Can an autistic boy chronic tip toe walking walk normal?

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I recently saw parents of a boy with severe autism. inability to communicate or understand instructions. Chronic tip toe walker, can stand flat foot with no pain. Will ankle orthoses help reduce the tip toe walking or is other treatment? would love any ideas that you may have tried please.

 

My initial question is why do you want to stop it?

Sure, he will most probably end up with equinus and other foot and leg problems however that is the least of this little boy's problem so why put him and the family through something they don't need to.

He will be toe walking for a number of reasons. Generally toe walking will provide additional sensory input via tactile, proprioceptive and vestibular input. One or all of these will be what he needs and the toe walking when he is anxious, stressed or at some defined time will be required. Similar to the flapping that is often characterised by autism, it gives something that is needed. It may also now be a habitual posture the child has adopted and in which case you will never change it as it is now what is comforting for him.

As for AFO, please don't. It will be a sensory minefield and cause everyone heartache especially the child. Some gait retraining or behavioural modification with a replacement of the sensory stimuli works with some children however it needs to be done by someone with experience in working with children who have autism. An OT would be your best colleague for this.

 

What Cylie said.

I have had some success with increasing the sensory input on the plantar surface with a moulded device(soft) and a top cover like techno PVC - In a few cases it has really made a distinct difference to the amount of toe walking. Other cases, no change observed.

Agree about the AFOs and besides which, you'll probably do well to take a decent cast or scan. Too much movement and the child will be able to overcome you no problem should he desire during casting

As a suggestion from leftfield, lycra leggings can sometimes help to increase proprioceptive feedback. Again some varied anecdotal success but it can be very time consuming and challengin from the parents so they have to be really on board. With lycra, more have not worked than worked in my clinical lifetime. Not all failures were to do with the lycra not working. Most of the time it was lack of patient concordance and in the grand scheme, it is not worth the hassle

 

Have you worked much with Theratogs Robin? I have a few kids in them that we have had successes with gait change with however again; compliance, cost, family dynamic and priorities all come into play.

 

All really interesting stuff but doesn't this take us outside the scope of podiatry?

Regards Dave Smith

 

I have a few OT's who fit them. That said, I have done the fit training and am comfortable fitting and adjusting the suit. The straps though, I would only do on the lower limb. It is just a fabric splint and plenty can be done within the area within our area, the straps are designed to go over muscle activation pathways. Really, just a fabric orthotic.

 

It begs the perennial question, what actually is the scope of practice of podiatry?

LL

 

Hi Cylie,

Yes I have. When they were first developed I did the training with Billie Cusick(not sure if she is still affiliated to Theratogs) who made it look amazing

Like most other orthotic devices, selecting the correct patient is essential. My experience was usage primarily with cerebral palsy and spastic neurological conditions. The main thing that we realised was that treating rotational abnormalities was much more successful than anything in the frontal or coronal planes. Very little experience with autism and Theratogs. For the hypotonic child, lycra has better compliance than Theratogs in my opinion.

As others have said, family are the main factor. If they are on board and proactive, go for it. If not, don't even start

Just my opinion though

 

Absolutely, just one of the tools in the tool box. Billie is still part of them last time I looked, I agree, she just makes it look too easy.

Autism and theratogs is a new thing a few colleagues are trialling in the last 18-24mths as it gives additional sensory input, similar to a weighted blanket theory and with good success sometimes. Someday's it's all just trial and error isn't it. I agree with the lycra though, it is far less fussy too.

 

I agree with luckylisfranc, what is the scope of podiatry?

Wouldn't you class it as health promotion? If you know of something that could ultimately help the patient you share it with them.

Many familes that have an autistic child they don't have the time to research such things because they are too tired, unaware, having to focus on more pressing things etc...I know this from experience as my own brother suffered from severe autism all of his short life.

I wonder if you would question it if it was something for a diabetic patient.
I digress, that's what this forum is so good as it allows us to share knowledge and experience that will help the patient.

