the child walk, testing ankle muscle flexibility, assessing balance abilities, and determining if the child exhibits gross motor delays. Once it can be determined which system(s) are contributing to toe-walking, a physical therapist can provide interventions to correct the problem.

Stretching has been utilized by many physical therapists to correct toe walking, but muscular tightness is often a result of toe-walking, not the primary cause. If a child is demonstrating decreased ankle flexibility, then stretching is appropriate, but it is not effectively addressing the underlying problem. This can be done by teaching the child and parent stretches that can be performed either as an independent exercise or as an assisted stretch.

In order to correct sensory deficits, the vestibular and proprioceptive systems must be addressed. The vestibular system can be trained by having the child perform exercises that reduce other sensations that allow him to detect his body position. Swinging is one way that physical therapists can do this; the child’s feet are not in contact with the ground, and the motion of the body relative to its surroundings can be detected only visually and via the vestibular mechanisms in the inner ear. Having the child perform balance activities with the eyes closed is another way to improve the input from the vestibular system, as this does not allow for visual input in determining body position. Adaptations to changing terrain or obstacles can also help to retrain the vestibular system, as the new input requires a change in head position for visual detection, followed by a change in body position to react appropriately. These interventions start slowly, and the physical therapist may have to provide additional cues to the child in the early stages of physical therapy, but input can be faded as the child’s vestibular function and kinesthetic awareness improve.

The proprioceptive system can be addressed using activities that require articulated, multiple joint movements to complete. Kicking is a great way to do this. The visual input of an external object, such as a ball at the child’s foot, provides a clue as to where he needs his foot to go to complete the task. Placing the child in different positions, such as kicking sideways or across his body, will help to train this sense further. Another way to provide an external cue is by placing visual targets on the ground during stepping or hopping activities. This will help the child understand where his feet need to go when they return to the ground. As he becomes more proficient with these tasks, visual cuing can be reduced. The brain and body will learn to communicate regarding position in the environment and create adaptations in response to change.

Treating toe-walking in children with ASD is necessary to ensure appropriate gross motor development and improving the ability to interact with their environments. This can be done with a combination of clinic visits and home exercise programs. If you have any questions or would like to speak with Dr. Kopko regarding treatment of toe-walking in your child, please contact her at 614-245-5359, by email at claire@showtimestrength.com, or visit her website, www.clairekopkodpt.com.

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