Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of Candidate& Address / PANIA DIIPTI RAJKUMAR
PLOT NO.370/371, FLAT NO.402
SUJANA ENCLAVE, KPHB 6TH PHASE,
KUKATPALLY HYDERABAD
2 /
Name of the Institution
/ DAYANANDA SAGAR COLLEGE OF PHYSIOTHERAPY3 /
Course of study and subject
/ MASTER OF PHYSIOTHERAPY(Physiotherapy in Pediatrics)
4 /
Date of admission to course
/ July;20135 /
TITLE OF THE TOPIC:
EFFECTIVENESS OF SUPRAMALLEOLAR ORTHOSIS ALONG WITH REBOUND THERAPY ON POSTURAL STABILITY IN CHILDREN WITH DOWN SYNDROME.6. Brief resume of the intended work:
6.1 INTRODUCTION
Down syndrome is one of the most common causes of human birth defects. It is also referred to as Trisomy 21 and is the most common genetic cause of intellectual disability. Human beings typically have 46 chrosomes that are arranged in 23 pairs. Most people with Down Syndrome (about 95%) have three copies of chromosome 21 instead of two. Hence the term Trisomy 21, so the total number of chromosome in these people is 47. In 3- 4% of people with Down Syndrome is due to translocation. Here, extra material from chromosome number 21 is attached or translocated to another chromosome, usually chromosome 14. In 1- 2% of people with Down Syndrome, the extra chromosome 21 is present in some but not all the cells of the body. This is called mosaicism. Whatever the cause of Down Syndrome the effects on the child are similar. However, some children with mosaicism may have milder degree of impairment if only a small proportion of their cells have extra chromosome 21.1
Down syndrome symptoms vary from person to person and can range from mild to severe. No matter the severity of the condition, personswith Down syndrome have a widely-recognized appearance. The head may be smaller than normal and abnormally shaped. For example, the head may be round with a flat area on the back. The inner corner of the eyes may be rounded instead of pointed. Common physical signs include: Decreased muscle toneat birth : excess skin at the nape of the neck ;Flattened nose; Separated joints between the bones of the skull (sutures); Single crease in the palm of the hand; Small ears; Small mouth; Upward slanting eyes; Wide, short hands with short fingers; White spots on the colored part of the eye (Brushfield spots). Physical development is often slower than normal. Most children with Down syndrome never reach their average adult height. Children may also have delayed mental and social development. Common problems may include: Impulsive behaviour; Poor judgment; Short attention span; Slow learning2.
As children with Down syndrome grow and become aware of their limitations, they may also feel frustration and anger. Many different medical conditions are seen in people with Down syndrome, including: Birth defects involving the heart, such as anatrial septal defectorventricular septal defect; Dementiamay be seen; Eye problems, such ascataracts(most children with Down syndrome need glasses); Early and massive vomiting, which may be a sign of a gastrointestinal blockage, such asesophageal atresiaandduodenal atresia; Hearing problems, probably caused by regular ear infections; Hip problems and risk ofdislocation; Long-term (chronic) constipation problems; sleep apnea(because the mouth, throat, and airway are narrowed in children with Down syndrome); Teeth that appear later than normal and in a location that may cause problems with chewing; Underactivethyroid(hypothyroidism).2
Hypotonia may be the presenting sign for many systemic diseases and diseases of the nervous system.3 It is described as reduced resistance to passive range of motion in joints; weakness is reduction in the maximum power that can be generated. A more useful definition of hypotonia is an impairment of the ability to sustain postural control and movement against gravity.4 Many areas of a child’s life are affected by hypotonia leading to developmental delays that include cognitive development. Causes may include: Brain damage or encephalopathy due to lack of oxygen before or right after birth, disorders of the muscle such as muscular dystrophy, disorders that affect the nerve supply to muscles (called motor neuron disorders), infections other genetic or chromosomal disorder or defect that cause brain and nerve damage, such as Down Syndrome, Prader- Willi Syndrome.5
Rebound Therapy: High amplitude bouncing can increase muscle tone in children with Hypotonia. The strong physical movement caused by high energy bouncing of the bed causes muscles to stretch involuntarily, this inturn stretches the muscle spindle – increasing nerve activity in the muscle. This leads to a stretch reflex occurring where motor neuron activity increases to contract the muscle in order to resist the stretch, increasing contraction in muscles will increase their muscle tone and reduce the effects of Hypotonia. Vigorous bouncing increases tone by stimulating the sensory systems and gentle bouncing can reduce tone by having a shaking effect on the muscle spindles6
Supramalleolar Orthosis: A foot orthosis is a medical device which is designed to alter the magnitudes and temporal patterns of reaction forces acting on the plantar aspect of the foot in order to allow more normal foot and lower extremity function and to decrease pathologic loading forces on the structural components of the foot and lower extremity during weight bearing activities.7 The SMO is thought to use compression to promote midline functioning and enhance joint receptor function. It can be fabricated from girth, length and width measurement, thus eliminating the need for a cast mold of the child’s foot.8
6.2 Need for the study
Decreased pronation associated with hypotonia of foot can lead to postural instability, improving postural stability leads to better functional motor performance in down syndrome. Studies showed that young children with downs syndrome showed immediate and long term improvement in postural stability with the use of flexible SMO. High amplitude bouncing movement can increase muscle tone with the use of rebound in children with hypotonia by the facilitation of muscle spindle system that can improve motor performance. So this study tries to analyse whether Supramalleolar Orthosis along with Rebound Therapy has any effect on postural stability in children with down syndrome.
