Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
Analysis of toddlers' gait after six months of independent walking to identify autism: a preliminary study.
Esposito G, Venuti P. Percept Mot Skills. 2008 Feb;106(1):259-69.
Quote:
This research analyzed gait in toddlers and tested the hypothesis that movement can be used as an early indicator of Autistic Disorder. It was proposed that an early identification method could indicate differences in the gait of toddlers with autism as opposed to those with typical development or with mental retardation. Observational methods were applied to retrospective home videos of 42 children after 6 mo. of independent walking. In particular, the Walking Observation Scale was used, which includes 11 items that analyze gait through three axes of foot movements, arm movements, and global movements. Analysis showed different distributions for the three groups, i.e., the autistic group differed from the other two on scores for the Walking Observation Scale and each axis. After 6 mo. of independent walking, different patterns in gait among groups were evident. These results agree with recently published evidence which acknowledges the importance of movement as an early indicator for differential diagnosis of autism.
Summary/conclusions
The specificity of movement disturbance, in children with autism spectrum disorders, may be of particular interest to addressing diagnostic issues. Indeed, movement symptoms may define specific subgroups of the autistic spectrum disorder. If movement symptoms are found to be present in individuals with ASD, this may lead to new ways of perceiving and addressing existing difficulties [1]. The data of our research, highlight differences among children with ASD, revealing a differentiation between high and low levels of the disease. Said data proves significant, indicating that in analyzing the children's movement capabilities, inferring the future effects of the disease is possible.
Introduction
The autistic spectrum disorder's (ASD) wide variety of effects suggests the existence of different neuronal pathway through which the disease develops. Gillberg [2] highlights at least two different pathways exist which could lead to autism: one connecting with primary temporofrontal dysfunction (late prenatal–early postnatal origins) and another linking to primary brainstem dysfunction (and early prenatal origins). These different developmental lines could produce different subgroups within the category of simply contracting ASD, with each subgroup defined by the differing beginning and baseline of the pathology. Movement is a function that could be used to differentiate these subgroups [3]. The anomalies in walking appear the clearest and most permanent of all movement alterations found in autism. Our study aimed to verify the possibility of distinguishing different subgroups of children with ASD by movement.
Statement of clinical significance
Leary and Hill [1] suggest that the possible neurological explanations for ASD are often being under appreciated because the majority of study hinges on social context as the principal framework for collecting data. They propose that a shift in focus to a movement perspective may provide new insights, which could result in the development of useful tools for future diagnosis and rehabilitation. We propose, according with Leary and Hill, that the specificity of movement disturbance may be of particular research interest with a view to addressing diagnostic issues. In fact, movement symptoms may define specific subgroups of the autism spectrum. If movement symptoms are found to be present in any individual with autism, this may lead to new ways of perceiving and addressing existing difficulties.
Methods
We have used the Walking Observation Scale [4]. The WOS is composed of 11 items which analyze the gait through three axis: foot's movements; arms movements; global movements. This new version of the WOS is composed of 11 items that analyze gait through three axes: (F) foot movements, 3 items; (A) arm movements, 5 items; (M) global movements, 3 items.
The three items for the analysis of foot movements (F) are: (f1) heel-to-toe pattern whereby there is full foot roll-off; (f2) tip-toe pattern whereby the subject walks on his toes; (f3) out-toeing pattern whereby at least one foot, during the gait, points outward. The five items for the analysis of arm movements (A) are: (a1) while walking, the forearms are held parallel to the ground, pointing forward; (a2) the arms are not held in a symmetrical position (e.g. an arm is fully extended downwards alongside the body while the other is held horizontal, pointing forward); (a3) at least one elbow is not held alongside the body, but in an irregular position (e.g. in high position); (a4) the arms are not fully extended downwards alongside the body, in particular the forearms are held rigidly; (a5) arm-and-hand flapping.
