Evaluating serial casting for idiopathic toe walking in autism spectrum disorder. (Anne McNee)

0:00Welcome to the ResearchWorks podcast broadcasting live from the Oceana Academy of Civil Palsy and other childhood on-set disabilities conference 2026 in beautiful city of Hope Art Australia. Join Dr. Danipool and the ResearchWorks team as we bring you an exclusive series of interviews with visionary keynote speakers and leading presenters. Captured right here and meet the groundbreaking discussions and innovations shaping the future of disability research and care. Hello everyone, welcome back. So glad you could join us for another episode. We are here at Oceania 2026 in Provide Tasmania, Australia, Marissa. How's your brain going? It's good. Yeah. Yeah. Don't need that bit of paper to write my notes down to get things out of my brain but it's been amazing. It's been so inspiring. It's been so inspiring. And every time we speak to someone we add another element to things we need to consider and how we can implement it into our practice. And our next guest is no exception to that because there's so many clinical implications for this when

1:02I read the title of this article and looked at the abstract I thought wow so many of our listeners are going to love this. So welcome to the microphone and to the pod and Mickney. Thanks for having me. Thank you. So nice to have you here. Look you have come all this way. It's a long way from the UK. It's a long fly, doesn't it? But you've come all the way to Hobart. We're so grateful for that because you presented on an article that's titled evaluating the effectiveness of serial casting for idiopathic toe walking in children with autism spectrum disorder. We don't see many publications on these. We don't see much work being done on this yet clinically. It's something we think about a lot and have conversations with parents law as well. How about you give us a bit of a background about why you decide to go into this area and look at this data? Yeah, no that's a great question. So it's interesting is that so if we could probably reduce the title down to serial casting in autistic toe walking. Yeah. Only because there's been a recent publication in regards to

2:09idiopathic toe walking is something we all come across. And there's a big spectrum and I come from the orthopedic perspective. So the kids I see have a contracture of ankle blood flexors. They've got a fixed ankle blood flexion contracture. So I think there's probably split into two. There's the toe walkers that don't develop a contracture and those that do. And I'm not sure we know an awful lot about why the wise and the house. And so I suppose the serial casting came in a little bit more. We started doing a lot more I work in newer orthopedics at the Chelsea Westminster Hospital in London. And we're a tertiary hospital center for northwest London. Okay. And so we do see a lot of people of all different neurodisabilities. But we seem to be picking up a lot more children with autism, a lot more idiopathic toe walkers. And in the literature you'll find that idiopathic toe walking sometimes has well autism. They may or may not have autism. But it seems that they might be very much a distinct group themselves. So

3:10also in the literature I think what you find is that everyone says it's a throwaway line that is actually they don't tolerate it. They need an ascetic to change a cast. They won't tolerate surgery. And that's just not what we found in clinic. And I suppose England was hit a little bit differently from Covid. And surgery closed down all the in our hospital, specifically all the theaters we used as intensive care. So we had no surgery. So actually we've got an option of providing casting. So our casting tended to take off a little bit more or not take off. That's probably the wrong word. But we seem to be wanting to do something. And so we thought we'd have a try of those with a little bit more substantial contractor than we probably would have tried before. And actually the results we thought we found we were seeing some good results and that they were tolerating it the way we were casting. And so that's why we decided we'd have a look at

4:11our results over the last five years. Oh that's fantastic to be able to publish this as well and to be able to talk about this information because you're absolutely right. There are a lot of these throwaway lines and I'm not sure where they necessarily come from but they do make their way through. And we all start repeating it and we kind of have to wait and go where did we get that information from? You know and I've certainly heard that too. You know if you're thinking about serial casting and a child has auto-spectrum disorder it's like caution in terms of a management strategy. Isn't it? Absolutely but in terms of and what you think if we're not doing this for kids and I know even as a therapist I've had these sometimes where I think about trying something with a child and I think I don't think they'll tolerate but I'm learning more and more that I give it a go but give it a go knowing what they're like. So having things in place to help their tolerance and I know you spoke about that when you you were applying the serial cast you obviously you were acknowledging they had ASD and you used techniques to help I guess their acceptance

