musculo-skeletal dysfunction and autistic spectrum

ABSTRACT

OBJECTIVES

to review evidence of:

A) A relationship between specific patterns of musculo-skeletal dysfunction and children diagnosed with an Autistic Spectrum Disorder (ASD);
B) Use of manual therapies for children diagnosed with ASD.

In order to determine whether assessment tools for gauging musculo-skeletal dysfunction in this identified group could offer a practical application within the field of manual therapy to provide evidence-based research for motor assessment which could in turn be utilized to demonstrate efficacy of osteopathic treatment for musculo-skeletal aspects of ASD.

METHOD Key word searches conducted using relevant databases and on-line journals retrieved 133 articles for consideration. Best practice guidelines for systematic reviews were adapted to suit narrative review and obtain objectivity of results on A) 20 & B) 17, selected papers.

RESULTS Bias risks and reliability ratings were added to summary charts for each paper reviewed.

CONCLUSIONS Poor quality accounts generally led to subjectivity and decreased reliability of papers reviewed. However, it underlines the need for more study in this area.

KEY WORDS Autistic Spectrum Disorders (ASD); musculo-skeletal dysfunction; motor dysfunction; manual therapy; osteopathy

INTRODUCTION

Autism – a brief history and definition

Autism was first recognised as a defined behavioural impairment by child psychiatrist Leo Kanner in 1943 (Wing, 1996a p.19). Previously considered to have a psychological basis, the complexity of the condition, and numerous symptom associations is indicative of the evolution which has taken place in respect of aetiology since this time; most significantly in its recognition as a neurodevelopmental condition in 1980 through the Diagnostic and Statistical Manual (DSM) (Wing, 1996a p.23). Regarded as the US standard in the classification of psychiatric and behavioural disorders, the introduction of the DSM-IV and its equivalent International Statistical Classification of Diseases and Related Health Problems (ICD-10) in 1994 and 1992 respectively, established consistent worldwide defining criteria for the spectrum of autistic conditions recognised today for clinical diagnosis, defined as “pervasive developmental disorders” (PDD) (Wing, 1996a p.23)¹.

This is still a grey area in research (Witwer & Lecavalier, 2008), particularly with regard to syndromes such as Rett’s (Wing, 1996a p.68), and Fragile X which can be found in cases without an ASD diagnosis (Zingerevich, 2009). The definition Autistic Spectrum Disorders (ASD) is more frequently utilised in research and amongst those who work with or are affected by the condition, and iminent publication of DSM-V may replace the PDD definition with ASD to better reflect current pathalogical and symptom knowledge (Swedo, 2009).

Today society is more familiar with ASD, partiularly following media attention accompanying the recently retracted evidence surrounding the MMR (Measles-Mumps-Rubella) vaccination as a causative factor (Bedford & Elliman, 2010 p.271). An apparent rise in prevalence of ADS amongst populations (Kidd, 2002 p.295) may be a result of increased awareness, knowledge, and availability of diagnostic tools (Wing, 1996b; Green et al, 2005 pp.24-5). However, utilising findings of Green et al’s prevalence study, the National Autistic Society (NAS) (2007) estimate that ASD could affect 13,354,297 under 18’s in the United Kingdom, based on 2001 census information.

Believed to be the result of either “a genetic fault, brain insult or brain disease” (Frith, 1991 p.2), an ASD is life-long and can be associated to myriad behavioural variances at different stages of development, however, at its core are a recognised “triad” of impairments in:

social interaction
communication
imagination

with consequent repetitive patterns of behaviour (Wing, 1996a p.92).

Although diagnosis before aged 2 can be problematic since traits are less easily defined from developmental delays associated to other neurodevelopmental impairments (Frith, 1991 p.2), early diagnosis is an area of growing research in consideration of the potential benefits early intervention may have on long term quality of life (Baranek, 1999; Teitelbaum et al, 2004; Nadel & Poss, 2007; Provost et al 2007).

Rationale

While ASD aetiology remains complex and underdetermined, the acceptance of a neurological basis in the condition could implicate manual therapies as important therapeutic tools. Hypothetically, the important link between the musculo-skeletal and neurological systems and the effect of touch on the nervous system (Field et al, 1997) implicit to osteopathic practice, makes it ideally placed to offer benefit to ASD children (Frymann et al, 1998). However, most evidence for efficacy in osteopathic intervention to date is anecdotal, relying on parental feedback (Hanson et al, 2007), and management of ASD is more typically multi-disciplinary, involving other CAM (complementary and alternative medicine) and/or biomedical treatments (Harrington et al, 2006; Wong & Smith, 2006; Hanson et al, 2007). In order to adhere to ethically sound practice with regard to justification of treatment (General Osteopathic Council, Standards of Practice, 2005 p.4 clause 8; Standard 2000, 1999 p.15 Capability L), it is important to seek the highest level of evidence possible to support the use of osteopathy, and encourage research in a poorly represented field.

Additionally, recent research has highlighted specific patterns of musculo-skeletal dysfunction which may correlate to ASD (Gillberg, 2003; Teitelbaum et al, 2004; Silva & Cignolini, 2005; Provost et al, 2007; Glazebrook et al, 2008). However, there are conflicting findings within studies to date (Page & Boucher, 1998; Gepner & Mestre, 2002; Noterdaeme et al, 2002; Freitag et al, 2007). Altered musculo-skeletal integrity impacts on the individual’s ability to relate to their environment, and during childhood development could be detrimental to a child’s fulfilling their potential: one of few longitudinal studies conducted by Perez & Sevilla (1993) demonstrated the predictive nature of motor skills ability of children with autism in determining functional outcomes 5 years later in areas of development such as vocation and leisure skills. This in turn could be indicative of the social isolation which remains a strong element in ASD diagnosis.

Provided evidence for these connections is found to be robust, potentially measures of motor development in ASD children could be employed as an assessment tool to gauge efficacy of manual therapy on ASD manifesting as musculo-skeletal dysfunction. Thus offering opportunity for research of the effectiveness of manual therapy, and ultimately osteopathy, in caring for children with ASD, and providing a higher level of evidence than is currently available.

Therefore, the aim of this project was to review the quality of current evidence through:

exploration of existing research on musculo-skeletal dysfunction presentation amongst children with ASD
identification of existing evidence to support/refute the use of manual therapies
reflection on the application of suitable musculo-skeletal function testing procedures identified from the above key points in the provision of future evidence-based research.

LITERATURE REVIEW

Musculo-skeletal Dysfunction in Children with ASD

The varied diagnostic tools available for ASD assessment are indicative of the variety of clinical features found in patients. Page & Boucher (1998), Gepner & Mestre (2002), Noterdaeme et al (2002), Gillberg (2003), Rinehart et al (2006) and Hanson et al (2007) all utilise the international DSM (2008) and ICD (2009) diagnostic systems reviewed by Waterhouse et al (1996). However, unclear aetiology and unique heterogeneity of impairments in each presenting case of ASD make it important to note diagnostic inclusion criteria when comparing research, which may otherwise skew conclusions drawn.

Stereotyped and repetitive motor mannerisms in gesture, facial expression, posture and gait (Wing, 1996a pp.48-9), while common features of ASD, are not detrimental to diagnosis, and have only more recently been investigated (Page & Boucher, 1998; Baranek, 2002; Noterdaeme et al, 2002; Rinehart et al, 2006; Freitag et al, 2007; Provost et al, 2007; Glazebrook et al, 2008). More frequent identification with Asperger’s Syndrome (AS) – a sub-group within ASD (Wing, 1996a p.29) – has led to “motor clumsiness” as an inclusion criterion for studies of AS (Gillberg & Gillberg, 1989 p.632). Additionally, a combination of deficits in attention, motor control and perception (DAMP), while associated with Attention Deficit Hyperactivity Disorder (Gillberg, 2003 p.905 Box 2), has been linked to AS in more severe cases (Gillberg & Gillberg, 1989).

Evidence of a clear difference in motor function between autism and AS is confused. Statistically significant postural instability in children with AS compared to those with autism (Gepner & Mestre, 2002) was invalidated by small sample size and ignorance of important normal age-related developmental stages (Westcott et al, 1997 p.631) for sample selection. Equally, studies contesting the idea of motor dysfunction differentiation (Page & Boucher, 1998 p.235; Noterdaeme et al, 2002 p.223-4) were unsubstantiated through absence of children with AS in their sample. Here links between language and speech problems and motor dysfunction were suggested, although statistical findings were equivocal, particularly in Page & Boucher (1998) which as a preliminary investigation used convenient sampling and omitted a control group.

In recent assessments of motor function considering kinematics, Glazebrook et al (2008) set out to clarify variances in motor preparation and coordination. However, although Glazebrook et al (2008) concluded autistic participants demonstrated most significant diminution in Experiment 2 testing strategic planning of movement, the results may have reflected decreased capacity for imagination rather than motor function in comparison to controls. Freitag et al (2007 pp.948-950) noted the ambiguity in standardized motor testing, which “do not differentiate motor function and other involved sensory or executive functions”, and utilised a neuromotor assessment tool to increase validity, although they commented on reproduction impracticalities within a clinical setting (Freitag et al, 2007 p.957).

Many papers used older children, however Provost et al (2007) compared children of 21-41 months old. Yet the study lacked a control group to understand the significance of their results in relation to normal development. In relation to practical osteopathic assessments, research to detect AS through abnormal primitive reflexes (Teitelbaum et al, 2004) may be valuable. Although a small, convenience sample with potential biases in data collection, if, as the paper surmises, there exists a positive correlation, this would indicate motor dysfunction as separate from developmentally later stage behavioural learning, and imply retained/non-emergence of reflexes instigating later postural, gait and behavioural immaturities found in ASD. Some studies were found to reflect upon motor dysfunction in consideration of “developmental milestones” (Baranek, 2002 p.398), and so the typical establishment of gross motor development (controlling posture and gait) by age 5 (Rosenbaum, 2005 p.4) may be critical: “subsequent changes in motor abilities…reflect a combination of personal interests, training, and practice…[and] do not in themselves reflect the biological underpinnings that make motor development possible”.