 

Maybe health education but as a podiatrist who primarily sees just children, the use of theratogs it is a conservative or non-surgical treatment that can make a positive change at the foot and ankle in children therefore why shouldn't I be proficient in the use of it?

I agree awareness is appropriate for generalist clinicians to refer to someone who is able to work with this demographic etc.

Rebecca has made a good point with something for someone who has diabetes. I can do a general diabetes assessment but no idea how to do a toe pressure. My clinic has the equipment and I could probably fumble through if I needed to as I could think through the process. It should be within my scope but I would refer as it isn't something I am proficient. We can't be experts at everything.

I often conduct this assessment: http://www.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAa58000
It has a hand/fine motor component. I have the training to do it. I have conducted many of these. Would I then go on to treat fine motor issues, no. Do I use it to refer the children I see, all the time. But then I use the balance component, bilateral coordination component, the strength and running speed/agility components to consolidate, report and recommend treatment.

Scope is a challenge for every health practitioner. My local GP won't do a PNA, it's in his scope. Does he think he should, no way. I don't know what the answer to scope but the comprehensive use of soft, hard and fabric external devices that change the function at the lower limb, I have no issues with.

 

I have no real issue with anyone treating anything that is outside their scope as long as they have the necessary training and experience. I know plenty of physios who know a lot more about foot ankle biomechanics than many podiatrists. Would I refer to a podiatrist that didn't know so much about foot/ankle biomechanics over a physio who is proficient purely because it is/should be more within their scope of practice - of course I wouldn't.

I am an orthotist so am used to other professions encraoching on to our scope purely because it is required(there are only about 550 orthotists in the UK) and because there are many orthotists who are not particularly "current". I have no problem - if we don't have the manpower or the necessary skills, then someone who can do it and has the resources to is more than welcome.

It is up to my profession to upskill and increase our influence within the Allied Health Professionals if they want to keep their job rather than being protectionist about what is their right to treat.

Gosh that was deep!

 

Bug, (and others) I'm not attacking you or your work, just exploring and working thru an argument so please don't feel threatened.

You wrote

and

and

There appears to be some individual and corporate cognitive dissonance going on here. We want to be free to use whatever mode of treatment we deem relevant

And yet how often do we question the ability or legitimacy of other clinical disciplines crossing over into the podiatric field, like prescribing and fitting orthoses for instance, would we be happy for an OT or neurologist to do this?

Robin wrote

Are we qualified to treat the upper motor neuropathology or just the mechanical consequences?

Rebecca wrote

Is it ok for a podiatrist to treat any condition with any mode of intervention as long as it has an effect on the feet or lower limbs?
Could I do vascular surgery, assuming I was qualified as a podiatric surgeon would you be fine with that?
I don't think it would be appropriate or legal for me to prescribe insulin for a diabetic even tho it may have long term beneficial effects on the condition of their feet and even if tho I may have a good understanding of the mode of treatment and kinetics and dynamics of the drug.

Regards Dave

 

Mahana:

I'm not sure of the relationship of this toe walker and Autism but I cannot see accepting this lying down. It must be calling on pathological tissue stress (TS) somewhere and over ones lifetime, that will take a toll. Autism of this intensity wears down the support system enough without adding eventual TAL's and worse.

In the old days, we called this "Prancers Syndrome".
It was basically habitual if the foot can painlessly reach the ground and there is an adequate ROM of the ankle on the sagittal plane which seems to be the case here.

I cannot understand why you would accept the proprioceptors of the heel to not be stimulated for biofeedback and overwork the triceps and jump to an AFO or more advanced bracing so quickly?

Let's put the kid into braces that his Mom will have to handle as one more thing to do in the morning, forever?