5:11as well. Yeah that's right I mean we use a as I said yesterday we use we use a normal clinic room it's nothing fancy we've just got some LED lights that change that change color that they can choose they can use the buttons you know we give them the controls you're in charge of the lights for the room. The lights are the bright clinic lights are down we've got a light in the ceiling if we need we don't tend to use it a lot but we do have access to a sensory box which have got lights and bubbles and things in a tiny clinic room but we also give them the option of what do you want to watch on TV? What do you want to you know do you want to use your iPad? We get the parents to say you know if they settle with food if it's at a time where they need to be with their hungry brings some food we're not bothered in the slightest bring your sibling we you know they can be involved in the process they're helpful they've got hands they can help bring the casting kit in you know with us and go to go and get so we can adapt it to them but I think you know parents of children who have autistic spectrum disorder know they've got to prepare

6:12their child for whatever's coming so the clinic appointments are longer we have a discussion with them we see them probably twice to discuss the process so they fully understand before we go ahead and and I think the other thing that we found is very helpful is that we do casting in sitting so they are in control they know what's going on they like to see it's not in print and we also find we can control the food a bit better when it's in sitting in a platform so yeah those things seem to work for us and I love that there's no like major wild adaptation that you had to do something for but what you're talking about is knowing the child give them some control altering the environment if you can so that it suits their needs but also ensuring that you're not rushing into it and I think that's often where things go wrong isn't it is if you're not spending that adequate time and preparation yeah and I think that's right you know if you think you're going to take a minute it's always going to take 10 that's right if you think you're going to take 10 minutes you you you relax into it actually you get it through a lot quicker I am not saying

7:18certainly for you know when you come talking about autistic I mean I have split it in to your different autistic spectrum classifications I don't know if that's the one you know there are lots of different ones around but we stuck with the simple the level one needs less less input or support and three needs a lot more the three's you know shouldn't have more needs probably do take longer yeah but we just built that into our clinic and or you adapt the clinic to for their needs yeah just as big an idea I know or check it'll be different for different kids but if they are level three and you're doing are you doing bilateral casts you know if they're a tow walker they will be bilateral and how long would that take maybe what what does a first cast look like and what does look like a second cast so when the first cast so we will have gone through all the equipment they will have seen all the casting material that they need to see they will have seen the room before we will have described the whole process they will have seen the kitty goat sprint that we tend to use afterwards um so we've hopefully shown them all the things that they will meet yes we've shown them the plaster saw we've turned the plaster saw on they've

8:21felt the vibration from the plaster saw so it's so so the first up point we will assess them again and we'll have everything out and do you remember all these things and then the fact it really does depend on the child but actually if they're settled we can have them out the door in 45 minutes wow okay um but then of course the change of plaster is at change of casts yes obviously those ones do probably take a bit longer and yeah but you know we tend to have our appointments and so it's not much longer than that I was going to say it doesn't sound much much different to that is does it I think the fact is you're putting in lots of preparation that goes ahead of time um but it's also it's important to know because I think people might think it might take so long they're still there for so long what that could look like and preparation is key no I think we've only had one chap who was um is on the autistic spectrum but he used cerebral palsy and you know there was one he took quite most of the morning but that was a specific issue that we needed to get to the bottom of he didn't go shopping in a particular shop so he didn't want to be involved okay so actually you know it's it's actually trying to work out and sometimes

9:24without parents there we can get to the bottom of what the issue is and often it's not the casting yeah okay often it's something else yes but we've got that relationship which seems and I think it doesn't take long as long as you're there asking the parents and the child actually what they what they need it's a soft skills again it's a soft skills yeah yeah they come in play just as much as the clinical skills oh absolutely absolutely so getting to your results now so this is a retrospective review during this period of time and he had 28 children come through that you including the analysis aged in 2 and 14 tell us a little bit about what that looks like for you in terms of oh you're okay so it's a little bit so actually because people start jumping up and down about the two-year-olds so I think there was that we actually excluded that from the results that we've now published so it's actually between 3 and I think it's 3 and 14 now so actually I went back through the data and I added some and actually there was one that I was a bit worried about so actually I've taken them out because we're not sure of