Manual Therapy Interventions for ASD

The small body of research on motor dysfunction is reflected by literature available concerning treatment and management of musculo-skeletal symptoms. It should also be noted that motor deficits are not tantamount to motor interventions (Baranek, 2002 p.399). Some research linked sensory processing abnormalities in ASD with resulting hypo- or hyper-responsiveness to stimuli to stereotyped motor symptoms. However, although methods employed in “sensory integration therapy” include tactile stimulation and deep pressure touch, with obvious connotations towards manual therapy, findings of research reviewed by Dawson & Watling (2000) provided no specific evidence of musculo-skeletal change.

Baranek’s literature review (2002) attempting to identify efficacy of sensory and motor interventions for autism, also noted the limitations of her study given the varied methodologies applied, identifying weaknesses in small sample size; lack of rigour in design; variability of dysfunction profile in those children used; lack of cross-sectional and longitudinal studies. Of particular relevance to osteopathy are the few empirical studies on “Sensory Stimulation Techniques” (Baranek, 2002 p.408) based on the principle that the nervous system can be affected through touch, although the randomised controlled trial in Field et al (1997) measuring effects of touch therapy did not quantify any physiological effect on the autonomic nervous system. “Sensorimotor Handling Techniques” (Baranek, 2002 p.414) more closely associated to the work of Frymann et al (1998), were not given credence by Baranek (2002). However, “manipulation and body-based methods” also received mixed opinion in parental surveys assessing CAM use (Hanson et al, 2007), although there was no indication of how questioning led to a category of “helpful”, and as Wong & Smith (2006 p.904) noted, effects of those methods could not be isolated from other concurrent treatments.

While many studies of the effects of massage/touch therapies on ASD looked at behavioural factors (Field et al, 1997; Escalona et al, 2001; Cullen & Barlow, 2002a; Cullen-Powell et al, 2005), few commented on implications for motor involvement (Cullen & Barlow, 2002b:), and only Silva & Cignolini (2005) targeted musculo-skeletal assessment. However, although post-treatment improvement was identified using a standardized motor function measure, baseline controls for similarly-aged children were omitted, but included one child who did not complete the tests (Silva & Cignolini, 2005 p.324 Table 3). Additionally, the time interval before post-treatment testing was inconsistent (Silva & Cignolini, 2005). As observational studies, none of these papers went far enough to limit bias and external influencing factors; however, because research was assessing parental involvement/impact rather than treatment modality, they offer limited value to this study.

A few papers detailed benefits of chiropractic intervention for treatment of ASD, but reviews were poorly conducted (Gleberzon, 2006), and the few that gave experimental detail were single case studies (Khorshid et al, 2006: Hoffman & Russell, 2008). Very little has been published with direct regard to the use of osteopathy: Lavine (1999) comes for an unreliable source, is not reproducible due to paucity of methodological information, while results provide insufficient evidence to raise concern regarding validity. The only peer reviewed research elicited through literature searches supporting osteopathic treatment of children with ASD (Frymann et al, 1998) failed to produce explicit outcomes: although the longitudinal study promoted improved motor performance amongst children with neurological deficits, there was no evidence to confirm that ASD cases were amongst those actually tested since the large drop-out rate deemed statistical analysis of specific disabilities unsuitable. However, the results implicate application of osteopathic treatment for a broad range of neurological developmental conditions; offering the opportunity for patient-centred treatment in a holistic sense that resonates with osteopathic principles, rather than according to diagnosis.

METHOD

Despite recognition of the under-represented field of knowledge being investigated, in order to achieve the most objective account possible, best practice guidelines for systematic review (Furlan et al, 2009; Moher et al, 2009) were utilised in combination with selection criteria from pertinent narrative review studies previously conducted (Vaux, 2006).

Previous literature reviews conducted by the author led to two naturally distinct avenues of exploration:

PART A examining musculo-skeletal dysfunction in children diagnosed with ASD;

PART B assessing the use of manual therapies for children diagnosed with ASD.

Searches for Literature

Literature searches comprised

computer-assisted searches of relevant databases: controlled-trials.com; www.http://clinicaltrials.gov/; Cochrane Library; Database of Abstract of Reviews of Effects (DARE); PubMed; Academic Search Elite; AMED; British Nursing Index; CINAHL Plus with Full Text; EJS E-Journals; Medline; PSycINFO; SocINDEX; .Autism Data (National Autistic Society); Biomed Central: Chiropractic & Osteopathy; PEDro: Physiotherapy Evidence Base.
Key word searches of on-line Journals: Journal of Autism & Developmental Disorders; Journal of the American Osteopathic Association (JAOA); Brain & Development.

Using (in various combinations) search terms: “autism”; “autistic disorder [MeSH]”; “children”; “osteopathy”; ”osteopathic physicians [MeSH]”; “manipulation, osteopathic [MeSH]”; “musculoskeletal manipulations [MeSH]”; “manual therapy”; “physical therapy”; “physical therapy modalities [MeSH]”; “exercise therapy [MeSH]”; “touch”; “motor impairment”; “motor dysfunction”; “postural balance [MeSH]”; “body image [MeSH]”; “expressing emotions”; “paediatric”.

Limits were applied for some PubMed searches: Humans, English, All Child: 0-18 years.

Titles retrieved were assigned to Part A or Part B of the study as appropriate, where studies were selected for review based on suitable criteria as follows.

Inclusion/Exclusion Criteria

Universal:

Unpublished data was not included in this review from the outset.
Duplicates of articles.
Items where no abstract was available, or the paper was not available in English language.

Papers excluded from Part A:

Those pre-dating 1980 DSM-III publication, when ASD was officially recognised as a neuro-developmental condition rather than a psychosis.
Those where ASD and/or motor dysfunction were not the main focus of the study, thereby containing insufficient data of interest to be able to draw valid conclusions: including psychology and pharmacology studies, also articles related purely to oromotor rather than gross motor function.
Those which were reviews of literature and not experimental studies.
Those with lowest population parameters >5 years of age, as development beyond this point is suggested to be governed increasingly according the child’s particular environment in learning skilled motor tasks and may skew conclusions drawn.
Studies which were found to re-use the same data.

Papers excluded from Part B:

Those which did not include ASD or manual therapies in their design: including acupuncture, not considered a manual therapy although relevant to concepts of touch.
Those which researched physical or exercise therapies as these forms of therapy are very different modalities from manual therapies. Holding therapy was also excluded as intent is also very different from manual therapies: a form of psychological therapy based on restraint.
Those which were reviews or commentaries and not experimental studies.
Those with an adult population.
Studies which were found to re-use the same data.

Blinding

In order to reduce reviewer bias, paper copies of each of the chosen articles for review in each category were manually blinded for details of author; publication; date; institutions involved; title of study. Within each group of papers still stacked in order of lead author (A-Z) and by date (oldest first), a random number generator designated numbers to each paper to act as a key and individual identifier during analysis. Random number generation then selected the order in which papers were analysed.

Analysis: Methodological quality

Taxonomy

Values indicated hierarchy of study type², (Furlan et al, 2009 p.1933 Table 1), with adaptations from Vaux (2006). Although quantitative studies do not exclusively indicate evidence of a hierarchical level higher than qualitative studies, for the purposes of this review it was deemed suitable to document them thus, with added weighting given to triangulated qualitative studies considered to increase the validity of qualitative data (Greenhalgh, 2006 p.168). Values obtained were considered separately from other bias risk criteria, since adding numerical values could skew results significantly where all other categories required scores of 0 or 1.

Table 1. Methodological Quality Assessment Criteria. (Final format following pilot study).

Adapted from Furlan et al (2009) with additions from Vickers (1995) & Vaux (2006).


I	TAXONOMY OF STUDY DESIGN
			GRADE
	Quantitative Studies
	Experimental studies with control group	RCT (randomised controlled trial)	I
		CCT (controlled clinical trial)	II-1
	Observational studies with control group	Cohort (longitudinal study)	II-2
		Survival cohort (readily available participants who meet criteria for study)	II-3
	Uncontrolled studies (observational or experimental)	Without control group case series and case reports (participants are described either as a group and studied once or before and after an intervention, or participants are individually described)	II-4

	Qualitative Studies
	Triangulated	2 or more qualitative research methods adopted	III-1
	Not triangulated	Single research method adopted	III-2
	Opinion	Anecdotal evidence from respected authorities, based on experience, descriptive work, or reports via expert committees	IV-1
		Anecdotal evidence from respected individuals, based on personal experience and descriptive work	IV-2




II	BIAS RISK	SCORE: “YES” = 1; “NO” = 0; “UNCLEAR” = 0

a	Adequate randomization methods employed
b	Concealed treatment allocation
c	Control group included
d	Index and control methods explicit
e	Groups were similar at baseline regarding important prognostic indicators
f	Existing co morbidities and/or therapies including medications received by participants outside the remit of the research being conducted were specified, and recognised within outcome measures
g	Participants or parents were blinded to the intervention
h	The care practitioner was blinded to the intervention
i	The outcome assessor was blinded to the intervention
j	Drop-out rate was described and acceptable
k	All participants were analysed in the group to which they were allocated
l	Compliance was acceptable in all groups
m	Relevant outcome measures
n	Timing of outcome assessment was similar in all groups
o	Follow up measurements described
p	Reports of the study were free from suggestion of selective outcome reporting
q	Peer review publication
r	Credibility – evidence the person/organisation has relevant experience or qualification in their field
s	Funding organisation or motivation is acknowledged and judged by the researcher to be neutral

	N.B. Criteria a, g, h, i & k apply only to PART B data

Bias Risk

Furlan et al (2009 pp.1934-1935 Tables 2 & 3) was utilised to base bias risk criteria for each paper, with additional criteria from Vaux (2006) and Vickers (1995).

For accessibility and uniformity of results a scoring system was utilised from Furlan et al (2009 p.1934 Table 2), whereby each criterion was rated “yes”, “no” or “unclear”: re-evaluation of results assigned a score of “1” for all positive ratings, and a value of “0” for all negative or unclear ratings.

