The Effect of Heel Stimulating
Orthotics on Toe-Walking in
Patients with ASD/ SPD
Mia Thomas, SPT & Victoria Rainaud, SPT
Ithaca College
Introductions
● Mia Thomas
o DPT 2015, Minor Exercise Science
o Lead researcher
o Creator of “InsertHeals”
o Clinical Experience: Orthopedics, Sub-Acute Rehab, & Pediatrics
● Victoria Rainaud
o DPT 2015, Minor Exercise Science
o Assistant researcher
o Past research in gait analysis
o Clinical Experience: Orthopedics, Sub-Acute Rehab, & Long-Term
Care
Autism Spectrum Disorder (ASD)
● DSM-5
o “persistent deficits in social communication and social interaction across
multiple contexts” accompanied by “restricted repetitive patterns of behavior,
interests, or activities” that are present during the early stages of development1
● Cause: Unknown
o Genetic & environmental factors are linked to different types of ASD 2
o Study to Explore Early Development (SEED) 2
● Current Interventions
o Medicinal 3
o Nutrition, Psychology, Audiology, Speech, Occupational/ Physical Therapy 4
Sensory Processing Disorder
● DSM-5?
o Neurophysiologic condition in which sensory input either from the environment
or from one’s body is poorly detected, modulated, or interpreted and/or to which
atypical responses are observed.5
● Cause: Unknown
o Linked to ASD, CP, & Fragile X Syndrome 6
o Prenatal & Birth Complications 6,7
o Environmental Factors 6,7
Toe-Walking
● Causes:
o Chromosomal duplications 8
o Dysfunctional Vestibular System 9
o Hyposensitivity (Sensation Seeking) or Hypersensitivity
o Neural/ brain dysfunction 10
● Persistent Toe-Walking, leads to:
o Contractures of Triceps Surae
o Early Arthritis
o Medial Tibial Stress Syndrome
o Achilles tendinopathies
10
Treatment Options
● Physical/ Occupational Therapy
● Ambient Prism Glasses 11
● Auditory Habit Reversal Technique 12
● Medications 10
● Ankle Foot Orthotics & Night Splints 9
● Serial Casting 9
● Percutaneous Achilles Tendon Lengthening 9
● Botulinum Toxin A Injections 9
Science Behind Heel Stimulating
Orthotics
● Placement of Hemispherical Studs
o Based on force plate reading of normal foot
kinematics of an adolescent during gait
● Increased stimulation by activating Merkel’s Disc (SA I) &
Ruffini Endings (SAII) mechanoreceptors
● Patient’s with ASD can satiate on a single stimulus,
however their response level may be restored through a
slight change in that stimulus
Research: Case Study
● Participant: 8 y.o. male, MD Dx’d with ASD, exhibits a
moderate amount of toe-walking associated with
excitement
o Inclusion Criteria: Diagnosis of Autism Spectrum
Disorder, toe-walking, full ankle ROM
o Exclusion Criteria: unable to actively DF, lack of full
ankle ROM
● Materials: Basic video recording of 143 steps; Polydots;
treadmill; InsertHeals manufactured by SoleSupports
Research: Protocol
Introducing the Treatment
** Determine 1 activity and 1 edible item for positive reinforcement **
1. Introduce orthotic and provide it with a name
a. “Look it’s an insert…it goes in your shoe!”