10:25diagnoses so I didn't want to muddy any water so so in terms of what you found from those kids in terms of their tolerance yeah and and what the results are from a I guess range of motion perspective what was that yeah so if we start with the clinical results as you will because that's what people are interested in is that actually they initially the overall group has a planned flexure contracture about just over 10 degrees the the whole group okay the ASD level ones and two ones and twos are around about eight degrees okay but your ASD three have come to us and they're they're getting towards a 20 degree contracture so at start of casting okay so actually what is interesting is splitting the different groups is that actually we're getting the really more the ones that need more help yes um that have more trouble with life a lot later right um and so but then overall as a group they gained about 13 degrees of range of motion so we aimed towards planter grade or just beyond right um that is not a functional um I'm out of movement

11:31but I think we find if they do um stick to the um you know if there's a post casting protocol which I'm sure we'll go through um and they use a um ankle and they're using their spins we do find that if they're getting a heel strike they do tend to gain more range right yeah following the casting so that's why we don't want to push it any way beyond that um and it seems to work for us so where that is with measured with the knee both inflection and extension to be honest I'm more interested in the knee extension yes because that's equates to standing and walking that's right that's right and how many casts on average were there it was an average of uh there was a um average of three casts but two in one and four okay depending on their contracture yeah right so those are more of the clinical outcomes what did you find with regards to their tolerance and and how they actually took to serial casting yeah so actually because you've measured that via an interview on us and we did we did a questionnaire with 15 of those families um just to get

12:35parental feedback actually what do you think is it harder than you think is it what are you what are you gaining from it and so actually what is the overwhelming um feedback was that it was really manageable that they needed information and most people said they had enough but someone really highlighted the fact that actually we need to give them as much information as we can we need them to have because we know that that's what they need and so um I think that just underscores the importance of you know sensitive and um accessible information for the child and their family so they can go through it so they're understanding what the process is coming up so that was one of the feedback from them and overwhelmingly they all achieved at least one goal and the goals this is not just a range goal this is about um the goals were along the lines of improving standing balance improving um they're walking pattern obviously and improving their endurance yes yes and I think standing balance is probably the thing that I wouldn't like to focus on most in regards to an outcome because

13:38then they can stand still in the school queue you do a lot more standing still than you do walking that's absolutely right or when you have a yeah plan of actually contracting it's really going to impact you functionally you can't stand still and so then you're going to get in trouble um yeah can you talk to us about us are you single late single limb stance as your measure for balance we did and it's a retrospective study we're looking at clinical notes and we tend to look at single limb stance and obviously um those who are less severely affected um were able to stand on one leg and actually they actually improved and actually we've got some who are now at two years done the track and they're still improving their single limb stance because they've got their range they're able to do it so they can practice it um the ASD level three often they couldn't stand on one leg so it wasn't the best measure but what parental feedback has been is that he now stands and looks me in the eye and that's really disconcerting because he never stood still before to look me in the eye so actually I think we need to probably reflect we know we were

14:40going for probably need a different measure and actually possibly standing with your hips and knees are neutral standing still and how long can you stand still for we hadn't probably we we haven't we've hit the floor in regards to the measurement um or to make it unaccessible to some so when you're when they had cast supplied as well did you give them exercises to do at home whiny specific recommendations yeah so they get changed the cuss get changed every week um we wedged the bottom of the cast if they're in a plant flexed position to ensure that they're getting heel strike and we want them to be able to stand with the hips and knees in neutral feet in a neutral position facing forwards um and that so they go home with they have to do standing balance for you know it is a bit you know how long's a piece of string but it's at least that we try and get it for one song so that's about three minutes yeah well this is focus to think about doing it right that's that's the point yeah three minutes yes do it for a song great um and they have um so

