Postural Sway in ADHD & Autism

What does it mean, and why does it matter?

I’ve seen a sudden uptick in conversation about Postural Sway in ADHD and Autistic people, but what does it actually mean, and why is it important to understand?

For one thing, because issues with postural instability and proprioception can have an impact on a person’s quality of life. In some cases, it can interfere with participation in activities and can cause physical pain.

In other cases, it’s more of an inconvenience but still can lead to more frequent injuries and difficulty with coordination.

On a personal note

I’ve been an athlete since I could walk and skate, but I’m getting older (38 is “old” in athlete years). In my 20s and into my early 30s, I was physically active every day and played high-level competitive soccer and hockey. I was also going to physiotherapy regularly due to ongoing sports injuries.

I remember one appointment my physiotherapist (PT) was showing me a new balance and core-strengthening exercise. You place a few pieces of paper (sticky notes or any flat object, really) on the floor in front of you, but within reach.

While standing on one foot, you reach down in a slow, controlled movement to touch one piece of paper. Then, while continuing to balance on one foot, you stand up straight, then bend down to touch another. You touch each piece of paper, then switch to balancing on the other foot and repeat.

Given that I was strong and in good shape at the time, my PT did not expect me to have any trouble with this exercise.

Unfortunately, she thought wrong.

I didn’t fall over, but I was wobbly, and found the exercise much more difficult than my PT – or I – had expected. I can’t say for certain why this was, but I was diagnosed Autistic and ADHD a few years later. In hindsight, it’s not all that surprising after all, and I’ll explain why.

Postural Sway

Postural sway relates to our sense of balance and refers to horizontal movement around our centre of gravity.

For example, if you’re on a boat and the floor beneath your feet tilts slightly, you adjust your posture in order to adapt and not fall over. Other examples are using balance boards at the gym, keeping yourself upright when riding a bike, or maintaining your balance while standing on one foot.

ADHD, Autism, and Postural Sway

Postural sway, or postural instability, is a common problem amongst ADHD and Autistic individuals. Postural instability refers to difficulty maintaining equilibrium under both dynamic (changing) and static (unchanging) conditions.

There are a few different theories for why this is, but I’ll discuss the two I found most interesting, which also have the most research to support their supposition.

The first theory posits that, due to hyperactivity and impulsivity, we over-respond and over-correct to changes in our environment, thus having a more difficult time maintaining or regaining our balance.

The second theory contends that postural sway is related to proprioception deficits. Proprioception gives us awareness of where our own body is in space, and in relation to other objects. If you are prone to bumping into things like I am, then you might have proprioception deficits.

Proprioception is the sense through which we perceive the position and movement of our body, including our sense of equilibrium and balance. It enables us to judge our limb movements and positions and combines with other senses to locate external objects relative to the body.

This would include objects in contact with our feet, such as the floor or ground, and our ability to judge correctly where we should place our feet or distribute our weight in order to maintain our balance.

Have you ever had that experience where you think there’s one more stair, so you lift your foot higher than necessary, and then are surprised when the floor is lower than you thought it was? Or when a chair is lower to the ground than you anticipated, then experience a brief sense of falling when you sit and have further to go than you expected?

Those experiences are common human experiences, so they certainly don’t mean a person is Autistic or ADHD. However, people who have insufficient proprioception have these experiences much more often than the general population.

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Concussion-like symptoms

An interesting and well-controlled study found that children with ADHD endorsed more concussion-like symptoms and performed worse on balance testing compared to non-ADHD peers.

Recent research found Visual-Motor Integration (VMI) deficits in Autistic children, and VMI is crucial to developing motor skills. This study also noted that Autistic children form internal sensorimotor representations that bias proprioceptive over visual feedback.

What that means is, rather than relying on visual information in the environment to guide skills like hand-eye coordination, Autistic children tend to rely on proprioceptive input. That is, they use the sense and awareness of their body in space and in relation to others, rather than using visual input to guide their movements.

Obviously, this is descriptive and not prescriptive, meaning it describes a generalization about Autistic children. Not all Autistic children will have VMI and proprioceptive deficits, but they’re much more common in Autistic people when compared to the general population.

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Hypermobility and EDS

Another reason for my experiences of postural sway and frequent sports injuries is probably the hypermobility in my joints and tendons. I do not have Ehlers-Danlos Syndrome, which can be a severe form of hypermobility that can be very painful and can also have more serious health effects.