I would recommend a multiple layered 1/4" adhesive felt wedge that fills in the space underneath the heel to just behind the MP Joints, B/L. (It may be very high from the ground to start)

Anecdotally, that will give the heel the sense of experiencing grf and will prompt the lad to power the rearfoot into it, especially when he walks fast or for distances as he fatigues.

As time goes on and the heel is powering, remove the 1/4" layers one by one and when successful, you will see the heel approach and finally touch the ground without any pads and allow a heel toe gait.

it's worth a try.

As a note, if this sounds like a reasonable progression of theory for Prancer's, and you also utilize met adductus derotational casting to correct met adductus by stressing the tissues to force wolf's and davis's laws to work favorably instead of pathologically, then perhaps you can begin to understand optimal functional position casting for orthotic shells and compensatory threshold training of muscles to alter foot types as a reasonable progression of a theory.

If these pads work on this kid, ask his mother if she believes it to be a logical progression or if she would want you to wait for high level evidence before suggesting or using it.

Good Fortune

Dennis

 

Dennis, with respect, there is a well established link with toe walking and autism that has been published within the literature for over 50 years and it has nothing to do with the foot and ankle and nothing at all to do with "Prancer's Syndrome". Old days or not, that is an incredibly offensive descriptor of the gait type that children and adults who have autism may present with. This terminology does nothing positive, instead stereotypes and feminizes a gait which is inappropriate at all times. Toe walking and hand flapping or arm positioning associated with autism is all to do with the brain and how it processes everything about it including the need for repetitious movement and sensory input of sight, sound, tactile perception, vestibular input and proprioception. It has NOTHING to do with "prancing" as it is totally involuntary response.

While I agree that wedging or heel raises work well with some kids with a diagnosed ITW gait . The problem is that for child who toe walks and has autism, the toe walking is intermittent, so use of anything in the shoes may not be appropriate and actually gait problems ie: Why put a heel raise in a health foot with no equinus?

Also, there is no such thing as habitual toe walking any more, there is toe walking associated with or without a diagnosis. The diagnosis then helps guide your interventions or even if you should. There is no one treatment that suits every child with this gait type. Putting something, ANYTHING, in the shoes can be totally inappropriate for the child with autism but every child with autism is different. This is why those of use who work with children of all abilities have all been talking about different options that may be appropriate.

 

Mahana, I suggest you read Cylie's response to the above as most of the information that you require is there.

Also, ensure that you do not use terminology like "Prancer's Syndrome" around the parents. You may find yourself in some trouble.

Dennis, please do not hijack another thread discussing your theories. I have been involved in 2 threads in the last couple of months. One has already turned into the usual minimalist vs maximallist running shoes and this one was fine(even your response - as you are entitled to your opinion) until a plug for your paradigm.

Thanks

 

David, sorry, I thought your response warranted a separate post and am in no way threatened. I'm quite good at knowing what I do and don't know how to do.

I agree with what you are saying but it is a tricky one. I work with many talented health practitioners who's work regularly cross over with mine and generally I am more than fine with it. I just don't know the answer here, I think some of it about self awareness of working within what we know we should and shouldn't do based on our training and area in which we have worked. All very fluffy really.

 

You're right Robin.

It's time for me to stop plugging on other threads than foot typing ones. I'll just stick to the topic.s

I mentioned Prancers historically and stated in the old days.

I also admitted that I had no real experience with Autistic kids.

Peace.

Dennis

 

Bug

Thanks for your reply, this probably needs splitting off into another thread but I regularly question myself about where does my scope of practice finish. For instance I use LA to do tibial blocks for plantar neuro corns and needling v.p. and for diagnostic testing but, how large and how deep can a lesion be before it moves into the field of the surgeon, how far up the leg can I go to apply a nerve block before its out of my scope?

Dave

 

How you doing with the needling, Dave?

Good question. I`ve always reckoned that our scope of practice is determined by our insurance and training. That said, indemnity insurance for an HPC podiatrist does differ according to professional body, regardless of post grad training. Why would that be?