15:41we're looking at stretching behind the knee because obviously it's a below knee cast so they do either bilateral or unilateral long leg sitting wonderful prone lying if that's more comfortable because then they can be distracted yes to get the gravity to help and then walking patterns so can you walk on your heels you know that's when you're getting towards the um the plantar grade position or just walking from this tree to the next tree whenever you're walking to school um with your feet in a neutral position so just giving them kind of physical points yeah that they can it doesn't you don't want to do it for long but I just from this point to this point every day you will do that um so lots of standing and walking in standing and walking is the main thing brilliant and when the uh kasa off all the main recommendations after that period of time was to continue the same kind of it is similar but we have developed a um a program we're looking at strengthening and stretching in of the ankle plan flexors and dorsiflexes so trying to strengthen in that gained range um as well as functional measures and then working on endurance

16:43we get sent them off with a selection there's three or four parts to it stretching kind of strengthening balance right and then walking activities and then in different planes yes so you know looking out to the side as well as going in that side of the plane um and we refer them to the local physio team we're a tertiary service we refer to the local community teams there are different ones around northwest London and so um we hope that they'll progress their exercises or adapt them so they know they yeah they're getting on with them right so they're not having to come back into the hospital all the time we did ask the parents that and actually only 60 percent got a physio program okay but what they did mention is that they they found it really helpful okay um and I think that's a reflection of how much input they've had potentially in the past um and that they've actually had someone do something and it seems to work so let's move on with that so I think that's um important for us to know that we will continue to do that and hope that um that the local teams can

17:43with within their capacities can help us with that and I love that you said that as well there's been within the Australian context there's been uh a new sort of addition to how uh disability services are delivered and uh for context for that you've got the NDIS but there's also a new stream called thriving kids and in thriving kids there was talk to start off with that there'll be no physiotherapy input for these children with ASD and so you know that the groups were very loud and in campaigning going there actually is a role and I feel like this work really does highlight it across the three different levels that you can get this improvement because if you don't I mean everyone will know if you can't stand if you lose range of motion and they get old and they get contracture well then that's going to be a burden on the health system if you need to have surgery for something that you couldn't have prevented through quite conservative management not that many hours not that many hours no and it's interesting isn't it because it's it is improving that but it's also about footwear and actually about you know progressive foot deformity

18:44and needing surgery down the track if it's not addressed um there's some significant things that we can do at a particular point in time and which is which is what we're meant to do that's part of our profession it's there's prevention as much as it is that intervention and ideally prevention is the best way to go oh absolutely and I think it's interesting you say that because I think it is prevention and every you know in idiopathic toe walking and around the serial casting world um that you think well it doesn't last for long so what's the point and I think I would argue that actually the the results we saw actually some people are maintaining it up to two years summer not all and that's yeah but that's a reflective of a growing body that's right yeah so actually your bones grow first and then your muscles catch up how many six typically developing 15 year olds do you know that I've got a property a langle of 90 yes absolutely right so I think if you can maintain a foot position foot structure that is able to hold them you know able to hold a normal shoe rather than having such a

19:48broad foot then actually maybe you do have to do it again we always say even to those who have idiopathic toe walking or the autistic group we may need to have to do this again if you grow really quickly chances are you will tighten up yes that's right and I don't see that as a bad thing I don't think it's either as a failure because it's always said as a failure absolutely right the language around that often is is that way inclined but yeah I think this is really encouraging for us as clinicians and and having these conversations of families and with doctors main message then from you and as a final take home for like clinicians and people who are listening I think serial casting in autistic toe walking is not inaccessible I think it's very manageable parents are happy that you're doing something I think we've got a lot of work to do on what whereas how we're assessing and what we're assessing and I think my take a message for clinicians are get the children who are walking on the toes who are developing a plan to flex your

20:48contracture get them get them seen earlier you know be aware that of the musculoskeletal system as well as all the other needs I know they've got a lot of other needs and that may well be a focus but this may help yeah and you need casting for less time if you've got less of a contracture yeah that's right that's a good final point well thank you so much for sharing this work with us we are so intrigued by it actually and it's it's work that I know that a lot of people will will use to advocate for for the people that they see as well so thank you so thank you for having me it's been brilliant oh good I'm so glad I'm so glad um well enjoy the rest of your time you have here in Australia thank you very much and all of our listeners hope you really enjoyed that as well look um there's so many more interviews to come still so stay tuned we'll talk to you all again really soon bye bye