Criteria q-s, and total bias risk for each paper, were completed after all other bias risk criteria had been assessed and numbered articles could be attributed back to their author and publication details without influencing the analysis.

Intra- & Inter-rater Reliability

A representative selection of 4 papers (~20%) from each group were identified for use in a pilot study, using a random number generator. A second reviewer analysed the same 8 papers selected to assess inter-rater reliability of criteria chosen. The second reviewer, in addition to being blinded from article information as stated above, was unfamiliar with the material and subject matter, with no allegiance to the fields being studied.

Intra-rater reliability was assessed by the primary reviewer repeating the same analysis on the same set of 8 papers one week later, without knowledge of results from the first pilot study.

Accordingly, some changes were then made to bias risk criteria before the rest of the papers were analysed.

Analysis: Methodological evaluation

Following the pilot study, changes made to bias risk criteria:

“Adverse effects were described”

Removed from Parts A & B of the study, since the papers all had small sample sizes, making it difficult and inappropriate for researchers to estimate adverse effects with any degree of reliability.

“Co-interventions were avoided or similar”

Removed from Parts A & B of the study, since this criterion was frequently confused with co-morbidity values (criterion f) amongst reviewers. Additionally, as selection processes had restricted papers reviewed to predominantly those which looked at sole interventions, this was not felt to add value to the research, and co-morbidity better reflected both the content of the studies, and the purposes of the research.

Criteria a, g-i and k were deemed unsuitable for inclusion in Part A, since they reflect intervention-led experimental study designs. Papers reviewed in Part A were seeking different outcomes and were not intervention-led – all participants were subject to the same methodological procedures and tested in a uniform manner.

Summary tables were completed simultaneously to bias risk data collection, enhancing objectivity of analysis while the researcher was still blinded to author details: with the exception of total bias risk values and overall rating scores which were completed once bias risk criterion q-s had been fulfilled.

Ethics

Ethical approval for this study was obtained from the British School of Osteopathy Research Ethics Committee. No criteria for harm minimisation were fulfilled since the research consisted of review of published material already in the public domain and therefore was not considered to pose any risk. However, it was considered important to clarify the nature of the research undertaken as a preliminary investigation, and was not to be taken as an endorsement of manual therapy over other measures employed in the management and treatment of a child with ASD, nor to imply manual therapy could offer a “cure” to ASD.

RESULTS

Table 2. Overview of database search results. Refer to Appendix 1.

DATABASE	NUMBER OF SEARCHES USING DIFFERENT SELECTIONS OF KEY WORDS	NUMBER OF RELEVANT HITS
Autism Data @ National Autistic Society: http://www.nas.org.uk/	10	59
PubMed	32	76
Academic Search Elite;AMED;British Nursing Index;CINAHL Plus with Full Text;EJS E-Journals;Medline;PSycINFO;SocINDEX	15	51
Ovid: Maternity and Infant Care	2	4
BioMed Central: Chiropractic & Osteopathy	2	4
http://www.pedro.fhs.usyd.edu.au/index.html PEDro: Physiotherpay Evidence Base	1	2
Science direct via Beford – EBSCO for journal (http://0-ejournals.ebsco.com.brum.beds.ac.uk/Journal2.asp?JournalID=107809)	1	4
http://www.journals.elsevierhealth.com/periodicals/bradev/search/quick	1	8
http://www.jaoa.org/	2	2
www.controlled-trials.com	1	0
www.http://clinicaltrials.gov/	1	0
www.crd.york.ac.uk (DARE)	1	0
www.cochrane.org Cochrane Collaboration Reviews (Cochrane Library)	1	0

In total, literature searches (including databases, hand searches of journals and following article citations) conducted between January and October 2009 retrieved 311 papers for consideration:

PART A 177 articles

PART B 134 articles

From these further rejections were made as identified in Method to select papers for review:

PART A 20 papers

PART B 17 papers

3 Flow chart showing review selection (not including duplicates identified in literature searches*). Adapted from Moher et al (2009 p.267 Fig.1):

Bias Risk

After pilot study and intra-rater reliability had been taken into consideration, the following bias risk criteria charts were completed according to methodology earlier stated.

Total bias risk was calculated for each paper as a percentage of the total number of criteria considered, and mean value scores were identified:

Part A (assessing 14 criteria) = 126/14 = 9

Part B (assessing 19 criteria) = 94/19 = 10.4

Based on individual percentage scores, each paper was given a rank order. Additionally, the percentage of papers which met each criterion was calculated and mean number of papers meeting each criterion was assessed:

Part A (assessing 20 papers) = 126/20 = 6.3

Part B (assessing 17 papers) = 104/17 = 6.1

Summary Charts

Simultaneously to bias risk evaluation, summary charts were developed, adapted from Banacek (2002) & Vaux (2006), including bias risk, grouped according to study type and theme for elucidation.

Methodological Assessment Through Risk of Bias Assessment:

Part A

Paper (author/publication date)	a	b	c	d	e	f	g	h	i	j	k	l	m	n	o	p	q	r	s	TOTAL (/14)	%	Rank
Loh et al (2007)		1	1	1	1	0				1		0	1	1	1	0	1	1	1	11	79	1
Rinehart et al (2006)		1	1	1	1	1				1		0	1	1	0	0	1	1	0	10	71	2
Provost et al (2007b)		0	1	1	1	1				0		0	1	1	0	1	1	1	1	10	71	2
Jasmin et al (2009)		0	0	1	1	1				1		0	1	1	0	0	1	1	1	9	64	3
Baranek (1999)		1	1	1	0	0				1		0	0	1	0	0	1	1	1	8	57	4
Ozonoff et al (2008)		0	1	1	0	1				0		0	1	0	1	0	1	1	1	8	57	4
Goldman et al (2008)		1	1	1	0	0				0		0	0	1	0	0	1	1	1	7	50	5
Esposito & Venuti (2008)		0	1	1	1	0				0		0	1	0	0	1	1	1	0	7	50	5
Esposito et al (2009)		0	1	1	1	1				0		0	1	0	0	0	1	1	0	7	50	5
Molloy et al (2003)		0	1	1	0	0				1		0	1	1	0	0	1	1	0	7	50	5
Provost et al (2007a)		0	1	0	1	0				1		0	1	0	0	0	1	1	1	7	50	5
Martineau et al (2008)		0	1	1	1	1				0		0	1	1	0	0	1	0	0	7	50	5
Vernazza-Martin et al (2005)		0	1	1	0	0				0		0	1	0	0	0	1	1	1	6	43	6
Teitelbaum et al (2002)		0	1	0	0	0				0		0	1	0	0	0	1	1	0	4	29	7
Ming et al (2007)		0	0	1	0	0				0		0	1	0	0	0	1	1	0	4	29	7
Gepner & Mestre (2002)		0	1	1	0	0				0		0	0	0	0	0	1	1	0	4	29	7
Teitelbaum et al (1998)		0	1	0	0	0				0		0	1	0	0	0	1	0	1	4	29	7
Teitelbaum et al (2004)		0	0	0	0	0				0		0	1	0	0	0	1	1	0	3	21	8
Page Boucher (1998)		0	0	0	0	0				1		0	0	0	0	0	1	0	0	2	14	9
Hsu et al (2002)		0	0	0	0	0				0		0	0	0	0	0	1	0	0	1	7	10
TOTAL (/20)		4	15	14	8	6				7		0	15	8	2	2	20	16	9
%		20	75	70	40	30				35		0	75	40	10	10	100	80	45

Part B

Paper (author/publication date)	a	b	c	d	e	f	g	h	i	j	k	l	m	n	o	p	q	r	s	TOTAL (/19)	%	Rank
Silva & Cignolini (2005)	0	0	0	1	1	1	0	0	0	1	1	1	1	0	1	1	1	1	1	12	63	1
Silva et al (2007)	0	0	1	1	1	1	0	0	1	1	0	0	1	1	1	0	1	1	1	12	63	1
Cullen et al (2005)	0	0	0	1	0	0	0	0	1	1	1	0	1	1	1	0	1	1	0	9	47	2
Silva et al (2009)	0	0	1	1	0	1	0	0	0	0	0	0	1	1	1	0	1	1	1	9	47	2
Hoffman & Russell (2008)	0	0	0	0	1	0	0	0	0	0	1	0	1	1	1	0	1	1	0	7	37	3
Cullen-Powell et al (2005)	0	0	0	1	0	0	0	0	1	0	0	0	1	1	1	0	1	1	0	7	37	3
Cullen & Barlow (2002b)	0	0	0	0	0	0	0	0	0	0	1	0	1	0	1	0	1	1	1	6	32	4
Escalona et al (2001)	0	0	1	0	0	0	1	0	0	0	0	0	0	0	1	0	1	1	0	5	26	5
Field et al (1997)	0	0	1	1	0	0	0	0	0	0	0	0	0	1	0	0	1	1	0	5	26	5
Ayres & Tickle (1980)	0	0	0	0	0	0	0	0	0	0	0	0	1	1	0	0	1	1	1	5	26	5
Harrington et al (2006)	0	0	0	0	0	0	0	0	0	1	1	0	1	1	0	0	1	0	0	5	26	5
Wong Smith (2006)	0	0	1	0	0	0	0	0	0	0	0	1	0	0	0	0	1	1	1	5	26	5
Cullen & Barlow (2002a)	0	0	0	0	0	0	0	0	0	0	0	0	1	1	1	0	1	1	0	5	26	5
Khorshid et al (2006)	0	0	0	1	0	0	0	0	0	1	0	0	0	0	0	0	1	1	0	4	21	6
Williams (2006)	0	0	0	0	0	1	0	0	0	1	0	0	0	0	0	0	1	0	0	3	16	7
Hanson et al (2007)	0	0	0	0	0	0	0	0	0	1	0	0	1	0	0	0	1	0	0	3	16	7
Lavine (1999)	0	0	0	0	0	0	0	0	0	0	0	0	1	1	0	0	0	0	0	2	11	8
TOTAL (/17)	0	0	5	7	3	4	1	0	3	7	5	2	12	10	9	1	16	13	6
%	0	0	29	41	18	24	6	0	18	41	29	12	71	59	53	6	94	76	35

