Investigation about proposals for rehabilitation of body balance in autism spectrum disorder: integrative literature review

Rodrigues, Nathana da Graça Sartori; Melo, Ellen Aguirre de; Santos-Filha, Valdete Alves Valentins dos

doi:10.1590/2317-6431-2024-2948pt

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Literature Review • Audiol., Commun. Res. 30 • 2025 • https://doi.org/10.1590/2317-6431-2024-2948en linkcopy

Investigation about proposals for rehabilitation of body balance in autism spectrum disorder: integrative literature review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose The present study aimed to review the national and international literature regarding proposals to rehabilitate/train postural balance in subjects with Autism Spectrum Disorder (ASD) and verify the speech therapist’s performance in that area.

Research strategy searches were carried out in the VHL, MedLine and Scopus databases using the descriptors autism spectrum disorder, postural balance and rehabilitation. Selection criteria: articles published in national and international journals in English, Spanish and Portuguese. Studies not addressing the subject, that only dealt with the assessment of postural balance, that reported other syndromes and/or sensory impairments associated with ASD and those unavailable for reading were excluded. The investigators evaluated the samples, objectives, instruments/ methods/techniques for assessment and rehabilitation of postural balance, therapeutic guidelines, professionals involved and main results obtained.

Results 53 articles were retrieved, 12 being selected for full reading. A variety of rehabilitation/balance training proposals for children and adolescents are identified, based on physical activity approaches and motor exercises. Improvement was observed in all proposed interventions, carried out by Physiotherapists, Occupational Therapists and Physical Educators.

Conclusion From the reviewed studies analyzed, it was concluded that, although it is a topic little explored by the scientific community, there is a wide range of feasible proposals for rehabilitation/training of postural balance in subjects with Autism Spectrum Disorder, capable of adaptation and reproduction in Brazilian clinical contexts. Even so, we point out that the research did not include the Speech Therapist in the postural balance assessment process, nor in the rehabilitation/training stage, although their role is necessary for comprehensive care and therapeutic success.

Keywords:
Autism spectrum disorder; Postural balance; Rehabilitation; Movement; Review

Title	Author(s)	Journal/year	Country
“Effect of hippotherapy on motor control, adaptive behaviors, and participation in children with Autism Spectrum Disorder: a pilot study”	Ajzenman et al.(¹²)	American Journal of Occupational Therapy/2013	United States of America
“A therapeutic skating intervention for children with Autism Spectrum Disorder”	Casey et al.(¹³)	Pediatric Physical Therapy/2015	Canada
“Using Posturography to examine the immediate effects of vestibular therapy for children with Autism Spectrum Disorders: a feasibility study”	Reinert et al.(¹⁴)	Physical and Occupational Therapy in Pediatrics/2015	United States of America
“The effect of SPARK on social and motor skills of children with Autism”	Najafabadi et al.(⁵)	Pediatrics & Neonatology/2018	Iran
“Effect of Motorized Elephant-Assisted Therapy Program on balance control of children with Autism Spectrum Disorder”	Nuntanee and Daranee(¹⁵)	Occupational Therapy International/2019	Thailand
“Short rehabilitation training program may improve postural control in children with Autism Spectrum Disorders: preliminary evidences”	Caldani et al.(⁷)	Scientific Reports/2020	France
“Combined Transcranial Direct Current Stimulation and Selective Motor Training enhances balance in children with Autism Spectrum Disorder”	Mahmoodifar and Sotoodeh(¹⁶)	Perceptual and Motor Skills/2020	Iran
“The effects of Aquatic versus Kata techniques training on static and dynamic balance in children with Autism Spectrum Disorder”	Ansari et al.(⁶)	Journal of Autism and Developmental Disorders/2021	Iran
“Physical activity design for balance rehabilitation in children with Autism Spectrum Disorder”	Roșca et al.(⁴)	Children (Basel)/2022	Romania
“Transcranial Direct Current Stimulation to facilitate neurofunctional rehabilitation in children with Autism Spectrum Disorder: a protocol for a randomized, sham-controlled, double-blind clinical trial”	Araujo et al.(¹⁷)	Frontiers in Neurology/2023	Brazil
“Intervention based on psychomotor rehabilitation in children with Autism Spectrum Disorder ASD: effect on postural control and sensory integration”	Ben Hassen et al.(¹⁸)	Children (Basel)/2023	Tunisia
“Balance rehabilitation for postural control in children with Autism Spectrum Disorder: a two-case report study”	Jabouille et al.(⁸)	Physiotherapy Theory and Practice/2023	France

