SUMMARY The Treatment principles of posture and gait disturbances first need a general assesment of child’s posture,following the motor development stages from 0-14 months and from 14 months to 6 years. Once walking developed,we need to asses the posture disturbances,taking into account the general development stage and that some postures are temporary physiological and they do not require intervention. We need to spotlight that the mature gait is to Be considered only afeter 6 years of age. It is important to educate the parents about the wrong postures of the child, like the \u201e W\u201d posture,and the child will go barefoot inside,for working the plantar muscles and the plantar torsion between the forefoot and the ankle. The ortopedic check up of the child is required for every gait disturbance noticed,to asses the normal or pathological aspect,that could Be corrected by using an orthesis or other apropriate rehabilitation. Keywords: posturology, treatment, orthesis<\/p>\n
Postural assesment-ontogenetic stage I (0-14 months)\t\u2013 Exam of archaic reflexes\t\u2013 Exam of muscular tonus (the scarf manoeuver, the poplitheal angle measurement)\t\u2013 Motor aquisition assesment-ontogenetic We must note down the strabism, torticolis, plagiocephaly. From 0-14 months, the postural system builds up on the main cephalic system (ear, mandible, vestibulary system). Acording to the law of cephalic-caudal development, the head movement control is the first develomental stage of postural control [1]. Motor development stages:\t\u2013 Head movement control – 3 months\t\u2013 The sitting posture – 6-7 months\t\u2013 Walking (assisted) – 10 months\t\u2013 Independent walking -12-15 months. Warning sign – lack of head movement control at 4\u00a0months, or sitting pose unaquired at 9 months. \u00cen the first ontogenic stage, postural training manouvers (between 8 weeks – 3 months), regard cervical extension stimulation to improve cervicodorsal muscle tonus. The exercises regard pronation lifts or placing the baby on the therapist’s forearm. At 4 \u00bd months we can start lateral and visual stimulation (placing objects into the visual field, starting from the median line to the periphery). At 9 months-initialising the crossed corporal scheme (rolling, sitting, walking on all fours, verticalisation). Walking on all fours is very important, ensuring eye-hand and visual field coordination, s trenghtening the lateral and posterior muscle chains and the skull moulding by the posterior cervical muscle traction. It also stimulates head lifting and cervical lordosis wich will improve tongue movement and nasal ventilation [2]. Postural assesment-ontogenetic stage II (14\u00a0months – 6 years) starts with walking-the postural system builds on the podal element, propriceptive, joints and cutaneous element. The organisation of postural control is now ascendant (feet-head). It is very important the stability of the hips, of side walking equilibrium [1]. At this time, is necessary for the child to aquire: \t\u2013 walking, between 12-15months
\n\t\u2013 running, at 24 months\t\u2013 climbing stairs altenating the legs, at 30 months\t\u2013 tricycle riding at 3 years\t\u2013 jumping on one foot at 4-5years. Warning – the child doesn’t walking independently at 1, 6 years. POSTURAL DISTURBANCED OF GAIT\t\u2013 Walking with one or both feet \u00een acentuated rotation, frequent falling;\t\u2013 Walking with asymetrical rotation of the feet;\t\u2013 Tiptoe walking (digitigrade);\t\u2013 Genu varum\/valgum acentuated\/asymetrical;\t\u2013 Dorso-lumbar joint rigidity, disfuntions \u00een hip joints. Unaquired walking at 18 months requires special recomandation for psycho-motor assesment [3]. Plantar Neurosensitive exteroceptive informations play their role \u00een ortostatism’s control [4]. Child’s gait is different from adult’s gait because:\t\u2013 Immaturity of equilibrium [5].\t\u2013 Insuficiency of muscular force [6].\t\u2013 Immaturity of neuronal network [7]. A mature gait is considered after 5-6 years of independent walking or after 7 years of age. After 2 years of age, the hip Goes \u00eento the suport stage, in internal rotation and adduction.The pelvis is less antevert and so the hip flexion decreases. Some children keep the pelvis anteversion, wich generates an internal rotation gait and a postural desequilibration [3]. Starting walking generates an internal tibial torsion, wich determines a physiological internal rotation of the forefoot. During growing period are noticed an external femural torsion and an external tibial torsion. There is an physiological oscilation between -genu varum\/ valgum. The lower limbs are \u00een their own axe around 7\u00a0years of age. Genu varum is physiological before 2 years, then it is genu valgum, wich disminishes until 12 years. It\u00a0is considered physiological genu valgum \u00een children between 3-10 years, if it is symetrical. At birth there is a normal tibio- tarseal valgum, wich will normally settle until 12 years [8]. Children between 1 and 5 are prone to have flat valgue foot, by insufficient development of the plantar curve [9].<\/p>\n
