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Résumé: This is a preliminary study to examine possible connections between posture, movement, coordination and attention in children upwards of 4 years of age. Method: In 2007 the catamnestic data of 30 patients were examined that had been selected randomly and anonymously from physiotherapeutic practices. Depending on age a minimum of two tests (MOT, KTK) was carried out on all the children at intervals of approximately 11 months. Result: There was an improvement in performance between the first and second test. There was found to be a close connection between diagnoses of foot abnormality, postural insufficiency, genu valgum and ADS/ADHS. Antje Haeger, Sigrid Graumann-Brunt and Waltraud Budrat, Erika Friedlein ADS/ADHS, foot abnormality, postural insufficiency and genu valgum Introduction: As a rule children are prescribed physiotherapy on medical grounds by a paediatrician or orthopaedist. A patient´s diagnosis usually indicates several findings. The most common medical diagnoses among children upwards of 4 are development, perception and coordination disorders, ADS/ADHS (attention deficit syndrome excluding or including hyperactivity), postural insufficiency, foot deformities or genu valgum; children were quite often found to have impaired attention. Our team was therefore interested in finding out whether a child´s attention level could be positively influenced by working on the child´s posture using physiotherapy. This seemed an obvious line of inquiry to pursue since we started out from the idea that there was a natural interdependence between posture and coordination of motor function development in young children and in later life. Posture was understood to mean the position taken up by the body under the force of gravity (3). Deviations such as kyphosis, lordosis or scoliosis were defined as a postural anomaly, postural insufficiency as a weakness of the body to hold itself upright under the force of gravity; coordination was defined as an order of movement in the sense of a harmonious interplay of the muscles involved in movement (3). For ADS/ADHS we presupposed a multifactorial disorder, usually comprising the symptoms of motor restlessness, fidgetiness, a lack of concentration, an "inability to sit still", constant distraction or day-dreaming. In an attempt to investigate thoroughly whether attention can be improved by working physiotherapeutically on posture, the team planned an extensive study. Beforehand, however, it would be necessary to gather information in a preliminary study that would be of use when planning further investigation. It is the findings of this preliminary study that are reported below because they proved to be of quite some relevance. The study concept In 2007, for the purposes of this preliminary study, the catamnestic data of thirty patients from three physiotherapy practices in Schleswig-Holstein, Germany, were selected anonymously and randomly. These patients had been examined at the beginning and once again approximately 11 months later. All the children had been prescribed physiotherapy on the grounds of a medical diagnosis. The following points were selected and listed individually as variables for the purposes of processing the data statistically: All diagnostic information from the initial diagnosis (Appendix 1) and that obtained from physiotherapeutic examination, appraisal of motor function impairment, nature of the therapeutic concept and the methods adopted for its implementation, some social variables (Appendix 2), data on pregnancy and birth and some other information. On both occasions the following points were looked at and noted: social skills, self-reliance, general school performance ( a simple screening of marks), enjoyment of physical exercise, emotional state, concentration and, as far as it was possible to do so, variables for mother´s and child´s motivation and emotional state at each appointment (Appendix 3). The test conducted on each occasion was either the MOT – motor function test (5) - or the KTK - body coordination test (2) - and took account of the age of the children. These tests had been selected because they are standardized and can also be easily applied in everyday therapeutic practice. Furthermore, they enabled individual items to be compared with one another and offered an insight into possible connections between items. These standardized values were supplemented by results obtained from a physiotherapeutic examination of posture. Evidence of postural insufficiency was confined to examination of the spine only. Foot deformities and genu valgum were recorded separately to enable more precise differentiation. The first and second test examinations were conducted an average of 11 months apart, during which time treatment was administered, consisting of Vojta, work on psychomotricity, exercises designed to strengthen the child´s back muscles and posture training. The age distribution of patients was as follows: 48 – 81 months, 20 children (tested using MOT), 75 – 134 months, 10 children (tested using KTK). One third of the children were girls, two thirds boys. In two thirds of cases social status was judged to be around medium, the other third almost evenly distributed between a higher and a lower status. Some of the variables recorded made no productive contribution and these results will therefore find no further mention here. These included the pre-term birth and multiple pregnancy variables. Caesarean birth was insufficiently represented. Nor could anything productive be derived from the kind of exercises carried out; the sub-groups were too small. The preliminary study which will be discussed here was not intended to serve as a form of method control; it was designed to select the items intended to be used in the principal study to ascertain their performance potential and to validate them. Results: Many of the differences between the first and second test results in both MOT and in KTK items and in the emotional state variable were of the highest significance taking all patients (1) as a whole. However, the results in respect of changes in emotional state could only be treated as pointers in view of the fact that the second test did not provide sufficient data to allow any accurate statement to be made. A more detailed consideration of the changes in the items in the sub-groups will have to be the subject of the main study proper with a larger number of persons. 