Comparative effectiveness of conservative and surgical interventions for toe walking in children with Autism Spectrum Disorder: a systematic review

Introduction: Toe walking (TW) is frequently observed in children with Autism Spectrum Disorder (ASD) and may be associated with sensory and motor dysfunctions affecting mobility and quality of life. This systematic review aimed to synthesize current evidence on reported outcomes of conservative and surgical interventions, with attention to unimodal and multimodal conservative strategies. Methods: A PRISMA-based systematic review was conducted using PubMed, Scopus, and Google Scholar. Studies reporting interventions for toe walking in children with ASD were included. Study characteristics, treatment approaches, outcome definitions, and reported improvement rates were extracted. Because of substantial heterogeneity, findings were summarized descriptively according to a predefined outcome hierarchy. Results: Eight studies including 424 ASD patients, aged 2-16 years, were included. Conservative and multimodal conservative treatment arms generally reported numerically higher improvement values than surgical and unimodal approaches, respectively. However, these summaries were unweighted, study-level descriptions based on heterogeneous and non-equivalent outcome measures. Discussion: Current evidence is of very low certainty and does not allow conclusions regarding comparative effectiveness or treatment superiority. Findings should be considered descriptive and hypothesis-generating only. Further high-quality prospective studies using standardized clinical outcomes and long-term follow-up are required.