|Year : 2018 | Volume
| Issue : 3 | Page : 81-85
Regulating developmental parameters in children with rickets having lower extremity angular deviations
Meenakshi Batra1, Vijay Batra2, Anoop Agarwal1
1 Department of Occupational Therapy, Pandit Deendayal Upadhyaya National Institute for the Persons with Physical Disabilities (PDUNIPPD), Ministry of Social Justice and Empowerment, Government of India, New Delhi, India
2 Department of Occupational Therapy, G.B. Pant Institute of Postgraduate Medical Education and Research (GIPMER), Government of NCT, New Delhi, India
|Date of Web Publication||9-Nov-2018|
Dr. Meenakshi Batra
A-3/90, Paschim Vihar, New Delhi - 110 063
Source of Support: None, Conflict of Interest: None
Background: Rickets is among the most frequent childhood diseases in many developing countries. Long-term consequences include permanent curvatures or disfiguration of the long bones, and the angular deformities of the lower limbs during childhood represent a variation from normal growth pattern. Objectives: The objective of the study is to see the effectiveness of sensorimotor modulating strategies for regulating developmental parameters in children with rickets having lower extremity angular deviations. Study Design: This study was an experimental control (with nonrandom assignment) design. Methods: Thirty children aged 2–7 years with a diagnosis of rickets having developmental angular deformities were included in the study. Baseline evaluation was done for angular deformities, foot progression angle, and range of motion. They were allocated to groups, namely, Group A (Neurofacilitation of Developmental Reaction [NFDR] group, n = 15) and Group B (conventional treatment [CT] group, n = 15). With Group A, NFDR and, Group B, CT were used for 12 weeks with a frequency of three sessions per week of 45-min duration each. Results: Reevaluation was done and P value was found to be significant for Group A (NFDR group) for the variables for hip external rotation right leg (P ≤ 0.046, 95% confidence interval [CI] of difference: −11.6 to − 0.1), hip internal rotation right leg (P ≤ 0.008, 95% CI of difference: −6.2 to − 1.0), tibial rotation left leg (P ≤ 0.26, 95% CI of difference: 1.2–16.9) and right leg (P ≤ 0.29, 95% CI of difference: 1.0–16.6), ankle dorsiflexion left leg (P ≤ 0.01, 95% CI of difference: 0.6–3.8) and right leg (P ≤ 0.011, 95% CI of difference: 0.5–3.9), intercondylar distance (P ≤ 0.015, 95% CI of difference: −4.9 to − 0.6), foot progression angle left leg (P ≤ 0.002, 95% CI of difference: 6.0–12.0) and right leg (P ≤ 0.004, 95% CI of difference: 5.8–11.0), and postural reaction score (P ≤ 0.013, 95% CI of difference: 6.8–7.0), showing better improvement than Group B (CT group). Conclusion: The lower extremity angular deviations in children with rickets can be regulated using specific and developmentally appropriate sensorimotor strategies based on postural dynamics.
Keywords: Angular Deviation, Genu Valgum, Genu Varum, Occupational Therapy, Posture, Rickets
|How to cite this article:|
Batra M, Batra V, Agarwal A. Regulating developmental parameters in children with rickets having lower extremity angular deviations. Indian J Occup Ther 2018;50:81-5
|How to cite this URL:|
Batra M, Batra V, Agarwal A. Regulating developmental parameters in children with rickets having lower extremity angular deviations. Indian J Occup Ther [serial online] 2018 [cited 2022 May 25];50:81-5. Available from: http://www.ijotonweb.org/text.asp?2018/50/3/81/244549
| Introduction|| |
Rickets is defective mineralization or calcification of bones before epiphyseal closure due to deficiency or impaired metabolism of Vitamin D, phosphorus, or calcium, potentially leading to range of deformities and fractures most frequent in many developing countries.,, The signs and symptoms of rickets may vary and include bone pain and tenderness, hypocalcemia, low physical growth, pelvic deformities, tetany and angular deformities (genu varum, thickened ankles and wrists, and genu valgum), and maladaptive compensatory strategies.,,,,,
The angular deformities of the lower limbs during childhood represent a variation in the normal growth pattern that may vary from genu varum to genu valgum to windswept deformity., Genu varum and medial tibial torsion are normal in newborns and infants, and maximal varus is present at 6–12 months of age. With normal growth, the lower limbs gradually straighten with a zero-tibiofemoral angle by 18–24 months of age (when the infant begins to stand and walk). At around age 3–4 years, knees gradually drift into valgus with an average lateral tibiofemoral angle of 12°., Finally, the genu valgum spontaneously corrects by the age of 7 years to that of the adult alignment of the lower limbs of 8° of valgus in females and 7° in males. Extrinsic and intrinsic factors may interfere with this normal angular alignment of the lower limbs.,,,,, The general treatment in rickets is constitutional augmented by dietary measures and pharmacological, orthotic, and operative measures., There is a paucity of literature on the effect of exercise therapy in rickets with no specific role defined for occupational therapy (OT).
During the initial stages of rickets, the softening of bone occurs; henceforth, the faulty positions, muscle actions, and weight-bearing are the main factors to be observed to prevent deformities.,, The alignment, weight-bearing, and muscle action are continuously modulated by the sensorimotor input based on task and functional requirement, if gets altered may result in abnormal sensorimotor modulation.
The essential elements of sensorimotor modulation (an ongoing process) include the way we modulate sensory and motor information. It is the capacity to regulate and organize the degree, intensity, and nature of sensory and motor input in a graded and adaptive manner to achieve and maintain an optimal range of performance and adapt to environmental challenges. Sensorimotor modulation is typically explored from both neurophysiological and behavioral levels of observation and functionally engages in meaningful repertoire of activities.,,
As per Wolff's law of development and equilibrium, any deviation from normal perpendicular axis for prolonged duration will lead to compensatory deviation or deformity. The children with rickets having poor lower extremity alignment in genu varum and valgum may present with shortening as well as lengthening of muscles resulting in poor modulation of sensorimotor strategies with respect to task requirements. The children during early developmental years have lower extremity alignment issues due to calcium/Vitamin D deficiency which are either neglected or are not easily identified. This results in poor posture and alignment and compensatory strategies contributing to secondary bony deformities.,,,, The need to identify and define role of OT for these angular deformities was realized so as to develop/formulate effective comprehensive, specific, and developmentally appropriate sensorimotor strategies based on the Neurofacilitation of Developmental Reaction (NFDR) approach, during early developmental years (when the growth and maturation are undergoing) and determine its effectiveness for regulating developmentally and functionally appropriate developmental parameters of lower extremity angular deviations and postural behavior response in children with rickets.
| Methods|| |
It was a quasi-experimental control design. Thirty children aged 2–7 years with a diagnosis of rickets having developmental rotational and angular deformities (genu varum or genu valgum) coming to the department of occupational therapy were included and written informed consent was obtained. The children with fixed deformities and associated neurological and psychiatric conditions were excluded from the study. The ethical clearance was taken from the Institutional Ethical Committee. The confounders such as pharmacological and orthotic interventions which could have influenced the results were kept constant for both the groups. The pharmacological intervention included the recommended oral doses of calcium and Vitamin D as prescribed by pediatrician/orthopedician on individual basis, while the orthotic intervention included single upright metal braces based on the type of angular deviation.
The baseline evaluation was done for angular deviations, postural response, and foot progression angle. The variables for outcome measurement were foot progression angle, Quadriceps angle (Q-angle), range of motion (ROM), hip external rotation, hip internal rotation, tibial rotation, ankle dorsiflexion, intermalleolar and intercondylar distance and postural behavior using postural reaction score on perturbation board.
Hip, knee, and ankle ROM (sitting and prone lying) and Q-angle (supine lying position) were assessed using goniometer; intermalleolar and intercondylar distance was assessed using measuring tape (standing position); foot progression angle was assessed using footprint method and postural behavior response using postural reaction score.,,,
The participants were allocated to two treatment groups, namely, Group A and Group B with 15 participants in each using the inverse sampling method. With Group A, NFDR and, Group B, conventional treatment (CT) were used for 12 weeks with a frequency of three sessions per week of 45-min duration each.
Treatment Strategy for Group A (Neurofacilitation of Developmental Reaction Group)
It incorporated selective muscle strengthening, perturbation training exercises, and activities using perturbation board, differential load/weight-bearing exercises.
The children with rickets present either with genu varum or genu valgum that may result from relative shortening or over lengthening of hip adductors, rotators, knee extensors and flexors (medial hamstrings), foot evertors, and long toe flexors. The NFDR approach involves selective muscle strengthening, graded stretching, and weight-bearing of these muscle groups based on postural ontogenesis and individual relative alignment of the femur with respect to the tibia. The graded weight-bearing was superimposed on facilitation of underlying culprit muscles in different functional positions (and support surfaces) based on NFDR for modifying functional parameters of developmental lower extremity rotational and angular deviations and modulate postural behavior and alignment.
The perturbation training based on graded loading with appropriate relative alignment of lower extremities and positions (initially in sitting position followed by standing position) based on individual postural behavior response threshold was given.
Conventional Strategy Conventional Treatment Group
It incorporated ROM and lower extremity strengthening exercises for hip (flexion–extension, abduction–adduction, and rotation), knee (flexion–extension), and ankle and foot (flexion–extension and eversion–inversion). The departmental activities & exercises such as multipurpose wheel, therapy ball activities and ball kicking, ascending descending ramp with weighted cuff and sit to stand & vice versa, along with hamstrings, quadriceps & dorsiflexors strengthening based on individual's capacity and endurance threshold, were also given.,,
Between-group analysis was done using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY: USA). A constant was added for tibial rotation, and normality was established. When distribution was normal, i.e., for the variables such as hip internal and external rotation, tibial rotation, ankle dorsiflexion, intermalleolar distance, and intercondylar distance, parametric independent (unpaired) t-test was used for between groups analysis. When distribution was skewed, i.e., for the variables such as foot progression angle (left and right) and postural reaction score, nonparametric Mann–Whitney U-test was used.
| Results|| |
On between-group analysis, the P value was found to be significant for Group A, i.e., NFDR group, hip external rotation right leg (P ≤ 0.046, 95% confidence interval [CI] of difference: −11.6 to − 0.1), hip internal rotation right leg (P ≤ 0.008, 95% CI of difference: −6.2 to −1.0), tibial rotation left leg (P ≤ 0.26, 95% CI of difference: 1.2–16.9) and right leg (P ≤ 0.29, 95% CI of difference: 1.0–16.6), ankle dorsiflexion left leg (P ≤ 0.01, 95% CI of difference: 0.6–3.8) and right leg (P ≤ 0.011, 95% CI of difference: 0.5–3.9), intercondylar distance (P ≤ 0.015, 95% CI of difference: −4.9 to − 0.6), foot progression angle left leg (P value ≤ 0.002, 95% CI of difference: 6.0–12.0) and right leg (P ≤ 0.004, 95% CI of difference: 5.8–11.0), and postural reaction score (P ≤ 0.013, 6.8–7.0) [Table 1] and [Table 2].
|Table 1: Between-group analysis Group A (Neurofacilitation of Developmental Reaction group) versus Group B (conventional treatment group)|
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|Table 2: Between group analysis for postural reaction score: Group A (Neurofacilitation of Developmental Reaction group) versus Group B (conventional treatment group)|
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| Discussion|| |
The comparison of sensorimotor modulation strategies based on NFDR with CT group on developmental parameters chosen showed significant difference for the variables such as right hip external and internal rotation, tibial rotation right leg, ankle dorsiflexion (left and right), intercondylar distance, foot progression angle, and postural reaction score in NFDR group in comparison to CT group.
The differences could be attributed to the intervention strategies used in Group A which incorporated pattern of change in frontal and transverse planes considered as elementary component regulated during perturbation training.,, The effect could further be related to the relative alignment, selective stretching, and graded weight-bearing in different loading conditions using perturbation board in controlled manner as evident by the significant P value for the variables such as intercondylar distance (P = 0.015), tibial rotation right leg (P = 0.029), and foot progression angle left and right (P = 0.002 and 0.004, respectively). Furthermore, the foot progression angle appears to be directly affected by degree of hip/femoral and knee/tibial rotation and improvement in mechanical axis as evident by significant differences observed for the variable intercondylar distance (P = 0.015).,,
The improved in alignment along with hip, knee, and ankle ROM helped in the modulation of weight-bearing line or mechanical axis, thereby augmenting remodeling and adaptation of bone through optimal mechanical loads and graded postural behavior modulation using perturbation board. The postural behavior responses can be attributed to the improvement in symmetry, alignment, and muscle extensibility augmenting the interaction of mechanical stimulus under different dynamic loads, thereby improving and regulating frontal and transverse plane stability.,,,
The sensorimotor modulation strategies, used in the study helped in controlling muscle forces and muscle extensibility in genu varum and genu valgum in frontal planes as well as generating and regulating appropriate postural behavior responses as evident by significant postural reaction score. These changes and responses could have helped in bone remodeling under differential loading conditions as stated by Wolff's law.,
The development of muscle and bone during the growth periods is influenced by forces associated with gravity and physical activity. Hence, the early modulation of weight-bearing and postural alignment has a qualitative impact on epiphyseal growth which serves an important role in defining musculoskeletal mechanics, thereby influencing sensorimotor modulation and developmental progression.,,
Limitations and Future Research
The treatment intervention was of 3-month duration. Further long-term studies can be conducted to see the effect of intervention on developmental aspects of gait deviation.
| Conclusion|| |
It can be concluded that the lower extremity angular deviations in children with rickets can be regulated using specific and developmentally appropriate sensorimotor strategies of NFDR, based on postural dynamics.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Misra M, Pacaud D, Petryk A, Collett-Solberg PF, Kappy M; Drug and Therapeutics Committee of the Lawson Wilkins Pediatric Endocrine Society, et al.
Vitamin D deficiency in children and its management: Review of current knowledge and recommendations. Pediatrics 2008;122:398-417.
Munns CF, Shaw N, Kiely M, Specker BL, Thacher TD, Ozono K, et al.
Global consensus recommendations on prevention and management of nutritional rickets. J Clin Endocrinol Metab 2016;101:394-415.
Ganavi R. Bow legs and knock knees: Is it physiological or pathological? Int J Contemp Pediatr 2016;3:687-691.
Wu DD, Burr DB, Boyd RD, Radin EL. Bone and cartilage changes following experimental varus or valgus tibial angulation. J Orthop Res 1990;8:572-585.
Gordon CM, Feldman HA, Sinclair L, Williams AL, Kleinman PK, Perez-Rossello J, et al.
Prevalence of Vitamin D deficiency among healthy infants and toddlers. Arch Pediatr Adolesc Med 2008;162:505-512.
Brooks WC, Gross RH. Genu varum in children: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:326-335.
Greene WB. Genu Varum & genu valgum in children: Differential diagnosis and guidelines for evaluation. Curr Opin Pediat 1996;22:22-9.
Van Gheluwe B, Kirby KA, Hagman F. Effects of simulated genu valgum and genu varum on ground reaction forces and subtalar joint function during gait. J Am Podiatr Med Assoc 2005;95:531-541.
Arazi M, Oğün TC, Memik R. Normal development of the tibiofemoral angle in children: A clinical study of 590 normal subjects from 3 to 17 years of age. J Pediatr Orthop 2001;21:264-267.
Espandar R, Mortazavi SM, Baghdadi T. Angular deformities of the lower limb in children. Asian J Sports Med 2010;1:46-53.
Do TT. Clinical and radiographic evaluation of bowlegs. Curr Opin Pediat 2001;13:42-46.
Bafor A, Augbemudia AO, Umebese PF. Epidemiology of angular deformities of the knee in children in Benin, Nigeria. Sahel Med J 2008;11:114-117. [Full text]
Bradway JK, Klassen RA, Peterson HA. Blount disease: A review of the English literature. J Pediatr Orthop 1987;7:472-480.
Cokenower JW. Rickets in its early stages and best treatment to prevent deformities. JAMA 1911;57:1507.
Zionts LE, Shean CJ. Brace treatment of early infantile tibia vara. J Pediatr Orthop 1998;18:102-109.
Zayer M. Long-term results after physiological genu varum. J Pediatr Orthop B 2000;9:271-7.
Champagne T. Sensory Modulation & Environment: Essential Elements of Occupation. 3rd
ed. Southampton, MA: Champagne Conferences & Consultation; 2008.
Liu D, Todorov E. Evidence for the flexible sensorimotor strategies predicted by optimal feedback control. J Neurosci 2007;27:9354-68.
Bernstein N. The Coordination and Regulation of Movements. Oxford, New York: Pergamon Press; 1967.
Batra M, Sharma VP, Batra V, Malik GK, Pandey RM. Neurofacilitation of developmental reaction (NFDR) approach: A practice framework for integration/modification of early motor behavior (Primitive reflexes) in cerebral palsy. Indian J Pediatr 2012;79:659-663.
Todorov E. Optimality principles in sensorimotor control. Nat Neurosci 2004;7:907-915.
Loeb GE, Levine WS, He J. Understanding sensorimotor feedback through optimal control. Cold Spring Harb Symp Quant Biol 1990;55:791-803.
Chou' PH, Chou YL, Su FC, Huang WK, Lin TS. Normal gait of children. Biomed Eng Appl Basis Commun 2003;15:160-163.
Schoenau E, Fricke O. Mechanical influences on bone development in children. Eur J Endocrinol 2008;159 Suppl 1:S27-31.
Samaei A, Bakhtiary AH, Elham F, Rezasoltani A. Effects of genu varum deformity on postural stability. Int J Sports Med 2012;33:469-73.
Mullender MG, Huiskes R. Proposal for the regulatory mechanism of Wolff's law. J Orthop Res 1995;13:503-512.
Rosa N, Simoes R, Magalhães FD, Marques AT. From mechanical stimulus to bone formation: A review. Med Eng Phys 2015;37:719-28.
Huiskes R, Ruimerman R, van Lenthe GH, Janssen JD. Effects of mechanical forces on maintenance and adaptation of form in trabecular bone. Nature 2000;405:704-706.
[Table 1], [Table 2]