6.3 Hypothesis :
Null Hypothesis: There will be no significant effect of Supramalleolar Orthosis along with Rebound Therapy on postural stability in children with down syndrome.
Experimental Hypothesis: There will be a significant effect of Supramalleolar Orthosis along with Rebound Therapy on postural stability in children with down syndrome.
6.4 Review of Literature:
Outcome Measures
Kathy MartinPT DHS, (2004) Effects of supramalleolar orthosis on postural stability in children with Down syndrome The GMFM can document change over time in gross motor function. Only dimensions D (Standing) and E(Walking, Running, and Jumping) were used in this study because one criterion for participation was independent ambulation, thus the other dimensions had little clinical revelance. For both GMFM dimensions, significant differences were found between orthotic conditions but not between testing sessions and there was no significant interactions between condition and sessions.8
Barbara H Connolly and Beth T Michael, (1986) Performance of Retarded Children, With and Without Down Syndrome, on the Bruininks Oseretsky Test of Motor Proficiency The purpose of this study was to examine the gross motor and fine motor abilities of children with mental retardation using the Bruininks Oseretsky Test of Motor Proficiency. As a group, the children with Down syndrome scored significantly lower than the children without Down syndrome in the areas of running speed, balance, strength, and visual motor control. The gross motor and fine motor skill composite scores were also significantly lower for the children with Down syndrome than for the children without Down syndrome.10
Down syndrome
Dr Seeta Durvasula, Ms Jill O’Connor, (2011) Down syndrome, The syndrome is named after Dr John Langdon Down, who in 1866 described a group of children with intellectual impairment and a characteristic set of physical features. Down syndrome, also referred to as Trisomy 21. Many children with Down syndrome will learn better visually than by auditory means,and providing visual supports in the classroom will aid their learning.11
Dale A et al, (2011) Physical Activity Benefits of Learning to Ride a Two-Wheel Bicycle for Children With Down Syndrome: A Randomized Trial People with Down syndrome (DS) display consistent patterns of physical inactivity. If these sedentary behaviors continue over extended periods of time, there will be negative health consequences. The objective of this study was to investigate the physical activity and health-related outcomes of teaching children with DS to ride a 2-wheel bicycle. The results indicated no group differences at the preintervention session. Body fat appeared to be positively influenced over time in participants who learned to ride.12
Martin, (2009)The floppy infant Hypotonia is characterized by reduced resistance to passive range of motion in joints versus weakness, which is a reduction in the maximum muscle power that can be generated. Based on strong research evidence, central hypotonia accounts for 60% to 80% of cases of hypotonia, whereas peripheral hypotonia is the cause in about 15% to 30% of cases. Disorders causing hypotonia often are associated with a depressed level of consciousness, predominantly axial weakness, normal strength accompanying the hypotonia, and hyperactive or normal reflexes.13
Jo Anna Leyenaar,Peter Camfield, andCarol Camfield, (2005)A schematic approach to hypotonia in infancy. Infants with hypotonia pose challenges for clinicians because hypotonia may be the presenting sign of both benign and serious conditions. On first glance, the magnitude of the differential diagnosis, the rarity of associated illnesses, and the ongoing advances in diagnosis and management may appear overwhelming. A developmental assessment is useful. Motor delay with normal social and language development decreases the likelihood of brain pathology. In contrast, loss of milestones increases the index of suspicion for neurodegenerative disorders. A dietary/feeding history may point to diseases of the neuromuscular junction, which may present with sucking and swallowing difficulties that ‘fatigue’ or ‘get worse’ with repetition.14National Dissemination Center for Children with Disabilities, (2004), Down syndrome is the most common and readily identifiable chromosomal condition associated with mental retardation. Approximately 4,000 children with Down syndrome are born each year, or about 1 in every 800 to1,000 live births. Research has shown that stimulation during early developmental stages improves a child’s chances of developing to his or her fullest potential. Continuing education, positive public attitudes, and a stimulating home environment have also been found to promote the child’s overall development.15