Summary Charts Incorporating Taxonomy and Bias Risk Details:

Key: BSID = Baley Scales of Infant Development motor scale

PDMS-2 = Peabody Developmental Motor Scales, 2^nd edition

VABS-2 = Vineland Adaptive Behavioural Scales, 2^nd edition

AOSI = Autism Observational Scale for Infants

CCDI = Chinese Children Developmental Inventory

EWMN = Eshkol-Wachman Movement Analysis System

Part A

General assessment including gross and fine motor evaluation & stereotyped movements

Authors & date of publication	Taxonomy (I)	No. of participants	Male/female ratio	Age range (mean) in months	ASD Diagnosis specified (ICD-10 or DSM-IV)	ASD classifications/ Groups compared	Motor tests/scales utilised	Other areas assessed	Relevant motor test outcomes	Bias score (II)	Ranking
Loh et al(2007)	II-2	32	16:16	12 / 18	DSM-IV + others	ASD Non-diagnosed siblings Control	Videotaped analysis conducted during AOSI assessment utilising taxomony for coding of stereotypic motor behaviours	None	Inconclusive relationship between ASD and specific posturing and motor stereotypies. At 12 months “arm bang surface” confers the highest difference (88% of ASD children exhibiting >median value for control group) as an “object stereotypy”, but where 46% of control group also exhibit this tendency, and the control group is double the size of the ASD group tested. At 18 months characteristics under the “posture” bracket appear to produce more consistently positive results for ASD children in comparison to “motor stereotypy” and “object stereotypy” criteria, but still with great variation throughout and bias towards a larger control group again. There is no data given relating to analysis at 36-months.	11	1
Provost et al (2007b)	II-4	38	30:8	21-41 (30.1)	DSM-IV Interdisciplinary in-house team	ASD: Autism or PDD-NOS DD without ASD	PDMS-2	None	No significant difference was found between gross and fine motor ability of a group of ASD children compared to age, gender, and cognitive ability-matched group with DD (non-ASD) including motor delay. This included subtests of locomotion, object manipulation & visual-motor integration but not stationary or grasping skills. However, it suggests an emergent pattern where motor development is not disproportionately advanced in ASD children in relation to other areas of dysfunction; results are in line with studies performed on older children; it demonstrates the benefit of using difference scores when assessing motor ability using PDMS-2 for the benefit of therapists. Suggestions for further research.	10	2
Jasmin et al (2009)	II-4	35	32:3	36-48 (44.1)	DSM-IV + others	Autism PDD-NOS	PDMS-2 VABS-2	· Sensory responses · Daily living skills	Inconclusive relationship between ASD and specific gross & fine motor impairments. PDMS-2: Overall gross motor quotient mean = 69 (SD7.3); fine motor quotient mean = 74.4 (SD10.1). Rated “poor performance” in ASD children tested, but claims of worst motor performances in the areas of locomotion, object manipulation and grasping are equivocal in relation to other groups (scoring 5 rather than 6) with a large range. Stationary scoring although 6, has a much tighter range and SD for reliability. VABS-2: 81.2 (SD10.7) overall motor skills, implies insignificant relationship (ρ=0.016) although it is unclear whether this is a comparison to ‘normal’/control children or subsets of Autistic; PDD-NOS children within this study.	9	3
Baranek (1999)	II-3	32	19:13	9-12	DSM-III-R or DSM-IV	Autism Developmental disabilities Typically developing	Retrospective home video analysis (VABS used to assess current behavioural scores)	Other sensori-motor criterion developed by the researchers	Investigating a range of sensori-motor behaviours, scoring historic home video sequences implied significant differences between the study groups with autistic children with higher deficits in social functions e.g. visual orientation/attention, delayed response, and touch aversions; and the developmental disability group more likely to present with the motor insufficiencies e.g. repetitive movements and unusual posturing. However, categories of vestibular modulation and anticipatory postures were removed from the study which would be more relevant to study of motor development per se. Additionally, statistical quality of results is poor due to small sample size, where a mean value of unusual posturing for autistic children = 0.11, and for DD children = 0.14, is the equivalent of approximately 1 child studies per group displaying these symptoms.	8	4
Ozonoff et al (2008)	II-2	103	78:25	Autism: 26-61 DD: 24-56 Td: 16-42 (Nb initial age – study conducted over 1 year)	DSM-IV	Autism: regressions and no regression Developmental delays Typical development	Coded observational analysis of retrospective home videos MFMAE vineland	None	This study takes a promising piece of qualitative study on motor behaviours, and tries to apply quantitative data obtained on the same participants a year later through typical motor battery testing. Overall motor results implicate motor deficiencies in DD group over the autism groups but data is not clearly represented in tables, and authors concluding dismissal of any motor testing being insignificant to autism diagnosis may be premature.	8	4
Goldman et al (2008)	II-4	227	209:68	35-97 (54)	DSM-III-R	ASD: High functioning or low functioning Non-autistic developmental delays: language disorder or low IQ	30-minute videotaped sequences of self-directed play during formal evaluation sessions, analysed retrospectively for motor stereotypies VABS	None	Analysis of observed motor stereotypies are suggested as present more frequently in those with autism than those with non-autistic developmental delays. However data representation is incomplete – only those with at least one identified stereotyped movement is included in tables (122/227), which contain a disproportionate number of low functioning autistic individuals which may skew results.	7	5
Provost et al (2007a)	II-4	56	42:14	21-41 (30.1)	Unknown –assessed by interdisciplinary in-house team	ASD: Autism & PDD-NOS DD Children with developmental delays without motor concerns	BSID II PDMS-2	None	Inconclusive relationship between ASD and specific gross & fine motor impairments – no differences compared to similar group of children with developmental delays. BSID II: 16% mildly delayed; 84% significantly delayed, but mean scores are comparable to children with developmental delays group (scores of 57.1 and 56.7 respectively). PDMS-2: most ADS children (58-74%) fell into a 25-49% “overall motor delay” category using age-matched scores, and were predominantly identified as “below average” in both fine and gross motor quotients. Within the ASD group visual-motor integration subcategory came out worst with a mean score of 5.7 (S.D 1.5). Those identified as autistic tended to rate lower than those PDD-NOS cases, but the number of autistic participants was double the number of PDD-NOS cases (25 and 10 respectively).	7	5
Page & Boucher (1998)	III-1	33	25:8	60-202 (121)	DSM-IV	Autistic disorder – not Asperger’s Syndrome	Informal observation of running, jumping, hopping, posture & gait	· Oromotor function; · Hand skills	Unable to provide evidence of relationship between ASD and gross motor function. 15/33 (45%) children had some deficits in gross motor function. No child had deficiencies across all areas observed in gross motor skills, of which hopping achieved greatest number of negative results (10/33). Older children seemed to fair poorer in tests overall, however, there tended to be higher prevalence of other medical conditions within this group. Results for hand skills had a large drop-out rate (21 participants) and so deemed inappropriate to draw conclusions.	2	9
Hsu et al (2004)	II-4	32	27:5	(male 44.5: female 44.9)	DSM-IV	(Autism)	Fine Motor Gross Motor	· Expressive language · Concept comprehension · Social comprehension · Self help · Personal social · General development	Taking developmental quotients in 8 domains as percentages of normal development based on chronological age, suggests gross and fine motor domains are not as reduced as some other areas (80+ % in one group. However, artificial boundaries were put in place to differentiate high and low function groups and large SD figures achieved demonstrate unreliability of significance. Following statistic data is inappropriate to the study.	1	10