1. Examination of the connections between the individual diagnoses The study came up with some surprising indications of connections between some of the individual diagnoses that were so relevant that they need to be discussed here. Four of the twelve diagnosis items painted a picture of a diagnosis complex (From here on the items measured and results obtained have been printed in bold / in italics for emphasis. ADS/ADHS (distribution N=8, does not apply in 8 cases /N=22, applies in 22 cases) Foot abnormality (distribution N=10 does not apply / N=20 does apply) Postural insufficiency (distribution N=4 does not apply / N=26 does apply) Genu valgum (distribution N=21 does not apply / N=9 does apply). Correlations between the diagnoses ADS/ADHS, foot abnormality, postural insufficiency and genu valgum: Table 1 
The most striking finding looking at the interconnections between the four diagnosis items was a correlation of the highest significance, .693***, between ADS/ADHS and foot abnormality. There was a further correlation of the highest significance between ADS/ADHS and postural insufficiency (in our case the diagnosis of postural insufficiency relates solely to the spine, see above) of .650***. ADS/ADHS correlated statistically to a lesser extent with the genu valgum item, but still significantly at .395*. All four items correlated highly with one another, postural insufficiency and genu valgum to a somewhat lesser degree (see Table 1). A factor analysis (see (4) for an explanation of the procedure; for these and all subsequent results of factor analysis: orthogonal rotation using Varimax) that was carried out on the values of the first test to get a better examination of the correlative results, revealed the same complex: The factor with the strongest variance, the first Factor A (with approx. 22% explained variance, showed the main items ADS/ADHS and foot abnormality, genu valgum and postural insufficiency, all of them with high loadings of between .69 and .80. Other loadings indicated that if the items from the tests were included, a factor structure consisting of five factors emerged with eigenvalues between 4.5 and 1.4 and explained variance between 22% and 7.2%. The ADS/ADHS item loaded on the first factor. Three other factors registered variance that had nothing to do with ADS/ADHS. One exception is the fourth factor, which can, however, be ignored here because of its low variance. All items with sufficient distribution and sufficient scaling quality, i.e. diagnosis and emotional state items and the test results for the individual items from the first test with MOT and KTK, were included in the factor analysis. The results pointed to a complex in which the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency often occurred together. 2. Examination of the connections between the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency and the test results from KTK and MOT. Examination of connections between the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency and the overall values from MOT and KTK brought hardly any information to light (KTK to ADS/ADHS -.34 and KTK to postural insufficiency -.35 not negligible in terms of the absolute figure, but neither of them significant in view of the small number of persons). More striking, statistically relevant connections to the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency could be found in single items of the MOT. 2.1. Item Balancing backwards 2.1.1. Changes in values from the 1st to the 2nd test: The mean value (1) of balancing backwards was 0.25 in the first test and 0.22 in the second test, indicating that these patients still found this exercise equally difficult on each occasion. This is also the item with the highest degree of difficulty in the MOT (MV boys in MOT 0.40; MV girls 0.51): 2.1.2. Statistically relevant connections between balancing backwards and the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency: Table 2 
In the first test balancing backwards produced significant negative correlations with respect to all four individual diagnoses: ADS/ADHS, foot abnormality, genu valgum, postural insufficiency (see Table 2). The high negative correlation value between ADS/ADHS and balancing backwards means that this task was more often performed less well by children with this diagnosis than by the test group as a whole. The task tended to be performed better by those children that had not been diagnosed with this disorder. The same applies to the individual diagnoses of foot abnormality, genu valgum, postural insufficiency. The probability values ascertained (significances) confirm these connections. What is striking in the second test is the quite high negative correlation between balancing backwards and postural insufficiency in contrast to the other diagnosis items: the absolute values of correlations between balancing backwards and ADS/ADHS, foot abnormality and genu valgum declined between the first and second test and cease to be significant. That means that those children whose initial individual diagnosis had been ADS/ADHS, foot abnormality, genu valgum, when tested the second time after having physiotherapy, no longer under-performed in the balancing backwards task in comparison to the group as a whole as they had done in the first test. One exception was postural insufficiency, where the problem appeared to persist. 