Finally, the last three items for the analysis of general body movements (M) are: (m1) myopathic gait or “waddling walk”, the general body movement is not fluid and continuative but progresses by waddling from side to side; (m2) lack of opposition movement pattern, the child does not swing his arms in opposition to his legs; (m3) stereotyped general movement, which is excessive repetition or lack of variation in movements.
The sample comprised of 20 children from ages 3 to 4 both with ASD and typical development (TD).
Results
Our data showed different distributions for the two groups (ASD group and TD group), both for the whole WOS and for each single axis. When we differentiated the ASD group into two subcategories – Low-Functioning and High-Functioning – the results were quite interesting. In particular, at the age of 36-48 months, the WOS was able to measure statistically significant differences (p value < 0.05) between the two ASD categories for the three axes of the WOS. The Low-Functioning ASD scored very poorly whereas the High Functioning scored similarly to the TD group.
Discussion
The resulting data not only showed differences between the two groups (p value < 0.05) but was also able to highlight differences among children with ASD, particularly in regards to the differentiation between children with high and low levels of the disease. These results proved significant because they strongly indicate that through analyzing the children's movement capabilities, it may be possible to infer the future effects of the disease
This has definitely caught my eye- I am requesting full text copies of both of those articles from our medical library at the hospital. I have many children that I am "screening" for autism/ developmental delay. I have been administring the Sensory Profile, but I had never heard of this Walking Observation Scale. (if this turns out to be fake, I'm gonna be mad!) I did find another reference while I was researching. I am still looking for a copy of the Scale.
Walking observation scale: a useful tool for early diagnosis of autism
Gianluca Esposito1, Paola Venuti
Gait disorders in the autistic syndrome have already been acknowledged and widely discussed in many studies (Hallett e al., 1993; Rinehart e al., 2001; Mari e al., 2003). Teitelbaum e al. (1998) have shown that movement analysis is a useful indicator to consider in order to obtain an early diagnosis of autism. The anomalies in walking seem to be the most clear and permanent of all gait alterations that can be found in autistic subjects. Many researchers indeed refer to the autistic way of walking as “parkinsonian mode” and ascribe it to a dysfunction of the dopaminergic system (Damasio e Maurer, 1978; Vilensky e al., 1981). Starting from Teitelbaum’s studies by home-video of autistic subjects, the aim of this research has been to verify through observational tools the difference between autistic and non-autistic children. According to this purpose we have built an observational scale to study the way of walking (WOS: walking Observational Scale). This scale analyses movements through three axis: fluidity, symmetry and activity-passivity. Normal performances in these three levels are reached within 15-18 months.
WOS has been applied to the home-videos of a 40 subjects sample by two observers (agreement by Cohen’s K=0.815). The sample was made up of a group (A) of 20 autistic subjects (with a DSM IV diagnosis, and sorted out in two subgroups: A1, subjects of 18-48 months; A2, subjects of 48-84 months) and a matched group (B) made up of non pathological subjects. Inferential data analysis and cluster analysis indicate differences between the A and B groups. The data derived from subgroups A1 and A2 show that performance improves with ages.
Considered data reveal from the analysis of the sample that there are differences between group A (autistic subject) and B (matched group). These results are in agreement with the recent evidence in the diagnostic field, which acknowledged the importance of movement as an early indicator for the diagnosis of autism. These results demonstrate that the WOS can be useful for the movement analysis and if they are included in a wider diagnostic protocol, they may represent a useful tool for early diagnosis of autism.
1Discof , Università di Trento, Via Matteo del Ben, 5 – 338068 Rovereto (Tn). Tel: 0464–483578 – Fax: 0464–483554
Hi Dawn:
PLEASE let us know what you find out and I also would like to see the WOS.
Subjectivity is always the problem with this type of interpretational testing.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
I have received the research articles I requested regarding the Walking Observation Scale. There was not a reference for reliability for the scale. I contacted my pediatric therapy professor (who works at a gait lab), and she said she had not heard of the scale. She said the other reference by the author was an Italian article, so she couldn't research it that way. I can't find out where to purchase the scale to even look at it, but I contacted the authors, so hopefully I will hear something from them.