Gait Analysis, Posture & Reflexes

Authors & date of publication	Taxonomy (I)	No. of participants	Male/female ratio	Age range (mean) in months	ASD Diagnosis specified (ICD-10 or DSM-IV)	ASD classifications / Groups compared	Motor tests/scales utilised	Other areas assessed	Relevant motor test outcomes	Bias score (II)	Ranking
Rinehart et al (2006)	II-3	22	16:6	Diagnosed group: 52-81 (70) Control group: 51-86 (69)	DSM-IV	Autism Typically developing children	GAITRite Walkway gait analysis Videotapes of gait during use of above equipment for subset of participants assessed using VAS	None	Gait analysis of a group of children with a recent diagnosis of autism compared to a control group non-randomly selected, demonstrated in observation analysis a statistical significant weakness within the autistic group in coordination, smoothness and consistency, but no statistical difference between the groups in patterns in terms of velocity, stride length etc investigated through quantitative data analysis. In attempting to compare and contrast findings with those typical of cerebellar ataxia, results suggest a significant difference between the 2 groups in missteps and y-axis range, but this is not represented in tables and not compared to other study data investigating cerebellar ataxia adequately within the text to be able to draw comparison.	10	2
Esposito & Venuti (2008)	II-3	42	42:0	Austitic group: (20.2) Mental Retardation: (21.0) Typical development: (20.5)	DSM-IV	Autistic Disorder Mental Retardation Typical Development	Home videotapes coded using the Walking Observation Scale	None	Based on the hypothesis that movement can be identified as an early indicator for autistic disorders, this study analyses the gait of toddlers, looking for atypical gait patterns and asymmetric posture related to cerebellar deficit assumptions. Measured by 3 axes: foot, arm and global movements achieved significant atypical gait behaviours in autistic group across aspects within each, particularly within arm movements, heel toe and waddling gait, however results also indicated more variability than the other 2 groups.	7	5
Esposito et al (2009)	II-3	48	33:15	<5 (12-21 weeks)	DSM-IV	ASD Developmental delays Typical development	Analysis of retrospective home videos using Eshkol-Wachman Movement Analysis System & PPSL: · Static symmetry · Dynamic symmetry	None	Based on the assumption that asymmetry of movement is a good indication of disruption to neural pathways early in life, this study assessed movement in lying positions of participants. Conclusions suggest hypoactivity related to abnormal movement prevalent in ASD, however, data was pooled and artificial boundaries given to distinguish between a high and low level of asymmetry found in ASD cases so this group only represents 8/18 ASD individuals included in the research. Additionally its conclusions that low level asymmetry is found in all late diagnosis (12-18 months) are spurious in view of earlier comments.	7	5
Molloy et al (2003)	II-3	16	16:0	ASD group: 84-148 (124.8) Control group: 86-151 (126.5)	Not specified	ASD control	Postural sway tested using a force platform & software to produce stabilograms	None	Postural stability analysis undertaken in order to compare afferent input from the vestibular, somatosensory and visual systems. Measures of sway area and sway distance from centre of pressure. ASD group tended to rely more on visual input to maintain stability – sway area increasing when this system was compromised. However, vestibular system was not tested as well as the others, and the paper suggests that sway responses are more indicative of general lack in integration of sensory input.	7	5
Vernazza-Martin et al (2005)	II-3	15	Not specified	48-72	DSM-IV	Autism Control	Kinematic gait analysis using an automatic motion analyser: Cameras record infrared reflection off anatomical markers on bodysuit the child wears as they perform motion tasks	None	Analysis of gait parameters identified only step length was significantly different – shorter for the autism group than the control which supports previous evidence. More significantly, vertical translation was shown to be more irregular in the autism group with increases in oscillation around the sagittal and frontal planes indicative of poorer accuracy in modulation of automatic locomotor pattern. However, there is insufficient supporting evidence in data represented in the paper. The authors most strongly emphasise a significant difference of poorer ability to adjust orientation towards experimenter-imposed goals, but there may be other causes for this e.g..cognitive ability of participants which has not been investigated and known problems through experimentation in compliance of autistic participants.	6	6
Teitelbaum et al (2002)	III-2	32	Not specified	Infant: <12 Not specified	Not specified	(Autism) Typically developing infants	Eshkol-Wachman Movement Analysis System Still-frame digital video disc analysis of retrospective home video recordings	None	Analysis of primary reflexes through retrospective video analysis of children known to have later received a diagnosis of autism, compared to a control group videoed at the time of the research. Data possibly re-used from another study. Examples are given of atypical posturing in infants later diagnosed as autistic, but the sample size is small and the study does not represent a fully-formed research paper.	4	7
Gepner & Mestre (2002)	II-3	15	9:6	Autism group: 92-137 (113) Asperger syndrome group: 66-116 (89) Control group: 60-147 (98)	ICD-10 DSM-IV	Autism Asperger syndrome Control	Visual stimulation via image processing system and its effect on postural control measuring changes to centre of gravity while standing on a force platform	None	Study found no significant difference between the groups tested, but suggests children diagnosed with autism are less reliant on visual motion for postural stability and posturally hyporeactive in relation to children with Asperger syndrome and control groups. However, sample size is so small and variable (3:3:9 respectively), it is inappropriate to attempt to draw conclusions about any variance between groups.	4	7
Teitelbaum et al (1998)	III-2	32	Not specified	Infant (<12)-60? Not specified	Not specified	(Autism) Typically developing infants	Eshkol-Wachman Movement Analysis System Still-frame videodisc analysis of retrospective home video recordings	None	Analysis of infant motor milestones of development comparing retrospective video analysis of children known to have latter received a diagnosis of autism, compared to a control group videoed at the time of the research. Any useful data is slightly lost within the paper, and there is little evidence to demonstrate objectivity throughout experimentation. Reported movement disturbances tended to be right-sided in the autistic group, but data represented is too limited to draw significant conclusions.	4	7
Ming et al (2007)	II-4	154	126:28	24-216 (median: 72)	DSM-IV	ASD: Autism PDD-NOS Asperger’s syndrome	Retrospective chart review , also clinical intake form completed by care giver Documentation from paediatric neurologist examination evaluating: · Hypotonia · Motor apraxia (oral and limb) · Toe-walking · Delayed gross motor milestones · Reduced ankle mobility	None	Participants split into 2 groups (2-6 yoa and 6-18 yoa) for evaluation, indicate overall mild – moderate motor delay in the younger age group. However, data was retrospectively collected and all had reached motor milestones by the time of the physical examination so it is not clear how data was merged. Additionally, it implies fewer participants at the younger end of the age spectrum were included in the study. The paper suggests there was no significant difference between ADS subgroup results, however there is no evidence to support this claim. In relation to the older age group, the younger group was reported to have significant deficiencies in all motor areas tested, however, this would be in line with normal developmental expectations, and without a control group is difficult to validate.	4	7
Teitelbaum et al (2004)	IV-2 ?	16	Not specified	“infant” not specified	Not specified	Asperger’s syndrome	Analysis of retrospective home videos using Eshkol-Wachman Movement Analysis System	None	Qualitative data from study of retrospective video recordings of infants who were later diagnosed with Asperger’s syndrome, drawing comparison with some findings on previous similar study on autistic infants. Although a good explanation of the EWMA is given and some of the reflexes looked at, there is insufficient methodological detail, or evidence of results to validate points put across and so can only be treated as an anecdotal piece of writing which suggest some similarities between the two groups in terms of withheld primary reflexes and delayed early stage motor development.	3	8

Neurological investigation of motor function

Authors &

date of publication

Taxonomy

(I)

No. of participants

Male/female ratio

Age range (mean)

in months

ASD Diagnosis specified

(ICD-10 or

DSM-IV)

ASD classifications /

Groups compared

Motor tests/scales utilised

Other areas assessed

Relevant motor test outcomes

Bias score

(II)

Ranking

Martineau et al (2008)

II-3

22:6

63-95

DSM-IV

(ASD/Autism)

Control

Videotaped involuntary movements during a sedentary task

Motor cerebral cortex and mirror neurone functioning – excluding ocular and motor artefacts

Assessment of brain activity via EEG recorded while children were watching videotaped sequences ranging from inanimate scenes to human movements, suggest atypical hemispheric activation in a group of ASD children, particularly when witnessing human movement, compared to an age-matched control group.