2. Model putting the insert in the shoe
3. Require participant to touch the insert
a. Provide immediate descriptive praise and edible
4. Have the participant put the insert into the shoe with assistance from parent/
researcher
5. Keep the insert in the shoe for 1 minute
6. Engage in preferred activity and provide praise “Nice job keeping the insert in, let’s
play with the iPad”
Methods
Week 1: BASELINE MEASUREMENTS
• Participant performed warm-up walking bout for approximately 10 minutes in his
hallway
• Immediately following warm-up, video recording of participant ambulating 143 steps
on the treadmill was obtained
• Introduced treatment after Friday baseline measurements using standard protocol;
accompanied by parent education
Week 2: InsertHeals ACCLIMATION
• Parents instructed to slowly increase participant's amount of time he feels
comfortable wearing the orthotics throughout the week using the standard protocol
• Satisfactory tolerance for orthotics was considered by researchers to be at least 30
minutes of continuous wear
Methods
Week 3: ALTERNATIVE TREATMENT MEASUREMENTS
• Participant performed warm-up walking bout for approximately 10 minutes in his
hallway wearing InsertHeals
• Immediately following warm-up, video recording of participant ambulating 143 steps
with InsertHeals on the treadmill was obtained
Week 4: BREAK IN TREATMENT
Week 5: FINAL BASELINE MEASUREMENTS
• Participant performed warm-up walking bout for approximately 10 minutes in his
hallway
• Immediately following warm-up, video recording of participant ambulating 143 steps
on the treadmill was obtained
Methods: Data Analysis
• After each week, researchers used video recordings to count the number of times the
participant struck with one of the following at initial contact: heel, toe, or midfoot
(shuffle/ stomp)
•
Measurements were obtained for each leg separately
•
To increase accuracy, each researcher took three trials of counts for each video
recording
• Averages were found for each day and week, and percent changes were calculated
for each weekly average
• Using results from the 1st day of week 1, an ICC analysis performed to assess
interrater and intrarater reliabilities
Research: Quantitative Results
● ICC values show no correlation between researchers’ measurements
● Mean toe strikes decreased 56% during treatment
● Mean toe strikes was 24% less with treatment compared to final baseline
Video: Baseline Measurements
Video: Treatment Measurements
Video: Baseline Measurements
Research: Limitations
● Lack of Objective and Subjective Measurements
● Poor Intra & Inter-Rater Reliability
● BIAS
o Sample of Convenience
o Inventor Involved in Research
o No Blinding
Acknowledgements
● Exercise Science Department: Jeff Ives, PhD & Deborah King, PhD
● Athletic Training Department: Todd Lazenby, ATC
● Physical Therapy Department: Hilary Greenberger, PhD
● Franziska Racker Centers: Chrysalis Kendall, OT
● Keith Copley, General Manager of Sole Supports
Questions?
References
1.
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3.
4.
5.
6.
7.
8.
9.
DSM-5 Diagnostic Criteria. Autism Speaks. Web Site. http://www.autismspeaks.org/what-autism/diagnosis/dsm-5-diagnosticcriteria. Accessed June 29, 2014.
Facts About ASD. Center for Disease Control and Prevention. Web Site. http://www.cdc.gov/ncbddd/autism/facts.html.
Published March 20, 2014. Accessed July 8, 2014.
Edelson S. Toe Walking. Autism Research Institute. Web Site. http://www.autism.com/symptoms_toe_walking. Accessed July
21, 2014.
Overview of Early Intervention. National Dissemination Center for Children with Disabilities. Web Site.
http://nichcy.org/babies/overview. Published December 2012. Accessed July 8, 2014.
What is SPD?. STARCenter Sensory Therapies And Research Web Site. http://spdstar.org/what-is-spd/. Published 2015.
Accessed February 2, 2015.
Ahn R, Miller LJ, Milberger S, McIntosh DN. Prevalence of Parents’ Perceptions of Sensory Processing Disorders Among
Kindergarten Children. Am J Occup Ther. 2004; 58: 287-293.
About SPD. Sensory Processing Disorder Foundation Web Site.http://spdfoundation.net/about-sensory-processingdisorder.html#causes. Published 2014. Updated February 2, 2015. Accessed February 2, 2015.
Fein D, ed. The Neuropsychology of Autism. New York, NY: Oxford University Press; 2011.
Edelson S. Toe Walking. Autism Research Institute. Web Site. http://www.autism.com/symptoms_toe_walking. Accessed July
21, 2014.
References
10. Edelson S. Self-Stimulatory Behavior. Autism Research Institute. Web Site. http://www.autism.com/symptoms_selfstim. Accessed July 15, 2014.
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Psychiatry Hum Dev. 1996; 27 (2): 81-91.
13. Bradley S, Grey I, Marcus A, et al. Treatment of Idiopathic Toe-Walking in Children with Autism using GaitSpot Auditory
Speakers and Simplified Habit Reversal. Res Autism Spectr Disord. 2010; 4(2): 260-267.
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