However, this has spawned a search for autism & cerebellar dysfunction. I will keep you posted if I find anything that is relevant.
There is not a way to purchase this scale. I have summarized what I found out about it.
Walking Observation Scale- comprised of 11 items that analyze gait through 3 axes: (F) foot movements- 3 items (A) arm movements- 5 items (M) global movements- 3 items
Foot movements
1) Heel to toe pattern
2) Tip-toe pattern
3) Out-toeing pattern (at least 1 foot)
Arm movements
1) While walking, forearms held parallel to ground pointing forward
2) The arms are not held in a symmetrical position
3) At least one elbow is not held alongside the body, but in an irregular position
4) The arms are not fully extended downwards alongside the body, in particular the forearms are held rigidly
5) Arm & hand flapping
Global movements
1) Myopathic gait or "waddling walk"- general body movement in not fluid and continuative but progresses by waddling from side to side
2) Lack of opposition movement pattern- lack of reciprocal arm swing
3) Sterotyped general movement- excessive repetition or lack of variation in movements
The scoring procedure for the Walking Observation scale evaluates each item with a scale from 1 to 100 based on the percentage of time the participant performs a specific item: the higher the number, the more atypical the pattern of walking. (i.e. assessing m1- myopathic gait- the amount of time is calculated for the child to perform the myopathic gait and the amount of time is divided by the total amount of time the child walks in seconds ....if a child performs 300 seconds of myopathic gait in 5 minutes, the scores will be 50% --> 300 sec/ 600 sec, which means 50% of the time he is performing an atypical gait)
The study was done taking home videos from children's first birthday and editing out all footage except where the child's whole body was visible when walking. The total time was 5 minutes for each subject. The videos were analyzed in slow motion at a speed of 4 frames per second.
Differences listed in Gait & Posture (2006) S270-271 showed slight differences in each category between typically developing children and high functioning autism spectrum disorder. There were major differences in each category between typically developing children and low functioning ASD.
The largest difference between typically developing children & high functioning ASD was seen in the arms then general movement then foot. This was the same between typical development and low functioning ASD, just on a greater scale.
Just thought you'd want to read a summary of what I found....
The Following 2 Users Say Thank You to DawnPT For This Useful Post:
There is currently a large study being conducted in Melbourne: children with diagnosed Asperger's and their gait. If you know anyone that may be interested can you pm me. They are currently in the stage of recruitment.
Thanks for that Dawn, would be interesting to see if anyone else is using it.
Last edited by Bug : 13th June 2008 at 06:07 PM.
Reason: Addition.
"Children with Autism have difficulties with communication and social interaction. Around two thirds have an intellectual disability with an IQ below 70. Others can be high functioning and have average or even above average intelligence. But the majority of people with Autism have problems with movement control. Chris has been diagnosed with Asperger’s Syndrome - which has long been considered a milder form of autism. To analyse how his brain is processing automatic walking, the positions of reflective markers placed on his joints are recorded as he walks at various speeds. The information is processed to create a 3D model of his gait. This can be compared to the gait of children who don’t have Asperger’s."
Awesome link David,
For a while I've been interested in gait in children with attention disorders and how so many children travel through their school life under the radar. It has been my understanding that Aspergers, autism and wrestless brain all present with signs in gait. I didn't know that Aspergers presented with a more stable pelvis. many thanks.
Lorraine
I know Anna, she heads up the Gait lab at Kingston Rehab Hospital. She doesn't do workshops etc but does show people around the lab and how it works.
As far as I know Nicole mainly lectures and does the conference/publication circuit.
That is the study I was previously discussing. They are still low on number because of the amount of testing they are doing, they are having a good number drop out due to difficulty. However their results are fascinating!
I have both of their contact details though if you want?