I do, however, have hypermobility, as diagnosed by my doctor and PT. I have tendon issues in my wrists and scapula, and I roll my ankle if I just look at it the wrong way.

Hypermobility spectrum disorders (HSDs) are highly co-morbid in Autistic people, and generalized joint hypermobility(GJH) is also common amongst those of us with ADHD. Conversely, those with diagnosed HSD and hEDS are also more likely to be Autistic or ADHD when compared to the general population.

HSDs are also thought to impact our proprioception, although the precise cause has not yet been identified. Research has found a reverse correlation between one’s Beighton score (the extent of hypermobility) and proprioception, meaning the greater the hypermobility, the poorer the proprioceptive abilities.

Did TikTok strike again?

While I’m not entirely sure why there is a sudden interest in postural sway, I suspect it may have something to do with this recent TikTok video that already has over 4.7 million views.

Whatever the reason, I’m certainly glad it came up again, because it gave me an excuse to do some deeper research on the subject.

References

Appeadu M., & Gupta V. (2021). Postural Instability. In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560906

Casanova, E. L., Baeza-Velasco, C., Buchanan, C. B., Casanova, M. F. (2020). The Relationship between Autism and Ehlers-Danlos Syndromes/Hypermobility Spectrum Disorders. Journal of Personalized Medicine; 10(4), 260. https://doi.org/10.3390/jpm10040260

Cham, R., Iverson, J.M., Bailes, A.H. et al. (2021). Attention and sensory integration for postural control in young adults with autism spectrum disorders. Experimental Brain Research 239, 1417–1426. https://doi.org/10.1007/s00221-021-06058-z

Clayton, H. A., Marius ’t Hart, B., & Henriques, D. Y. P. (2021). Sensing hand position in Ehlers-Danlos syndrome. Somatosensory & Motor Research, 38:4, 303–314. https://doi.org/10.1080/08990220.2021.1973403

Cook, N. E., Kelshaw, P. M., Caswell, S. V., Iverson, G. L. (2019). Children with Attention-Deficit/Hyperactivity Disorder Perform Differently on Pediatric Concussion Assessment. The Journal of Pediatrics, 214, 168–174.e1. https://doi.org/10.1016/j.jpeds.2019.07.048

Glans, M., Thelin, N., Humble, M. B., Elwin, M., Bejerot, S. (2021). Association between adult attention-deficit hyperactivity disorder and generalised joint hypermobility: A cross-sectional case control comparison. Journal of Psychiatric Research; 143, 334–340. https://doi.org/10.1016/j.jpsychires.2021.07.006

Jansen, I., Philipsen, A., Dalin, D., Wiesmeier, I. K., Maurer, C. (2019). Postural instability in adult ADHD: A pilot study. Gait & Posture, 67, 284–289. https://doi.org/10.1016/j.gaitpost.2018.10.016

Kindgren, E., Quiñones Perez, A., & Knez, R. (2021). Prevalence of ADHD and Autism Spectrum Disorder in Children with Hypermobility Spectrum Disorders or Hypermobile Ehlers-Danlos Syndrome: A Retrospective Study. Neuropsychiatric disease and treatment, 17, 379–388. https://doi.org/10.2147/NDT.S290494

Lidstone, D. E., & Mostofsky, S. H. (2021). Moving Toward Understanding Autism: Visual-Motor Integration, Imitation, and Social Skill Development. Pediatric Neurology, 122, 98–105. https://doi.org/10.1016/j.pediatrneurol.2021.06.010

Schulze, M., Lux, S., Philipsen, A. et al. (2020). Sensory Processing in Adult ADHD: A Systematic Review. Research Square. https://doi.org/10.21203/rs.3.rs-71514/v1

Taylor, J. L. (2009). Proprioception. In Larry R. Squire (Ed.). Encyclopedia of Neuroscience. (pp 1143–1149). Academic Press. https://doi.org/10.1016/B978-0-12-407237-4.00005-0

Zoccante L, Ciceri ML, Chamitava L, Di Gennaro G, Cazzoletti L, Zanolin ME, Darra F, Colizzi M. (2021). Postural Control in Childhood: Investigating the Neurodevelopmental Gradient Hypothesis. International Journal of Environmental Research and Public Health, 18(4):1693. https://doi.org/10.3390/ijerph18041693

Postural Sway in ADHD & Autism