Summary Charts: Part B

Massage / Touch Therapies

Authors & date of publication	Taxonomy (I)	No. of participants	Male/female ratio	Age range (mean) in months	ASD Diagnosis specified (ICD-10 or DSM-IV)	ASD classifications of those assessed	Manual Therapy interventions employed	Practical tests/scales utilised	Practitioner: P = professional; C = carer/parent	Other interventions assessed	Overview of relevant findings	Bias score (II)	Ranking
Silva & Cignolini (2005)	II-4	8	7:1	40-66 (52)	DSM-IV	Autism Autism-R (regressive form of autism)	Medical Qigong massage	CARS ABC Rossetti PLS-3 PDMS-2	P & C	None	Indicated overall decline in autistic symptoms using CARS and ABC for 5/8 participants, although there is disparity between these scales. Indications that those diagnosed with sensory abnormalities; diarrhoea; sleep disturbances through ABC showed improvement post-treatment were not validated in results. All children over the age limit for suitable use of Rossetti in ‘normal’ population, so although age equivalent ranges suggest on average 5.5 improvement in language comprehension and 4.4 improvement in language expression this cannot be reasonably verified. PDMS-2: Reported between 8 and 12 months (up to x4 actual time period in most) improvement on average in areas of stationary; locomotion; object manipulation; and visual motor integration, while little change in grasping (0.7 months average). In addition although this study was indicated to be over 2.5 months, a longer testing period was included for 2 participants which could significantly skew results for such a small sample size.	12	1
Silva et al (2007)	III-1	13	13:2 unclear which 2 dropped out	36-72 (58 @ start)	DSM-IV	Autism	Qigong Massage	Standardized measures inc. VABS & ABC Parental questionnaire (Sensory Profile) Scoring system specific to massage protocol	P & C	Control (all children enrolled on WESD pre-school programme)	Cignolini methodology of Qigong massage developed and previously found through case study to improve parent-child bonding, was investigated in an attempt to reproduce results through small case-controlled investigation over 5 months, re-assessed after this time by a blinded examiner. As the study was split into 3 sections with professional twice weekly massage only in the first and last, it was decided to give massage to the control group after the initial period and results were then pooled to present 20 participants. It is unclear how much of this data was used within the results displayed which would have a significant affect on validity. Overall, authors reported improved sensory profiles of statistical significance amongst the treatment group, with decreased autistic behaviour for both groups. However, the effect of ongoing WESD programme throughout the entire period of the project is not properly accounted for, and results are poorly represented suggesting further subjectivity.	12	1
Cullen et al (2005)	III-1	14	13:2	24-156	Not specified	ASD	Touch therapy (primarily effleurage)	Semi-structured telephone interview Home Record Sheets	P & C	None	Over the 8-week programme Home record sheets were only completed by 8 parents. Of those, 5 parents reported children seemed calmer; more relaxed with reduced sleep problems post-treatment, while 3 described their children as more energetic and talkative. In one case (possibly interesting the only male parent participating) the chid became more moody and hyperactive post-treatment. At 16 week follow-up interviews, general consensus between parents was to have a positive impact and increased touch between parent and child, although frequency with which therapy was continued at home was extremely variable.	9	2
Silva et al (2009)	II-2	46	37:9	<72	Not specified	Autism	Qigong Sensory Training	PDDBI ABC Sense and Self-Regulation Checklist Videotaped sessions	P & C	None	Purports to be an RCT 5-month investigation incorporating 20 direct qigong massage intervention training & treatment visits from a professional, continued with daily massage given by parent, and its effect on sensory and physiological systems. Before and after treatment data was collected according to components of the QST model in contexts of home and school, with follow-up data collection 5 months after this. Reports significant improvements in the test group overall, achieved through use of statistics performed on various scoring methods employed, but what figures represent in real terms and in comparison to expected natural improvement over time is unclear. Additionally not all tests were specifically geared towards assessing autistic topicalities so should they have been used? Status as an RCT is questionable due to inconsistencies in sampling methods employed.	9	2
Cullen-Powell et al (2005)	III-2	14	13:2	24-156 (median 78)	Not specified	Autism	Massage (effleurage primarily)	Semi-structured telephone interviews	P & C	None	A massage programme designed to give parents skill and thereby increased autonomy/assist bonding in caring for their child with autism was utilised to investigate meaning and relationship between parent and child during this process. Interviews with parents were conducted pre-intervention; post-intervention and a 16-week follow-up, and results were analysed using interpretive phenomenological analysis to produce themes. Post-intervention reports suggest positive outcomes and importance of touch in emotional bonding, with all those interviewed continuing massage to greater or lesser extent. Apart from parents feeling closer and greater bond/communication to their child, cases were reported where children were requesting massage. However, in relation to sample size there was a heavy drop out rate (6/14 participants).	7	3
Cullen & Barlow (2002b)	III-1	12	11:1	36-156 (median 60)	Not specified	ASD	Touch Therapy	Audio taped telephone interviews with parent before and after programme parent diary during programme observational records completed by therapist	P & C	None	Parents interviewed before and after an 8-week programme of Touch Therapy, involving weekly 1-2-1 sessions with a therapist instructing/overseeing parent-child dyad, continued by parent at home in between sessions. Suggest programme had positive affect on children’s willingness to respond to touch and allow parental touch in everyday circumstances, also had a possible calming influence over 1 participant, however, results given heavily drawn from post-programme parental response and observations made by therapists are not commented on at all. The objectivity and therefore reliability of this study is therefore questionable.	6	4
Escalona et al (2001)	II-4	20	12:?	36-72 (5.2)	DSM III-R	Autism	Massage Therapy	Revised Conners Scales Classroom & Playground Behaviour Observations Sleep diaries	C	Reading Attention (control)	Children with autism assigned to treatment group receiving daily massage from parents (who had received training) or a control group, read Dr. Seuss stories: administered every night for 15 minutes prior to sleep. The environmental setting of assessment introduces considerable researcher bias to results. Methodology is poorly explained, and so resulting figures and poorly displayed statistics carry little meaning despite claims of significance for the massage group in emotional index, DSM-IV criteria for inattentiveness and ADHD index.	5	5
Field et al (1997)	II-3	22	12:10	(54)	DSM-III-R	Autism	Touch Therapy	Classroom observation using 10-second time sample unit coding sheets ABC ESCS	P	control	Amongst a group of ASD children, the treatment group received 8, 15 minute therapy sessions over 4 weeks, while the practitioner engaged in object play over similar time frame for the control participants. Tests conducted pre-and post-research period however are highly suggestive of researcher bias and claims that both groups improved touch aversion and off-task behaviour are unsupported by poor representation of results.	5	5
Cullen & Barlow (2002a)	III-1	10	9:1	24-156 (median 54)	Not specified	Autism	Touch Therapy Programme	Audio-taped telephone interviews with parent before and immediately after programme parent diary during programme observational records completed by therapist	P & C	None	Investigating parental experience of caring for a child with autism and the potential benefits of a touch therapy programme, where parents were interviewed before and after an 8-week programme of Touch Therapy, involving weekly 1-2-1 sessions with a therapist instructing/overseeing parent-child dyad, continued by parent at home in between sessions. Suggest programme had positive affect on children’s willingness to respond to touch and allow parental touch in everyday circumstances, also had a possible calming influence over 1 participant, however, results given heavily drawn from post-programme parental response and observations made by therapists are not commented on at all. The objectivity and therefore reliability of this study is therefore questionable.	5	5
Williams (2006)	II-4	12	10:2	146-187 (169)	DSM-IV	Autism	Aromatherapy Massage	Sleep patterns observed and time intervals recorded	P	None	Investigating the effects of aromatherapy massage on the sleep patterns of autistic children identified no significant difference with treatment used. However, the research is poorly conducted demonstrating flaws in design and procedural variations in practice which make statistical data collected null and void.	3	7

Other

Authors &

date of publication

Taxonomy

(I)

No. of participants

Male/female ratio

Age range (mean)

in months

ASD Diagnosis specified

(ICD-10 or

DSM-IV)

ASD classifications of those assessed

Manual

Therapy

interventions

employed

Practical tests/scales utilised

Practitioner:

P = professional;

C = carer/parent

Other

interventions

assessed

Overview of relevant findings

Bias score

(II)

Ranking

Ayres & Tickle (1980)

II-4

9:1

42:156

(88.8)

Not specified

Autism

Series of sensory stimulation tests including light touch, joint traction; vibration

Sensory tests

(as mentioned)

Auditory

Olfactory

Gustatory

Investigating sensory processing disturbances as a predictor to therapeutic outcomes by subjecting participating autistic children to a series of 14 sensory tests on each twice weekly therapy session over 1 year. However, 3 children had co-morbidities which would severely affect their sensory capabilities (2 deaf and 1 partially sighted), additionally the study reports poor compliance with tests chosen.

The authors suggest therapeutic procedures employed were more effective on those who were hyper-reactive than hypo-reactive subjects however this is not supported by evidence. Reasonable qualitative results for each child were not supported by poorly conceived statistics, which pool data and do not add value to the research.

Surveys of CAM use

Authors & date of publication	Taxonomy (I)	No. of participants	Male/female ratio	Age range (mean) in months	ASD Diagnosis specified (ICD-10 or DSM-IV)	ASD classifications of those assessed	Manual Therapy interventions employed	Practical tests/scales utilised	Practitioner: P = professional; C = carer/parent	Other interventions assessed	Overview of relevant findings	Bias score (II)	Ranking
Harrington et al (2006)	III-2	62	48:14	24-336 Median: 8	Not specified	Autism	Chiropractic Manual Integrative Therapy Reiki	Parental questionnaire	P	Conventional therapies Dietary restrictions Other CAM therapies	A parental questionnaire was undertaken to investigate parental beliefs concerning their child’s diagnosis and treatment for autism, confidence in physicians and use of CAM. Results are of limited value to this research: 10% parents reported they would increase use of CAM, but there is no indication whether these were amongst the parents who had tried 27 different treatment methods, or0 treatments. Chiropractic is the only manual therapy listed individually within results which 2 families had used, other manual therapies assigned to 1 treatment method apiece were grouped together, and no accompanying indication of parent view of these treatments.	5	5
Wong & Smith (2006)	II-3	100	72:28	2-17	DSM (edition not specified)	ASD Control – non-ASD	manipulative and body-based therapies: inc. sensory integration, chiropractic, massage	Telephone interview with parent of ASD children Face-to-face interviews with primary carer of control group children	P	Other CAM: Alternative Medical Systems Biological Based Therapies Mind-body and psychological therapies	Investigating the use of CAM in a group of 50 diagnosed ASD children in comparison with a control group without physical or mental disabilities. Only 26/50 reported use of CAM but some employed multiple therapies which is not clearly represented in results, leading to confusion and manipulation of findings. 13 parents of ASD children reported using the “manipulative and body-based therapies”, but none of those using chiropractic reported they had found it beneficial, however, none of this information can be taken at face value as we don’t’ know other influences from potential other CAM therapies being used simultaneously.	5	5
Hanson et al (2007)	III-2	112	92:20	<60->120 unspecific	Unclear – relied on parental reporting	Autism PDD-NOS	Massage/bodywork Craniosacral therapy	Parental questionnaire	P	Conventional therapies Other CAM therapies	Parental questionnaire produced a 35% return investigating a multitude of treatment methods. 25% reported use of a “Body Based Method” but this category includes some non-manual therapies inc. “auditory integration” and “special exercises”. Of this only 12 were reported to have used massage/bodywork, and 11 participants to have used Craniosacral therapy (which includes chiropractic and osteopathic manipulation under this heading). Of these figures the massage/bodywork appears to have reported better outcomes with 73% finding it helpful, opposed to 30% for craniosacral therapy, but figures are confused. Considered a socioeconomic connection between use of these methods and ethnicity (ρ=0.05) although this cannot be identified within results. No differentiation of those with more global and/or mental developmental problems, and some overlapping of those with Autism and those with PDD-NOS.	3	7

Osteopathic or Chiropractic Treatment

Authors & date of publication	Taxonomy (I)	No. of participants	Male/female ratio	Age range (mean) in months	ASD Diagnosis specified (ICD-10 or DSM-IV)	ASD classifications of those assessed	Manual Therapy interventions employed	Practical tests/scales utilised	Practitioner: P = professional; C = carer/parent	Other interventions assessed	Overview of relevant findings	Bias score (II)	Ranking
Hoffman & Russell (2008)	II-4	1	0:1	42	Not specified	Autism	Chiropractic	Thermal and EMG scans	P	None	A case study of 1 child with autism who underwent a 10-week programme of chiropractic care. Scans were incomplete but were claimed to display evidence of asymmetry in autonomic and motor function. Following a series of adjustments performed by the practitioner, similar scans were claimed at 1 and 2 months post-treatment to demonstrate improved symmetry and balance, and parent reported behavioural improvements in the child during this interim. However, methodology is poor, and results using images of scans have not been adapted for reader use, making findings very subjective.	7	3
Khorshid et al (2006)	II-4	14	13:1	48-192	Not specified	Autism	Chiropractic		P	None	3-month study comparing cervical adjustment against full spine adjustments using the ATEC scoring system. X-rays included are selective, and demonstrate changes to alignment, but not how this corresponds to results of the ATEC scoring. ATEC results in themselves are too confused to obtain useful detail from – average improvement over different areas of ability to encompass one overall improvement score is erroneous.	4	6
Lavine (1999)	IV-2	25	17:8	(52 on 1^st visit)	DSM-IV	ASD: Autism Asperger’s syndrome Autistic characteristics which didn’t meet diagnostic requirements	Osteopathy (cranial osteopathic techniques)	Not specified	P	Homeopathy	Investigating the presence/absence of cranial distortions and strain patterns and their possible relationship to autism amongst 25 consecutive children displaying autistic tendencies who presented in the author’s clinic. Although interesting comments are made which would support suggestions of cerebellar involvement in autism, and patterns similar to those described by osteopaths this author has conversed with, this can only be regarded as a discussion piece as it does not conform to any research criteria in terms of methodology or results, and is an extremely subjective account.	2	8

DISCUSSION

Part A

Diagnostic Value

Many of the papers reviewed in Part A placed an emphasis on diagnostic value of their research. While more recent diagnostic tools for ASD incorporate elements of sensory testing e.g. DISCO (Leekham et al, 2007), they are still predominantly based around psychological evaluations. Therefore, at present musculo-skeletal testing per se plays a minimal role, and where assessed, is more generally done in conjunction with other sensory-motor elements (Baranek, 1999; Hsu et al, 2004; Jasmin et al, 2009). In attempting to limit variables of their studies, researchers gave less credence to DMS and ICS classifications than might be assumed: Gepner & Mestre (2002 p.231) questions the accuracy of these scores in defining subtleties of sub-types of ASD. Researchers tended to evaluate the strength of motor testing against other disparate diagnostic tests which predominantly incorporate subjectivity through use of parental questionnaires and are not always ASD-specific (e.g. use of VABS), using statistics inappropriately for small sample sizes to make statements about the general population; leading at best to confused findings and at worst presenting irrelevant/invalid conclusions. However, this may reflect the undeterminable varience of ASD, rather than testing methods.