__________________
Cheers,
Cylie.... in a permanent state of confusion
Postural and gait performance in children with attention deficit/hyperactivity disorderPaul Buderatha, Kristina Gärtnera, Markus Fringsa, Hanna Christiansenb, Beate Schochc, Jürgen Konczake, Elke R. Gizewskid, Johannes Hebebrandb, Dagmar Timmanna Gait & Posture (in press)
Quote:
Up to 50% of children and adolescents with attention deficit/hyperactivity disorder (ADHD) exhibit motor abnormalities including altered balance. Results from brain imaging studies indicate that these balance deficits could be of cerebellar origin as ADHD children may show atrophy in those regions of the cerebellum associated with gait and balance control. To address this question, this study investigated postural and gait abilities in ADHD children and compared their static and dynamic balance with children with known lesions in the cerebellum.
Children diagnosed with ADHD according to DSM IV-TR diagnostic criteria were compared with children with chronic surgical cerebellar lesions and age-matched controls. A movement coordination test was used to assess differences in motor development. Postural and gait abilities were assessed using posturography, treadmill walking and a paced stepping task. Volumes of the cerebellum and the cerebrum were assessed on the basis of 3D magnetic resonance images (MRI).
Children with cerebellar lesions showed significant performance decrements in all tasks compared with the controls, particularly in the movement coordination test and paced stepping task. During dynamic posturography ADHD-participants showed mild balance problems which correlated with findings in cerebellar children. ADHD children showed abnormalities in a backward walking task and minor abnormalities in the paced stepping test. They did not differ in treadmill walking from the controls.
These findings support the notion that cerebellar dysfunction may contribute to the postural deficits seen in ADHD children. However, the observed abnormalities were minor. It needs to be examined whether balance problems become more pronounced in ADHD children exhibiting more prominent signs of clumsiness.
Hi all, thanks for a very interesting discussion.
Just o introduce myself, I am full-time podopaeds in a Child Development Centre in an area of the UK where we have an ASD rate of 40%. Thirty percent of my caseload are on the spectrum. I thought I'd pop a few of my obs:
Do not forget that often children with ASD have severe Sensory Integration disorder: this has big implications on gait - particularly failure to integrate visual information, poor proprioception and tactile defensiveness / sensory avoidance. This relates to poor core stability, which along with tactile defensiveness, leads to a high percentage of these children toe-walking.
They also tend to be hypermobile and fatigue quickly, so require advice on gross motor conditioning and may need specific strengthening.
There is a lot of overlap with other disorders such as DCD (formerly known as dyspraxia). Common features tend to be hypermobility, impaired motor corodination, ideation and motor planning
They can be very difficult to examine! Actually, I have just finished a draft on an article with a sensory specialist OT on how to conduct/survive an examination for a child with ASD/ADHD. The draft is at the stage where we are sending it out to people who don't work in our context to test it for clarity, helpfulness etc. prior to submission for publication. Would anyone like to volunteer to be a test reader and priovide some feedback and comments??? Please email me for more info: sal_smillie@yahoo.co.uk
__________________
One of my patients:
"Mummy, I know you're pregnant... but why is your bum big too?"
Postural and gait performance in children with attention deficit/hyperactivity disorderPaul Buderatha, Kristina Gärtnera, Markus Fringsa, Hanna Christiansenb, Beate Schochc, Jürgen Konczake, Elke R. Gizewskid, Johannes Hebebrandb, Dagmar Timmanna Gait & Posture (in press)
It may be of interest that I am at recruitment stage of a study looking at balance, stability, temporal and spatial parameters of gait in children with Developmental Coordination Disorder, with and without UCBL style orthoses. You may have noted my earlier post with regard to the large overlap with all these conditions, including ADHD.
Last edited by Admin : 8th November 2008 at 06:20 AM.
Reason: removed check4spam message
Great to hear from you. I work in Melbourne, Aust with a similar case load and would love to give you some feed back on your article. If you want to fling it to cyliebug@gmail.com
I'm currently doing my PhD on idiopathic toe walking and it's link with sensory modulation/sensory seeking or sensory avoiding behaviours.