Reference *	Objective(s)	Sample: size, age group	I/M/T evaluation and re-evaluation EP	E/T training/rehabilitation and description of application	Beacons: No. of sessions, time, periodicity, total duration	Professional	Main results
Ajzenman et al.(¹²)	To determine whether equine therapy (horseback riding) increased the functionality and participation of children with ASD.	6 children, from 5 to 12 years old	- Eight-camera video motion capture system (Cortex® software)	Animal Assisted Intervention (Equine Therapy):	12 sessions 45 min, 1x/week 12 weeks	Occupational Therapist and Occupational Therapy Assistant	Postural sway decreased significantly after the intervention.
			- 50 cm x 50 cm three-dimensional force platform	Progression strategy based on five domains (motor control, communication, cognition, social skills and interactive play), ranging from participation in basic to advanced activities.
				Positions on the horse: sitting forward (mounted), prone, supine, mounted backwards, sitting sideways, kneeling, quadrupedal and standing. The participant had to follow complex instructions through changes of position, obstacle courses and tasks/games (e.g. starting from the activity of simply holding the ball to playing a basic game of catch with the therapist and progressing to playing ball with another colleague).
Casey et al.(¹³)	To evaluate the effects of a highly structured therapeutic skating intervention on motor results and functional capacity in two boys with ASD.	2 children, from 7 to 10 years	- Pediatric Balance Scale	Therapeutic Skating:	Phase I: 30 sessions, 60 min, 3x/week (10 weeks)	Physiotherapist and skating coaches	There was an improvement in balance, motor behavior and functional capacity in the post-tests, whose gains remained above pre-test levels in the follow-up stage.
		2 children, from 7 to 10 years	- Flamingo test (dynamic)	Phase I (ice rink - sports complex): warm-up stage with gradual increase in speed; exertion stage with continuous moderate to vigorous physical activity; relaxation. The participants trained separately with skating coaches in a 1:3 ratio.		Physiotherapist and skating coaches
			- Floor to Stand	Phase II: took place in the same ice rink, but incorporated into an inclusive community “free skating” environment. The rink included individuals with and without ASD in order to promote social integration. Participants with ASD were encouraged to skate and wear full field hockey equipment during the intervention.
			- Timed Up and Go (TUG)
			- Timed Test of Climbing and Descending Steps		Phase II: 9 sessions, 60 min, 3x/week (3 weeks) 13 weeks
			- Timed Up and Down Stairs Test
			- Six-minute walk test
Reinert et al.(¹⁴)	To determine the feasibility of posturography for monitoring acute changes in postural control induced by a Sensory Integration therapeutic intervention. The secondary objective was to identify which posturography result parameters, test conditions and data analysis methods could be most useful in identifying post-intervention changes.	10 children, aged 6 to 10	- Posturographic platform (BP505, Bertec® Corp.)	Sensory Integration Therapy - Vestibular Balance:	1 session (single), 10 min, 1 day	Occupational Therapist	All the participants showed a reduction in the average speed of sway in the eyes-open condition on the flat surface after the intervention. Posturography can be useful for assessing physiological responses to the Sensory Integration intervention with vestibular balance.
			- Functional Range Test	TEA: single protocol - on the vestibular swing, each subject had to participate in a throwing game, engage in make-believe games, reach and place puzzle pieces on the floor and interact socially, while the researcher controlled the movement of the swing (initially in a simple way, progressing to being rotated). DT: were not trained.
		ASD group (n=5)	- Bilateral Coordination subtest of the Test Bruininks-Oseretsky of Motor Proficiency (BOTMP-2)
		DT Group (n=5)
Najafabadi et al.(⁵)	To evaluate the effectiveness of a selected group of exercises known as Sports, Play and Active Recreation for Kids (SPARK) on the motor and behavioral skills of children with ASD.	28 children, aged 5 to 12	- Bruininks-Oseretsky Test of Motor Proficiency (BOTMP-2)	SPARK program:	36 sessions, 40 min, 3x/week 12 weeks	Physical Educator and Psychologist supervision	The SPARK program significantly improved static and dynamic balance, bilateral coordination and social interaction.
				Treatment: session divided into 3 parts - 10 min warm-up; 20 min activities according to treatment objectives (stability and movement); 10 min cool-down. Fitness activities - aerobic dance, running games and skipping rope. Physical fitness activities - sports such as soccer, basketball, games frisbee and kickball. Control: only performed routine tasks.