With this in mind, it is perplexing why so many studies failed to recognise and/or exclude co-morbidities in their samples (Page & Boucher, 1998; Teitelbaum et al 1998, 2002 & 2004; Ozonoff et al, 2008), consequentially making it impossible to draw conclusions relating to the influence of ASD alone. It would be hard to judge whether this design flaw is a product of convenience sampling used throughout, since reliance on an ASD diagnosis makes randomised populations untenable. Furthermore, investigations did not lend themselves to longitudinal studies or follow-ups that would assess robustness of outcomes and rigour of design. Indeed, one paper did claim to pursue a 36-month follow-up (Loh et al, 2007), with no supporting evidence.

Relevance of musculo-skeletal dysfunction

Implications from earlier reserach that motor dysfunction was not verifiable amongst autistic populations, was to some extent supported by papers reviewed. The most statistically significant study of generalised motor behaviours resulting from bias risk performed (Loh et al, 2007), suggested certain stereotypical movements more prevalent amongst ASD children at 12 months than the control group utilised. However, despite triangulation methods employed, the small convenience sample size led to a control group double that of the ASD group. Not only does this demonstrate the unreliability of research reviewed, it could also raise questions concerning the validity of bias risk performed for this review.

Yet, claims that repetitive motor behaviours whilst symptomatic in ASD cases, could at such a young age also be conducive to typically developing infants (Loh et al, 2007 p.26), were challenged by evidence presented in Provost et al (2007b) suggesting motor development in younger ASD children is not typical of standardized tests due to poor compliance, and refuted motor function as a comparative strength of ASD in relation to other developmental delays by significantly demonstrating a uniform pattern of delayed development in fine and gross motor function amongst groups of ASD children, definable from controls.

Posture, gait and reflex studies were significantly represented in those papers selected for review, and possibly offer the most usefully accessible comparisons between typically developing and ASD children, supported by understanding of developmental sequencing. Muscle activation responsible for maintaining stability is a result of “postural strategy” (Carreiro, 2003 p.15); resulting from a trial-and-error process by infants: possibly indicative of studies which commented on reduced mobility of ASD infants (Esposito et al, 2009 p.136). Some studies identified gait patterns suggesting cerebellar involvement (Teitelbaum et al, 1998; Rinehart et al, 2006), however, overall methodological quality was questionable. One paper (Vernazza-Martin et al, 2005) used distraction techniques which may have affected performance, and did not acknowledge potential variability of mental understanding of tasks. Other studies utilising Eshkol-Wachman Movement Analysis claimed significant asymmetrical patterns amongst ASD children suggesting disruption of neural pathways (Esposito et al, 2009) and demonstrated retained primary reflexes with important implications for motor development (Teitelbaum et al, 1998). However, this system involved a conceptual model restricted to 80 identifiable symmetric positions involving 2-dimensional interpretation of 3-dimentional observations (Esposito et al, 2009: p.133). Using stop-start frame-by-frame analysis of video footage, it is unclear how the distinction was made between a transitional movement and what determined a “dynamic” or “static” symmetry.

In relation to these studies, and in response to the age limits placed on article selection, videos were a frequent resource utilised, suited to motor assessment of those too young to comply to given instruction. However, motor function assessment was never the primary aim of the recordings made and analysis is predominantly retrospective with a view to predicting known diagnostic outcomes, presenting considerable participant and researcher bias risks.

Motor assessment within the context of manual therapy

Apart from aforementioned lack of longitudinal studies relevant to continual assessment through treatment sessions, some testing methods would be inappropriate as assessment tools within a therapeutic setting, either in terms of equipment required (Gepner & Mestre, 2002; Rinehart et al, 2006) or necessary knowledge base required to complete testing. Additionally, although this review was limited to children under 5 years, some studies were included with a broader age distribution to gain a suitable number of papers for review. This weakens the validity of the review since it therefore includes some testing methods in appropriate for the age group being studied.

Possibly of greatest value within a therapeutic setting, are the observations of motor mannerisms specified and recorded by Loh et al (2007 p.33-5), creating specific and objective records of changes over time, and would already to a less stringent extent naturally contribute towards any osteopathic structural examination. Provost et al (2007b p.31-2) highlights the clinical value of difference scores and the sensitivity of testing required when classifying motor development as performance indicators. However, the danger lies in the starting criteria whereby lists made of known traits would never be self-limiting in view of the variability of ASD presentations. It is also far easier to make specific observations through frame-by-frame analysis than it is in a face-to-face consultation.

Part B

Measuring effectiveness of manual therapy

Papers reviewed demonstrate increasingly variable outcome measures. This is reflected in the statistical findings from bias risk calculated in comparison to Part A data. Methodological consistency fell short across the board; criterion a, b, & h not being met by any of the papers studied. Although this makes objective conclusions difficult to establish, this is not unexpected in terms of prior estimated research quality.

Certainly those which achieve increased validity and robustness, tend to be qualitative studies. However, a number of those which attempted to triangulate qualitative data (Cullen & Barlow, 2002a & b; Cullen et al, 2005), omitted evidence of some of these sources. Two papers written by the same author (Cullen & Barlow, 2002a & b), seem to have duplicated quotes from post-programme telephone interviews in both studies without acknowledging the other paper, questioning the validity of both papers.

Similar co-morbidities issues were observed as in Part A (Cullen et al, 2005; Ayres 1980), while drop-out rates from experiments were significantly high in relation to the small convenience samples utilised. Other variables such as location of professional contact (Cullen & Barlow, 2002b p.176) could significantly skew results in response to child interaction with particular environments: one study suggests it took several sessions for the children to feel settled within the clinic appointments (Cullen et al, 2005 p.185).

Issues of hyper- and hypo-sensitivity

More than half the papers identified for review which looked directly at use of manual therapies in ASD children drew upon therapeutic touch and massage, considered to improve bonding between parent and child (Escalona et al, 2001; Cullen & Barlow, 2002a & b; Cullen et al, 2005). Therefore studies often reflected outcomes relevant to the parent rather than the child. While parental influence on experimental procedures was intentional within the context of those studies, in terms of this review, it introduced a significant restriction in attempting to determine any therapeutic effect from professionals’ work. The only study encountered which included a control group where children were read a bedtime story rather than given massage (Escalona et al, 2001), gives misleading reports with inappropriate use of statistics. Assessments carried out pre-and post-experimental period were conducted within the school children attended incorporating significant assessor bias.

No studies report significant hypo-/hyper-sensitivity issues post-programme, though it is worth considering the publication power of positive outcomes. The distinct patterns of sensitivity and descriptions of a reduced sense of “’wanting’ to communicate” (Cullen & Barlow, 2002b) disparate from other developmental dysfunctions, appears to have been reduced within the parent-child bond during therapeutic programmes. However, children would not necessarily respond to treatment in the same way if only provided by a professional.

Of these studies, Silva & Cignolini (2005) & Silva et al, (2007) were assessed to be the most valid in terms of bias risk. However, generally positive outcomes documenting decreased touch aversion and increased attentiveness (Escalona et al, 2001; Cullen & Barlow, 2002b; Cullen-Powell et al, 2005; Silva & Cignolini, 2005; Silva et al, 2009) while in line with earlier investigation, should be viewed with caution. Crucially, while studies remain vague on many areas of methodology, many do report specific sequencing to therapeutic massage techniques taught to parents (Field et al, 1997; Silva et al, 2009). While this does not account for variability in home environment in individual cases, and the capabilities of parents to conform to methods, questions should be raised concerning the effect familiarity would have on child compliance over the duration of the programmes.

Suitability of Manual Therapy

The few CAM surveys identified for review (Harrington et al, 2006; Wong & Smith, 2006; Hanson et al, 2007) offer no new knowledge, and manual therapy is poorly represented, suggesting selection processes warranted further scrutiny of exclusion criteria. However, paucity of information supports findings demonstrating a lack of consideration to musculo-skeletal involvement in ASD found through previous searches. Specific use of other manual therapies was scarce: the 2 chiropractic case studies (Hoffman & Russell, 2008; Khorshid et al, 2006), and singular osteopathic study (Lavine, 1999) identified through literature searches are anecdotal and subject to relatively high bias risk in relation to other manual therapy studies found. Objective findings are lacking in all cases, and so if nothing else prove the validity of identifying ways to meet evidence-based demands. Additionally, comparison to massage and touch therapy studies may be invalid: although Qigong massage (Silva & Cignolini, 2005 p.316) with an Eastern philosophy bears closer resemblance to osteopathy than the Western biomedical model of healthcare, osteopathy would not employ the same uniform procedure during an appointment as were demonstrated through those experiments reviewed. Possibly, a broader search of literature is warranted to be able to speculate on this further. In consideration of studies on primary reflexes identified in Part A, this is an area which may lend itself to osteopathic treatment, but again is another area for future consideration.