Would love to have a chat sometime.
__________________
Cheers,
Cylie.... in a permanent state of confusion
Your PhD sounds very inteteresting! The main way we deal with it here is sensory OT techniques of progressive desensitisation with patting and brushing, using singing to bring an anticipated close to the activity. I can send the parent into sheet if you like it. I can probably find references too if you don't have them already. I am looking at doing a toe walking study too, with our local paed.orthopod using Botox for certain sub-types of ideopathic TW's. In the pipeline...
For everyone who isn't doing their PhD in ideo / sensory toe walking: you might suspect it if when questioned you find that they only toe-walk barefoot or certain situations, hate having feet touched or nails cut (this has obvious complications), hate particular textures: grass, sand, carpet etc. I've got 1 patient who can't even touch his own feet - he takes his socks off by pulling his hand into his sleeve to pull his sock on. Daily dressing is very traumatic!
Re: ASD article - I will email the draft to you. It's intended purpose is as a general introduction to the wonderful world of ASD, and to help make consultations a little more productive than the child diving under the chair and therapist just chatting to parent. Our article does not include de-sensitisation programs, but I can send that to you too
Seems like there is some interesting things happening!
Thanks Sally, the parent sheet would be great. Flinging through any references too if you get a chance would also be much appreciated in case there is something new.
I'm looking more at the cause at the moment rather than the treatment. I, like you and many others, are sure there is a link with idiopathic toe walking however there is no solid research linking sensory integration/modulation and idiopathic toe walking.
I think that the treatment options are great however until we have proof of this link we then can't do some solid research into validated treatment protocols for these kids. For kids without ASD, we use triplanar wedges, vestibular stimulation, brushing, tapping, plates/long orthotics in boots, casting. Some of those also used with kids with ASD.
For your Botox study - you might want to contact a physio at the Royal Children's hospital here in Melbourne: Chris Blackburn. She is currently in the middle of doing exactly this. However the argument still stands - are you treating the equinus or the toe walking habit. I would argue the equinus. There are a number of studies that show even after long term "normal" ankle ROM is achieved a child, adolecence, adult will still toe walk at times.
__________________
Cheers,
Cylie.... in a permanent state of confusion
Hi Cylie, I've emailed the ASD article to you. I haven't got the parent sheet on patting/brushing in electronic form, but I've requested from our OT babe and I'm sure I'll have that soon enough. I don'k think it is particularly ground breaking, but can be useful - especially as parents tend to look at you as if aliens have abducted you and playing a joke on them, they can take the sheet home and realise you were perfectly serious.
Regarding toe walking after attaining sufficient ankle ROM: admittedly I am quite clinically oriented, but how I address it is to break it into two stages firstly making it physically possible (ie. gain ankle ROM) and secondly breaking the habitual element (heel-toe walking along a 'tightrope', and heel walking as daily activities). My thinking here is to re-train motor planning and normalise heel-toe pattern. I also use these activities as a stepping stone to strengthen tib ant and frequently add tib post strengthening as these key players have never experienced normal movement patterns. I would be interested to see what you and others think of this.
__________________
One of my patients:
"Mummy, I know you're pregnant... but why is your bum big too?"
Regarding toe walking after attaining sufficient ankle ROM: admittedly I am quite clinically oriented, but how I address it is to break it into two stages firstly making it physically possible (ie. gain ankle ROM) and secondly breaking the habitual element (heel-toe walking along a 'tightrope', and heel walking as daily activities). My thinking here is to re-train motor planning and normalise heel-toe pattern. I also use these activities as a stepping stone to strengthen tib ant and frequently add tib post strengthening as these key players have never experienced normal movement patterns.
Nothing wrong with clinical orientated. I treat with a similar process. My research is hopefully going to help that, if we have a clearer idea of what causes the habit then it is easier to break, especially if it also involves brushing, tapping, stomping and spinning.
__________________
Cheers,
Cylie.... in a permanent state of confusion
Gait analysis to identify autism
Linear Mode
