Toe Spread Out Exercise With and Without Walking Surface Training in Children With Autism

Effects of Toe Spread Out Exercise With and Without Walking Surface Training on Navicular Drop and Jumping Performance in Children With Autism

Flatfoot is a common postural deformity in children, characterized by the collapse of the medial longitudinal arch, leading to abnormal foot posture, gait disturbances, and postural instability. Arch collapse in flatfoot is also due to navicular drop a condition where the navicular bone, located in the midfoot, shifts downward excessively when bearing weight.

This excessive drop reflects poor structural support in the foot and is often linked to weakness in the intrinsic foot muscles. The intrinsic and extrinsic muscles of the foot, particularly the abductor hallucis (AbdH), play a vital role in maintaining arch stability.

Strengthening exercises like toe spread out movements are specifically designed to target these muscles by abducting and flexing the toes, helping to support and elevate the medial arch. This study aims to investigate the combined effect of toe spread out exercises and walking surface training on navicular drop and jumping performance in children with ASD, focusing on muscle strength and sensory-motor integration to support functional movement and postural control. This randomized controlled trial will be conducted over ten months at Step Up Autism Center and Rehab Care, Lahore, following ethical approval from the Research Ethical Committee of Riphah International University Islamabad (Lahore Campus). Children aged 7 to 12 years, clinically diagnosed with autism spectrum disorder, navicular drop, and poor locomotor skills will be recruited through non-probability convenient sampling. After obtaining informed consent from guardians, eligible participants will be randomly allocated into two groups. Group A will perform toe spread out exercises only, while Group B will perform toe spread out exercises combined with walking surface training. Both interventions will be carried out three times a week for eight weeks. This will be a single-blinded study, where the assessor will remain unaware of the group allocations. Data collection will involve pre- and post intervention assessment using the Navicular Drop Test, Wet Footprint Test (Clarke's Angle), Horizontal Jump Test, and the Test of Gross Motor Development-Second Edition (TGMD-2) to evaluate changes in foot posture, arch structure, lower limb power, and locomotor skills in participating children.

Study Overview

• Status: Not yet recruiting
• Conditions: Autism
• Intervention / Treatment: Other: Toe spread out exercise; Other: Toe spread out exercises with walking surface training

• Study Type: Interventional
• Enrollment (Estimated): 34
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Imran Amjad, Phd; Phone Number: 03324390125; Email: imran.amjad@riphah.edu.pk
• Study Contact Backup: Name: Fareeha Kausar, PPDPT; Phone Number: 03216758180; Email: fareeha.kausar@riphah.edu.pk

Study Locations

• Pakistan
  • Punjab Province
    • Lahore, Punjab Province, Pakistan
      • Special needs and autism community center
      • Contact: Fareeha Kausar; Phone Number: 03216758180; Email: fareeha.kouser@gmail.com
      • Principal Investigator: Eman Amjad, MSPPT

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Children aged 7 to 12 years of age
• Children of both genders male and female
• children having navicular drop >9mm

Exclusion Criteria:

• Neurological conditions affecting movement (e.g., CP)
• Inability to follow simple verbal commands
• Visual or auditory impairment impacting motor performance

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Toe spread out exercise group	Other: Toe spread out exercise; Partcipant will sit on the edge of chair with hips and knees at 90 degree flexion, with foot flat on the floor. This position makes sure that there is equal weight distibution across the calcaneus, metatarsals and phalanges. It is also made sure that the feet are hip width apart.Then the participant is asked to lift the toes off the ground(dorsiflexion) , keeping the heel and ball(metarsals) of foot on the ground. While maintaining dorsiflexion of toes, the participant will be asked to flex the first toe medially (bending downward and toward the midline), similarly the fifth toe will be flexed laterally (bending downward and away from the midline) .The position will be held for 3 to 5 seconds with 10 repetiotns.
Experimental: Toe spread out exercises with walking surface training group	Other: Toe spread out exercise; Partcipant will sit on the edge of chair with hips and knees at 90 degree flexion, with foot flat on the floor. This position makes sure that there is equal weight distibution across the calcaneus, metatarsals and phalanges. It is also made sure that the feet are hip width apart.Then the participant is asked to lift the toes off the ground(dorsiflexion) , keeping the heel and ball(metarsals) of foot on the ground. While maintaining dorsiflexion of toes, the participant will be asked to flex the first toe medially (bending downward and toward the midline), similarly the fifth toe will be flexed laterally (bending downward and away from the midline) .The position will be held for 3 to 5 seconds with 10 repetiotns.; Other: Toe spread out exercises with walking surface training; Walking Surface • The participant will be barefoot and will be asked to walk in their usual manner and speed. • There will be three different surfaces i.e pile carpet (18mm thickness) for soft sensation, vinyl tile for flat smooth and loose gravel (average height of 14mm) for uneven sensation respectively. • The participant will be asked to walk on the 4 meter walking surface, taking 10 rounds on each

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Navicular Drop by Navicular Drop Test	The Navicular Drop (ND) Test evaluates medial longitudinal arch stability by measuring the difference in navicular height between neutral/seated and weight-bearing positions. A drop of 5-9 mm is typical, while > 10mm indicates excessive pronation (arch collapse) or instability, often linked to structural issues	Baseline and 8th Week
Jumping Performance by using Horizontal Jump Test	Horizontal jump tests, particularly the Standing Long Jump (SLJ) or Broad Jump, measure lower-body explosive power by recording the furthest distance of three attempts from a takeoff line to the nearest heel landing. Elite men typically exceed 2.50 m, while women excel over 2.0 m , often aiming for a distance greater than their height.	Baseline and 8th Week

Collaborators and Investigators

• Sponsor: Riphah International University
• Investigators: Principal Investigator: Fareeha Kausar, PPDPT, Riphah International University

Publications and helpful links

General Publications

• A-C, BOCA I-C, RUSU M-E, CRISTEA D. The Benefits of Physical Therapy in the Rehabilitation of Flat Feet in Autism Students between the ages of 10 and 14. Romanian Journal of Physical Therapy/Revista Romana de Kinetoterapie. 2023;29(51)
• Kim J, Lee J, Kim D, Islomjon B, Lee K, Yoon T. Acute response of toe-spread-out exercise on medial longitudinal arch height and balance. The Asian Journal of Kinesiology. 2021;23(1):27-33
• Kang M-H, Cha S-M, Oh J-S. The effect of toe-tap exercise on abductor hallucis activity and medial longitudinal arch angle in individuals with pes planus. Isokinetics and Exercise Science. 2020;28(4):415-22
• Lee H-j, Kim S-h, Baik S-m, Cynn H-s. Comparison of Foot Muscle Activity During Short Foot and Toe Spread-out Exercises in Different Weight Bearing Conditions in Individuals With Pes Planus. Physical Therapy Korea. 2024;31(1):63-71.

Study record dates

Study Major Dates

• Study Start (Estimated): February 4, 2026
• Primary Completion (Estimated): July 30, 2026
• Study Completion (Estimated): August 30, 2026

Study Registration Dates

• First Submitted: February 23, 2026
• First Submitted That Met QC Criteria: February 23, 2026
• First Posted (Actual): February 27, 2026

Study Record Updates

• Last Update Posted (Actual): February 27, 2026
• Last Update Submitted That Met QC Criteria: February 23, 2026
• Last Verified: February 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Autism Spectrum Disorder; Mental Disorders; Neurodevelopmental Disorders; Child Development Disorders, Pervasive; Autistic Disorder
• Other Study ID Numbers: Eman Amjad

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No