Background: Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder, resulting in an impairment of socio-communicative interaction, restricted interests, and repetitive behaviors [1]. Growing evidence suggests that individuals with ASD may show sensorimotor deficits. Toe walking (TW) is a possible finding during gait observation in about 20% of subjects with ASD [2]. TW persistence could lead to a secondary shortening of the Achilles tendon [3]. However, there is no consensus about TW management.

Objectives: The aim of this systematic review was to summarize the evidence for conservative, pharmacological, and surgical interventions for treating TW in children and adolescents with ASD.
Methods: The study followed the PRISMA recommendations. Articles were searched on PubMed, CINAHL, PsycINFO, The Cochrane Library, Google Scholar, and OpenGrey from inceptions until May 2022. Two review authors independently screened titles and abstracts for eligibility; then independently screened full-text of potentially eligible studies. Hand-searching of the reference list of included studies was also performed by the reviewers to identify additional primary studies. Methodological quality was assessed using the Mayo Evidence-Based Practice Centre tool.

Results: The records identified through database searching were 658. After duplicate removal, 432 records were screened for relevance, and 423 records were excluded. Nine articles were included in qualitative synthesis. All studies were case reports, with a total 17 participants (16 males; age range: 4-15yrs). The methodological quality was heterogeneous (Table 1). All the studies applied a conservative treatment. Five studies assessed the effectiveness of behavioral interventions using acoustical feedback or tactile stimulus in addition to positive reinforcement; one study evaluated the efficacy of a lymphatic drainage technique, and one work used cognitive-motor dual-tasking and primitive reflex integration exercises; the remaining two studies administrated serial casting. All studies reported a reduction of TW frequency, but the follow-up was lacking in 7/9 studies. No studies assessed the effectiveness of pharmacological and surgical interventions in TW subjects with ASD.

Conclusion: There is a lack of high-quality studies with a sufficiently large and well-characterized sample to assess the effectiveness of treatments for TW in children and adolescents with ASD. The present findings strongly support the need for future studies on this area for providing higher level of evidence.

Notes:

1 School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
2 Autism research unit, Villa Santa Maria Foundation, Tavernerio (CO), Italy
3 Department of Physical Therapy, Waldron College of Health and Human Services, Radford
University, Roanoke, Virginia, USA