		Treatment Group (n=12)
		Control Group (n=14)
Nuntanee and Daranee(¹⁵)	To create a motorized elephant-assisted therapy program and examine its effect on improving balance control in individuals with ASD.	20 subjects, aged 8 to 19	- Swaymeter Test (Physiological Profile Assessment subtest)	Motorized elephant-assisted therapy:	8 sessions, 90 min, 2x/week	Occupational Therapist	The pre-test control and experimental groups did not differ in balance control, but in the post-test, the postural sway of the experimental group was significantly different from that of the control group in the eyes-open and eyes-closed conditions.
			- Bruininks-Oseretsky Test of Motor Proficiency (BOTMP-2)	Experimental: 2 motorized elephants were used in 4 activities: 10 min introduction; 20 min washing and drying the elephant with a towel; 20 min riding and controlling the elephant to the correct direction after a command; 30 min playing a game with colleagues; 10 min closing and putting away materials. Control: no intervention.	8 sessions, 90 min, 2x/week
		Experimental Group (n=10)
		Control Group (n=10)			4 weeks
Caldani et al.(⁷)	To explore the effect of a short postural rehabilitation training program on postural abilities in children with ASD.	20 children, average age 11 years and 7 months	- Postural stability (Equilibre Multitest System,	Rehabilitation training protocol for postural control:	1 session (single), 6 min,	Medical	In the first recording, postural instability was similar in the two groups of children with ASD despite the viewing conditions. In the second recording, immediately after training, there was an improvement in postural control related to a mixed effect of the training/rehabilitation, but also of the test-retest.
			Framiral®)	G1, “Buoy” exercise: the participant had to stand on the platform Framiral and look at a screen (340 cm × 170 cm) 2.5 m away, on which a buoy (130 cm × 130 cm) in the sea was projected. Body movements were expressed by a green dot on the buoy and the objective was to move your body at specific points on the buoy while avoiding swimming in the sea. Crowd” exercise: consisted of passers-by walking down the street towards the participant with an average speed varying from 0.5mm/s to 1.5mm/s. The participant had to move their body to avoid hitting the passers-by. G2: were not trained.		(ENT)
		G1 (n=10)			1 day
		G2 (n=10)
Mahmoodifar and Sotoodeh(¹⁶)	To investigate the effects of anodic tDCS combined with selective motor training on the balance of children with ASD.	18 subjects, aged 6 to 14	- Movement Assessment Battery for Children-2 (MABC-2): EC subscale (1 static and 2 dynamic tests)	TDCS combined with motor training:	10 sessions, 20 min	Trained therapist (Physical Education Department)	Both anodic CBT combined with motor training and simulated CBT combined with motor training had significant impacts on balance. However, participants who received real eCBT and motor training performed significantly better than those who received simulated eCBT and motor training.
				Experimental: anodic CBT (1.5 mA over the left primary motor cortex) combined with motor training (jumping; jumping on a hula hoop; walking on a 5 cm × 2 m board on tiptoe; walking with one foot in front of the other). Control: 20 s simulated tDCS at the beginning of each session, providing 1.5 mA of stimulation, but immediately interrupted.
		Experimental Group (n=9)			Not available
		Control Group (n=9)
Ansari et al.(⁶)	To compare the effect of a land exercise program and swimming on balance skills in children with autism.	30 subjects, aged 8 to 14	- Stork test (static)	Aquatic exercises and techniques:kata	20 sessions, 60 min 2x/week: 30 min (up to 2nd week); 45 min (3rd to 4th week); and 60 min (5th to 10th week)	Swimming coaches;	Both interventions had a significant effect on balance skills (p < 0.001). Interestingly, a greater improvement in balance performance was found in the technique groupKata .
			- Heel-to-toe walking test (dynamic)	Water exercises group: 5 min warm-up (walking, running, jumping jacks, arm/leg movements); 15 min orientation training (sagittal, transverse and longitudinal rotation); 20 min basic swimming (breathing, floating and stroke skills); 15 min free swimming (group activities and playing with toys); 5 min cool-down. Techniques GroupKata: blocking, punching, hurricanrana and kicking movements with explosive speed against an imaginary opponent. Control Group: no intervention		Kata coaches;
		2 Experiment Groups (n=10 each)			10 weeks	chief researcher
		1 Control Group (n=10)
Roșca et al.(⁴)	To analyze the evolution of postural stability after physiotherapeutic exercises based on balance training in subjects with ASD.	28 subjects, aged 8 to 14	- RSscan pressure and force platform	Physical activity protocol:	72 sessions, 30 min, 3x/week	Physiotherapist	The application of the program based on physical exercises led to a significant improvement in the balance parameters of the participants, under complex evaluation conditions.
				List of 6 exercises: breathing and stabilization; walking on a narrow gym bench (4x); standing on one leg - 10 s each (6x); standing on one leg, with the other leg in front, to the side and behind without touching the ground (6x); jumping from one leg to the other while using circles on the ground to mark (4x); walking on a balance board (with/without support).
					24 weeks
Araujo et al.(¹⁷)**	Determine	30 children, aged 3 to 8	- Movement Assessment Battery for Children-2 (MABC-2)	TDCS combined with neurofunctional motor training:	10 sessions, 20 minutes, 5x/week	Physiotherapist	The authors believe that the three intervention groups will show improvements in motor skills, mobility and functional balance. The effect size is expected to be greater in the experimental groups compared to the control group. It is also believed that the effects obtained in the experimental groups will be maintained in the follow-up assessments four and eight weeks after the end of the interventions.
	whether anodic tDCS on the primary motor cortex and cerebellum can improve		- Pediatric Balance Scale	Experimental group 1: anodic tDCS (1 mA, 20 min) on the primary motor cortex combined with neurofunctional motor training. Experimental group 2: anodic tDCS (1 mA, 20 min) on the cerebellar region combined with neurofunctional motor training. Control group: simulated tDCS (gradual intensity of 1 mA during the initial 30s) combined with neurofunctional motor training.
	the effects of gait training and postural control on motor skills, mobility, functionality	Experimental Group 1 (n=not available)	- Timed Up and Go (TUG)	Neurofunctional motor training: immediately at the start of CBTCT with gait and postural control training (10 min each). Gait: the child should walk on the treadmill, with the maximum training speed being that at which they can maintain adequate foot support at initial contact and throughout the support phase of the gait cycle - gradual increase in the initial 2 min and gradual reduction in the final 2 min. Postural control: a circuit of 4 individually selected exercises, based on the MABC-2 (balance and aim subscale) and the child's performance, which will be performed for 40 seconds with a 20-s rest interval (e.g. balancing on one foot; walking on tiptoe). A total of 2 complete circuits with a 2-minute rest between circuits.	2 weeks
	balance, cortical excitability, cognitive aspects and behavioral aspects in children	Experimental Group 2 (n=not available)
	with ASD.	Control (n=not available)
Ben Hassen et al.(¹⁸)	To investigate the effectiveness of psychomotor training on postural control in children with ASD.	30 children, average age 8 years and 6 months	- Stabilometric platform (Posture Win, Techno Concept®)	Psychomotor training:	18 sessions, 45 min, 2x week	Not available	Psychomotor training significantly improved postural control in the orthostatic position in different conditions when compared to the control group, in all the parameters assessed.
				The program consisted of 4 stages: 5 min warm-up, 15 min of activity on the trampoline followed by 20 min of psychomotor exercises in the form of a circuit, and finally 5 min of warm-down and stretching. Balance activities, cognitive stimulation games, fine and gross motor exercises and jumping and sensory integration activities (e.g. transferring bottles of different colors from side A to side B while following an obstacle course, moving up and down when necessary).
		Experimental group (n=16)			9 weeks
		Control group (n= 14)
Jabouille et al.(⁸)	To investigate the effect of balance rehabilitation on postural control in conditions of low and increased cognitive load in two children with ASD.	2 children (10 years and 5 months old; 7 years and 3 months old)	- Posturographic platform: Single task: OA/OF; Double task: recognition of	Own protocol:	8 sessions, 40 min, 2x/week	Physiotherapist	The program resulted in a 30% to 96% improvement in postural control parameters in the single-task condition for both participants. In the dual-task condition, participant 1 progressed in all conditions, while participant 2 progressed in 3 of the 5 conditions.
			Emotions (images representing a neutral condition, sadness, anger, happiness and fear)	Balance exercises, jumping and stabilization situations, associated with cognitive-motor tasks (Wii® Balance Board):	8 sessions, 40 min, 2x/week
				First 30 min: 4 dual-task exercises; final 10 min: balance exercises on Wii® (average of 3 different games per session).	4 weeks

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