The child walks with everted feet, with sole valgusit dissapears when shoes are talent off [10]. Most of the times, the flat valgue foot spontaneously regresses. The benign caracter of this posture can be checked by asking the child to walk on tiptoes, looking for the Jack sign (the toe extension) [9]. Tiptoe posture anihilates the eversion. This is why we indicate walking barefoot inside, for training the sole muscles. The internal arcade needs to be shaped by the physiological torsion between the forefoot and the backfoot, and rigid wich presents normal when standing on toes or barefoot. It is not necessary to wear orthopedic shoes or undergo kinetotherapy, but to go barefoot inside and wear flexibile sole shoes outside. WALKING ANALYSING We should observe the front barefoot walking, then the back and side walking. Walking analyse criteria:\t\u2013 Legs distancing for a bigger sustaining area;\t\u2013 Syncronisation between upper\/lower limbs;\t\u2013 Anterior or posterior postural desequilibrium;\t\u2013 Ankle attack \u00een support phase;\t\u2013 Foot rotation during the support phase;\t\u2013 Tiptoe walking;\t\u2013 Genu recurvatum;\t\u2013 Arms balance, girdle dissociation;\t\u2013 Checking the shoes\u2019soles for abnormal support or vicious postures. PATHOLOGICAL GAIT I. Walking \u00een internal rotation of the feet [12]. a) Internal rotation is normal until 3 years. b) Exagerate femoral antetorsion is frequent before 6 years and it is often familial. We need an X Ray – exam to exclude hip displasia. Internal rotation walking, with knees and feet inside orientated can lead to frequent falling, especially when running [3]. This abnormality is frequently isolated, but it can be seen \u00een cerebral palsy, congenital malformations or secondary to congenital hip luxation or a vicious calous after hip epiphysiolisis or Legg – Perthes- Calve disease [14]. The favourite W pose (kneeling with the bottom between ankles, calves \u00een external rotation) generates exagerate femoral antetorsion, and should be forbidden [15].
\nc) Excess internal tibial torsion [10]. It is rare. The child preferes to sit with the legs \u00een internal rotation and stuck under the bottom. Metstarsus adductus-it is a rarer cause of internal rotation walking. d) Pelvic persistent anteversion – is the most frequent cause of internal rotation walking, especially \u00een girls. II. External rotation walking – the it is rarer. a) Torsion al abnormalities:\t\u2013 Reduced femoral antetorsion [15]\t\u2013 External calf rotation\t\u2013 Femoral epiphysitis\t\u2013 Neuromuscular abnormalities. b) Pelvic retroversion – it is rarer than the snteversion. It is characterised by smaller lombar lordosis and compensating dorsal cyphosis. III. Genu valgum – is frequent between 2-7 years and it is not pathological if it\u2019 s symetrical. From 2 years of age therek is an femuro-tibial valgum, wich lowers progresively to 5 grades at 8-9 years, stabilising at puberty. \u00cen case of asymetrical valgum is required an
\n X Ray-exam [16]. One sided valgum is pathological – posibile epiphysiolisis. IV. Genu varum-there is an external knee angulation wich is physiological before 2 years. Idiopatic genu varum represents an accentuation of this phenomenon after 2 years. We must search a familial history, with good prognosis. Walking is a little balanced but not painful [16]. \u00cen obese children, the fatty tissue from inside the knees can lead to a genu varum like appearence. Genu varum can be accentuated \u00een case of femoral torsion and genu recurvatum [12]. V. Digitigrade walking There must be excluded non-postural origins: congenital shortening of Achilles’ tendon, cerebral palsy, miopathies. Digitigrade walking-clinical findings\t\u2013 When standing still the child stands on the whole sole, when walking he lifts himself on toes\t\u2013 No previous history \t\u2013 No achillean retraction. Until 5, tiptoe walking is due to – immaturity of postural control. If it persists after that, we should test the sural triceps (with extended knee).