Lisa Selby-Silverstein,(2001)Orthotic solution for hypotonia. Paper reports that foot orthosis affected the gait of children with Down syndrome; effects included reduced heel eversion and transverse plane foot angle during gait, but also a decrease in walking speed, and in a small (two-subject) 2012 study, researchers found that a flexible supramalleolar orthosis improved functional motor performance, whereas a less flexible one impeded it.16
Intervention
Ailsa miller May, (2007) Rebound Therapy . Where is the Evidence, discuss the current evidence for Rebound therapy and make suggestions further scientific research needed. Rebound therapy has been found to be a very useful adjunct to therapy for children with profound and multiple learning disabilities, as its use continues to grow so does the need for scientific research into its therapeutic effects.17
George DA,Elchert, (2007) The influence of foot orthosis on the function of a child with developmental delay. Foot orthosis may lead to improved function when used to control faulty foot biomechanics. The purpose of this case report was to describe the influence of modified stabilizing foot splints (SFSs) on the function of a child with developmental delay. The outcomes indicate that future study of the modified SFS as an intervention is warranted.18
Elisabeth Graham, (2006) The Effect of Rebound Therapy on Muscle Tone claims that abnormally high muscle tone is reduced because of the vibratory effect on the muscle spindles and that abnormally low muscle tone is increased because of the stimulatory effect upon the sensory systems. Improving muscle tone is of paramount importance for physically disabled children. By doing so, it not only improves balance, movement capacity and functional capabilities, but may contribute to an improved quality of life, especially for a child with cognitive delay.19
Kathy Martin, (2004)Effect of Supramalleolar Orthosis on postural stability in children with hypotonia. This study explored the effects of a flexible supramalleolar orthosis (SMO), indicated to decrease pronation associated with hypotonia, on postural stability in children with Down syndrome. Improving postural stability leads to better functional motor performance (Westcott et al. 1997, Lauteslager et al. 1998). Anecdotal reports from physical therapists and parents indicate that children with Down syndrome have improved postural stability when they use orthoses.20
N.A.S.A, (1981) A report on Rebound Therapy’s usefulness with Children with Disabilities - Nonspecific floppy baby syndrome. The disorder is a non-specific medical disorder, so is not caused by one problem, but often as a consequence of the manifestation of disorders that affect motor neurons and the brain. Study into rebounding include report on Rebound Therapy’s usefulness with Children with Disabilities, project aims to investigate and summarise the usefulness of Rebound Therapy when applied to children with a variety of disabilities.21
Angela Bauer, David Speers, Jason Wening, (1980) The effects of supramalleolar orthosis on the gait of children with excessive pronation associated with benign hypotonia. Supramalleolar orthosis (SMOs) are commonly prescribed devices for young children who present with benign hypotonia and excessive pronation. Martin found that postural stability improved immediately with use of SMOs and further improved after several weeks of wear. In the subjective surveys on the effect of the SMOs, all guardians reported that the SMOs improved the child’s quality of life in one or more capacities including improved balance, greater endurance, ability to better keep up with peers, and ability to jump when wearing SMOs.22
6.5 Objectives of the study:· To find out effectiveness of Supramalleolar Orthosis along with Rebound Therapy
on postural stability in subject with down syndrome
7 / Materials and Methods:
7.1 Source of Data
· Physiotherapy Clinic, Dayananda Sagar College of Physiotherapy, Bangalore.
· Sagar Hospitals, Bangalore.
· NIMHANS Bangalore
· Pediatric centers in and around Bangalore
7.2 Method of collection of data: