ASD, sensory processing disorder, idiopathic toe walking (11/5)

ASD pathophysiology

developmental disability→social, communication, behavioral challenges

neuro based

several genetic disorders associated w ASD

boys>girls—gender related or just easier to dx boys?

1 in 36: changes in diagnosis criteria and better dx efforts in recent years

ASD dx

difficulty in 2 main areas:

• difficulty w/ social-emotional reciprocity, nonverbal communication, social relationships

• restricted or repetitive patterns of behavior (at least 2): stereotyped/repetitive motor movement, object use, speech; inflexible adherence to routine; highly restricted, fixated interested; hyper or hyporeactivity to sensory input

deficits must: cause fxl impairments, be present in early childhood, not be better described by other condition

ASD differential dx

early motor delay could be an indicator

AAP states these signs → immediate eval for ASD

• no babbling/gestures by 12 mo old

• inability to speak 1 word by 16 mo old

• inability to combine 2 words by 2 y old

• any loss of language/social skills

ASD body fx & structures

sensory processing differences, balance, coord, strength, muscle tone (hypo)

activity limitations ASD

gait (toe walking), higher level motor skills, ball skills, gross motor delay

participation restrictions ASD

play w family & peers, participate in school activities

subjective & systems review ASD

previous therapy services (incl EI)

screen for assoc conditions

preferred communication & interaction style

interests

ASD potential impairments

hyper/hyposensitive

balance/postural control

coord

strength

postural alignment

decr muscle tone

ASD body fx & structures exam

sensory profile 2 (standardized)

balance, postural control—static, dynamic

coord—run, jump, hop, skip, stairs

strength—MMT, fxl mvmt

posture

ROM

ASD activity limitation & participation restrictions exam

assess gait

observe motor + ball skills

standardized motor: MABC, BOT-2, school fx assessment (SFA)

ASD co-occurring conditions

ADHD

communication disorders

epilepsy

GI disorders

intellectual disability

learning disability

motor planning/dyspraxia

obesity

psychiatric disorders

sensory processing differences

sleep disorders

toe walking

co-occurrence of intellectual, learning, and sensory processing disability is 83%

establishing goals ASD

top down approach: pt desired goal/activity, work backwards

goal depends on setting & team members

intervention strategies

earliest intervention possible

family involvement in interventions

individualized programming—preferences, interests, strengths

systematic intervention—target meaningful skills, collect data

structured/predictable environment

fxl approach to behavior

motor learning interventions

visual supports—picture schedules, video prompting

task specific training

blocked & distributed practice

exercise & physical activity interventions

active lifestyle throughout lifespan

positive effects on decr stereotypic behaviors, aggression, off-task behavior, elopement & incr on task behavior & improved motor skills

sensory processing intervention

adapt tasks, environment, routines

use w/in natural context—home and community

toe walking

absence or limitation in heel strike in gait- natural part of gait development

persists past 2 y/o

in absence of medical or psychiatric condition

no known cause, family hx common (autosomal dominant)

initially can WB on flat foot when concentrating, equinus contracture may develop

common to have potential various development delays

common comorbidity of sensory processing impairments

toe walking dx

rule out dx

usual presentation: neuro “normal”, normal mm strength/control, prefers walking on balls of feet 100% of time or variable, normal to tight heel cords, can (usually) self correct when prompted

toe walking systems review—which conditions may cause?

neuro: CP, muscular dystrpohy, spina bifida, tethered cord, charcot-marie-tooth—PMHx, reflexes, muscle tone, movement pattern observation

neurogenic+dev disabilities: ASD, sensory processing, developmental coordination disorder—PMHx, clinical presentation to r/o conditions

traumatic/biomechanical: club foot, leg length discrepancy, scarring, tumor in gastroc belly—PMHx, postural alignment, leg length discrepancy

toe walking subjective

birth hx

any existing dx

when it began

is child able to self ccorrect when prompted

previous milestone attainment

toe walking tool: questionnaire to differentiate ITW from other conditions

ITW body function & structures exam

ROM/flexibility: silfverskiold test (compare DF ROM with knee ext vs knee flexed)

strength: weak core + hips, eccentric PFs

coord

balance

posture: calcaneal alignment, longitudinal arch development

sensory processing differences

activity limitations & participation restrictions exam

impairments: forefoot IC, decr hip/knee movement, decr push off, stride length, velocity, loss of first 2 rockers; higher level motor skills & stairs

age appropriate standardized assessment for motor skills, observe snesory involvement

ITW ankle ROM intervention

stretch: DF, hamstrings, hip flexors; goal=10 deg

serial casting: may be indicated if <0 DF afters tretching & strength program; goal=10 deg w/ KE

orthotics: may be appropriate if full ROM but still toe walking to “break” pattern of toe walking

ITW strength interventions

DFs+PFs, hip abd+trunk

ITW gait interventions

address other deficits: balance, coord, gross motor skills

casting + PT unsuccessful→tendon lengthening?