REVIEW LIMITATIONS & SUGGESTIONS FOR FURTHER STUDY

With such a limited data pool from which to work, it is questionable, particularly for Part B, whether subjecting papers to bias risk analysis added significant value to conclusions drawn. Identifying appropriate populations for study would always ensure some criteria could not be met by studies of this nature. Additionally, small populations would increase bias and concordantly the likelihood for exaggerated treatment effects. In itself, the bias risk analysis performed was quite subjective, as a result of researcher opinion. Ways to minimise this effect include piloting data not included in the final analysis, but relies on obtaining a larger initial data pool. Additionally, the papers could have been double-marked with a reasonable time interval between, or assessed by a second reviewer. Generally, poor control of variables within the studies reviewed led to reduced validity which could be improved by broadening search terms to be more inclusive. However, this study has highlighted areas for further consideration: clearly more thought should be given to musculo-skeletal involvement in ASD presentations, particularly in areas relating to posture and primary reflexes. In support of this, investigation into the use of observational gauges to assist in demonstrating quantifiable treatment objectives and progress would be valid, possibly through surveying health professionals to identify practical applications. However, demonstrably, the numerous variances in ASD presentation and various diagnosis measures employed, weaken the validity of any study conducted at this level.

CONCLUSION

In view of limited research available, it remains highly questionable whether there is a distinct relationship between patterns of musculo-skeletal dysfunction and ASD. Indeed, reflecting on complexity of ASD presentation, this author is found to question the relevance of demonstrating this connection, particularly within the realm of osteopathy, where the individual is treated as a whole and not as a sum of their presenting symptoms. However, there are elements of observational procedures raised by experimental research, that may lend themselves to application within a therapeutic setting. The paucity of research available makes it difficult to speculate on the effect of manual therapy in isolation, and care should be taken in researching this area as over-inclusion would be easy to achieve.

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Silva, Louisa M.T., Cignolini, Anita, Warren, Roxanne, Budden, Sarojini, & Skowron-Gooch, Annette. (2007). Improvement in Sensory Impairment and Social Interaction in Young Children with Autism Following Treatment with an Original Qigong Massage Methodology. The American Journal of Chinese Medicine, 35(3), pp.393-406 [Online]. Available at: http://0-web.ebscohost.com.brum.beds.ac.uk. (Accessed: 28 January 2009).

Silva, Louisa, M.T., Schalock, Mark, Ayres, Robert, Bunse, Carol, Budden, Sarojini. (2009). Qigong Massage Treatment for Sensory and Self-Regulation Problems in Young Children With Autism: A Randomized Controlled Trial. The American Journal of Occupational Therapy, 63(4), pp.423-432).

Swedo, Susan. (2009). Report of the DSM-V Neurodevelopmental Disorders Work Group [Internet] USA, American Psychiatric Association. Available from: http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports/Neurodevelopmental-Disorders-Work-Group-Report.aspx. (Accessed: 7 February 2010).

Teitelbaum, Philip, Teitelbaum, Osnat, Nye, Jennifer, Frymam, Joshua, Maurer, Ralph. (1998). Movement analysis in infancy may be useful for early diagnosis of autism. Proceedings of the National Academy of Sciences of the USA, Volume 95, pp.13982-13987 [Online]. Available at: http://www.pnas.org/content/95/23/13982.full.pdf. (Accessed: 10 February 2009).

Teitelbaum, Philip, Teitelbaum, Osnat B., Frymam, Joshua, Maurer, Ralph. (2002). Infantile Reflexes Gone Astray in Autism. The Journal of Developmental and Learning Disorders, (no page reference) [Online]. Available at: http://www.movementnotation.com/publications/docs/ReflexesGoneAstray.pdf. (Accessed: 10 February 2009).

Teitelbaum, Osnat, Benton, Tom, Shah, Prithvi K., Prince, Andrea, Kelly, Joseph, Teitelbaum, Philip. (2004). Eshkol-Wachman movement notation in diagnosis: The early detection of Asperger’s syndrome. Proceedings of the National Academy of Sciences of the USA, 101(32), pp.11909-11914 [Online]. Available at: http://www.pnas.org/content/101/32/11909.full.pdf+html + supplemental data: http://www.pnas.org/content/101/32/11909/suppl/DC1. (Accessed: 31 January 2009).

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Vernezza-Martin, S., Martin, N., Vernazza, A., Lepellee-Muller, A., Rufo, M., Massion, J. & Assaiante, C. (2005). Goal Directed Locomotion and Balance Control in Autistic Children. Journal of Autism and Developmental Disorders, 35(1), pp.91-102 [Online]. Available at: http://0-web.ebscohost.com.brum.beds.ac.uk. (Accessed: 21 October 2009).

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Wing, Lorna. (1996b). Autistic spectrum disorders: no evidence for or against an increase in prevalence. British Medical Journal, Volume 312, pp.327-328 [Online]. Available at: http://www.bmj.com/cgi/content/full/312/7027/327. (Accessed 7 February 2010).

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APPENDIX 1: LITERATURE SEARCH DETAILS

Database	Search Terms				Limits	No. of hits
PubMed	“children autism/th”				Humans; English; last 10yrs; all child:0-18; complementary medicine	2/128
	“autism spectrum disorders”					5/67
	“autism”		“osteopathy”		None	1/59
			“manual therapy”			6/96
			“expressing emotions”			7/10
			“RCT”			3/30
			“physical therapy”			3/145
			“massage”			14/16
			“musculoskeletal manipulations”			2/15
	“Autistic Disorder”[MeSH] AND		“Osteopathic Physicians”[MeSH]			0
			“Osteopathic Medicine”			0
			“Manipulation, Osteopathic”[MeSH]			0
			“Manipulation, Chiropractic”			0
			“Musculoskeletal Manipulations”[MeSH]			0/14
			“Motor Skills Disorders”			1/51
			“Physical Therapy Modalities”[MeSH]			3/29
			“Body Image”[Mesh]			1/24
			“Postural Balance”[Mesh]		Humans; English language; All Child: 0-18 years	2/10
			“Exercise Therapy”[Mesh]			0/5
			“Musculoskeletal Abnormalities”[Mesh]			2/53
PubMed	“Developmental Disabilities”[MeSH] AND		“Manipulation, Osteopathic”[Mesh]		None	0
			“Osteopathic Medicine”[Mesh]			2/2
			“Musculoskeletal Manipulations”[Mesh]			0/8
			“Physical Therapy Modalities”[Mesh]			4/80
	“Osteopathic Physicians”[MeSH] AND		“developmental disabilities”			0
			“motor skills disorders”			0
			“mental disorders diagnosed in childhood”			0
	“Musculoskeletal Manipulations”[MeSH] AND		“mental disorders diagnosed in childhood”			2/149
	“Musculoskeletal Manipulations”[MeSH] AND		“disabled children”			1/20
	“motor function”		“manual therapy”		Humans, English, last 5yrs, all child:0-18	0/124
	“Posture”[Mesh] AND		“Autistic Disorder”[Mesh]			1/5
	“primitive reflexes”					1/11
Academic Search Elite;AMED;British Nursing Index;CINAHL Plus with Full Text;EJS E-Journals;Medline;PSycINFO;SocINDEX	“autism”		“osteopathy”		None	1/1
			“manual therapy”			0
			“physical therapy”			13/48
			“chiropractic”			5/19
	“autism”		“motor dysfunction”			1/47
	“autism”		“motor function”			0/72
	“autism”		“motor control” or “gait” or “posture”			1/19200
	“manual therapy”		“motor function”			1/11
	“manual therapy”		“children”			0/54
	“motor dysfunction”	“physical therapy”		“children”		6/17
Academic Search Elite;AMED;British Nursing Index;CINAHL Plus with Full Text;EJS E-Journals;Medline;PSycINFO;SocINDEX	“motor dysfunction”	“osteopathy”		“children”	None	0
	“motor dysfunction”	“manual therapy”		“children”		0
	“motor impairment”	“physical therapy”		“children”		2/31
	“autism”	“child”		“posture”		6/95
	“Journal of Autism and Developmental Disorders” AND	“motor” [All Fields]				15/68
Autism Data @ National Autistic Society: http://www.nas.org.uk/	“osteopathy”					2/10
	“manual therapy”					1/22
	“physical therapy”					12/69
	“physiotherapy”					2/9
	“complementary therapy”					2/20
	“chiropractic”					1/2
	“movement therapy”					4/51
	“developmental coordination disorder”					1/4
	“touch”					3/74
	“motor impairment”					31/98
Ovid: Maternity and Infant Care	“autism”				(1971-Dec 2008)	4/146
Ovid: Maternity and Infant Care	“osteopathy”				(1971-Dec 2008)	0/50
BioMed Central: Chiropractic & Osteopathy	“autism”					1/1
BioMed Central: Chiropractic & Osteopathy	“motor dysfunction”					3/22
http://www.pedro.fhs.usyd.edu.au/index.html PEDro: Physiotherpay Evidence Base	“autism”					2/2
Science direct via Beford – EBSCO for journal: http://0-ejournals.ebsco.com.brum.beds.ac.uk/Journal2.asp?JournalID=107809	“Journal of Bodywork & Movement Therapies” AND	“autism”			None	4/4
http://www.journals.elsevierhealth.com/periodicals/bradev/search/quick	“Brain & Development” AND	“autism”				8/65
http://www.jaoa.org/	JAOA	“autism”				0/1
http://www.jaoa.org/	JAOA	“paediatric”				2/116
www.controlled-trials.com	“autism”					0/229
www.http://clinicaltrials.gov/	“autism”				None	0/196
www.crd.york.ac.uk (DARE)	“autism”					0/92
www.cochrane.org Cochrane Collaboration Reviews (Cochrane Library)	“autism”					0/47

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musculo-skeletal dysfunction and autistic spectrum

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