\nWe should take podoscopic prints for carved -foot, neurologic -exam (MRI, Babinsky). TREATMENT OF POSTURAL GAIT DISTURBANCES Growing steps are not symetrical, do there are postural asymetries, and we shouldn’t correct one leg’s shortening during growing period. Correction is necessary only when the shortening is post traumatic or there is a serious malformation. If the lenght asimetry is corrected, it has to be checked regularly [13]. Proprioceptive orthosis Exteroceptive plantar sensors have a precision of few milligrams. By contrary, upper sensitivity limits for mecanoreceptors is about 150g [17]. A bove this limits, they won’t give any informations. So, a postural adjustment trough proprioceptive sole supports can be done only with very fine elements, about 3 mm [18]. Proprioceptive stimulation can interact with postural control depending on their localisation, and they have neurosensitive action. Mechanic orthesis Sole orthesis will be recomended to soothe the pain \u00een flat valgue feet, bilateral [19]. They will be recomended only in asymetrical pronation, associated with a pelvic anteversion on pronation’s side [20]. Indications of proprioceptive and mechanical orthesis\t\u2013 Proprioceptive orthesis are inefficient if child’s mielinisation is not complete (before 4-5 years).\t\u2013 Before mielinisation is complete, the cutaneous plantar test leads to toe’s extension-in this case mechanical orthesis can be prescribed.\t\u2013 After mielinisation is complete, the cutaneous plantar test is in flexion, so proprioceptive orthesis can be prescribed. TREATMENT OF INTERNAL ROTATION GAIT A.Treatment of a torsion abnormality Antetorsion\/anteversion of femoral neck is mantained by the \u201eW\u201d pose, with external rotation of the legs, pose wich should be forbidden. Sitting pose with legs undergo bottom, in internal rotation, shoud also be forbidden [21]. There 2 poses are frequent seen before 6 years and the abnormality disminishes with age, by lowering the femoral antetorsion. Under 5-6 years, if internal rotation is accentuated and the cutaneous plantar test is in
\nextension, mechanical orthesis is recomended. If the test is in flexion, proprioceptive orthesis can be recomended, as well as postural and proprioceptive training. B.Treatment of internal rotation gait due to pelvic anteversion Pelvic anteversion leads to an internal rotation of hips, wich can be hidden in case of ligament laxity. Treatment becomes necessary after 5-6 years. Pelvic anteversion required postural treatment if they lead to a sagital desequilibrium. \u00cen torsional asymetrical abnormality with gait disturbances, we must check for an pelvic anteversion associated with traumatic anteriorised ileon (falling on buttocks). TREATMENT OF EXTERNAL ROTATION GAIT A. Related to a tensional abnormality – very rare cases, can be fixed spontaneously or short term use of mechanical orthesis. B. Related to Pelvic retroversion – they require treatment only if there is a sagital desequilibrium.
\n We can use proprioceptive orthesis and postural training [21]. TREATMENT OF DIGITIGRADE GAIT Generally we recomend postural treatment after 5-6 years (if there is no-neuromuscular pathology involved) training and proprioceptive orthesis can be recommended. TREATMENT OF GAIT DISTURBANCES BECAUSE OF GENU VARUM AND GENU VALGUM An accentuated genu varum\/valgum leads to gait disturbances and recurent falling. Treatment alternatives depending on cutaneous plantar test. Mechanical orthesis can be prescribed after 3 years of age, with postural training. PROPRIOCEPTIVE TRAINING OF SOLE AREA \u00cen case of hipotone feet with postural disturbances, pelvic retroversion or flat back, proprioceptive sole supports won’t give adequate relief. Training can be done by stimulation of sole interactions (irregular surfaces and objects) and muscle stimulation. <\/p>\n
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SUMMARY The Treatment principles of posture and gait disturbances first need a general assesment of child’s posture,following the motor development stages from 0-14 months and from 14 months to 6 years. Once walking developed,we need to asses the posture disturbances,taking into account the general development stage and that some postures are temporary physiological and they […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"footnotes":""},"categories":[545,544],"tags":[],"class_list":["post-4140","post","type-post","status-publish","format-standard","hentry","category-numar-1-vol-2020","category-vol-2020"],"_links":{"self":[{"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/posts\/4140","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/comments?post=4140"}],"version-history":[{"count":2,"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/posts\/4140\/revisions"}],"predecessor-version":[{"id":4142,"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/posts\/4140\/revisions\/4142"}],"wp:attachment":[{"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/media?parent=4140"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/categories?post=4140"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/snpcar.ro\/en\/wp-json\/wp\/v2\/tags?post=4140"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}