2.1.3.Factor analysis with the values from the first test: In the factor analysis balancing backwards loaded on the strongest factor "A", which was characterized by the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency with -.66. This result confirmed the connections discussed in 2.1.2. 2.1.4. Comparison of the groups with the individual diagnoses of ADS/ADHS, foot abnormality, genu valgum, postural insufficiency and the other remaining groups to which this diagnosis did not apply (Table 2) with regard to their respective performance in the balancing backwards item. In the first test before commencement of therapy those children diagnosed with ADS/ADHS, foot abnormality, genu valgum, postural insufficiency performed the balancing backwards task less well than the remaining group to which the diagnosis did not apply. In the second test this was only the case with the children who had been diagnosed with postural insufficiency. 2.2 Balancing forwards item 2.2.1 Change in values between the first and second test: The median value of balancing forwards was 0.60 in the first test and 0.77 in the second test. Balancing forwards is one of the easier items in the MOT (MV boys in MOT: 1.45; MV for girls: 1.58). 2.2.2 Statistically relevant connections between balancing forwards and the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency: Table 3 
Balancing forwards produced lower negative correlations with the four diagnosis items than the corresponding backwards movement and none whatsoever with ADS/ADHS (see Table 3). 2.2.3. Factor analysis with the values from the first test only: There were lower valancies than with balancing backwards; but balancing forwards still nevertheless had a loading of -.54 on factor "A". This result points to a stronger connection to the diagnosis complex from Section 1 than can be seen from the correlation calculation. 2.2.4.Comparison between the groups with the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency and the remaining groups to which the diagnosis did not apply (Table 3) in respect of their performance in the balancing forwards item: In the balancing forwards item the children that had been diagnosed with foot abnormality, postural insufficiency or genu valgum performed less well in terms of the absolute value than the remaining group to which the respective diagnosis did not apply, the difference, however, being much less apparent than when balancing backwards; there was no significance. There was no connection at all to the diagnosis of ADS/ADHS (correlative value around the .0 mark), nor any differences to be found between the two test results. This item produced very little change in terms of connections to other items between the first and second test. 2.3. Putting tennis balls into boxes item: (there are 3 tennis balls in a box on the floor. Another box is placed on the floor 4 metres away from the first. The child has to take out one ball at a time and put it in the other box as quickly as possible. The time taken by each child is recorded by the test supervisor). 2.3.1 Changes in values from the 1st to the 2nd test: The median value for putting tennis balls into boxes of 0.50 in the first test at the commencement of therapy improved considerably to 1.12 in the second test. It is one of the items of a medium degree of difficulty in the MOT (MV boys in MOT: 1.06; MV girls: 0.89) 2.3.2 Statistically relevant connections between putting tennis balls into boxes and the individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency: The task of putting tennis balls into boxes indicated only partially (negative) significant correlations with these individual diagnoses (see Table 4). Table 4 
There was a noticeable high negative correlation with foot abnormality in the 1st test; this was not to be seen in the 2nd test; the connection between the putting tennis balls into boxes item and ADS/ADHS also declined. 2.3.3. Factor analysis with the values from the first test: In the factor analysis (values from 1st test only) the putting tennis balls into boxes item loaded on factor "A" with -.57, confirming the results from the correlation calculation. 2.3.4 Comparison between the groups with the individual diagnoses of ADS/ADHS, foot abnormality, genu valgum, postural insufficiency and the remaining groups to which the respective diagnosis did not apply (Table 4) with regard to their performance in the putting tennis balls into boxes item: The children initially diagnosed with foot abnormality performed less well in the 1st test in the task of putting tennis balls into boxes than the remaining group to which the respective diagnosis did not apply; this result was not found in the 2nd test following the programme of therapy. A change in the same direction after therapy was also in evidence where ADS/ADHS had been initially diagnosed. 2.4. Item: Standing up and sitting down whilst holding a ball: (The child sits cross-legged on the floor, holding the ball with both hands above its head. It has to stand up, keeping the ball in the same position, and then sit down again with legs crossed as before). 2.4.1. Changes in values from the 1st to the 2nd test: The median value of standing up and sitting down whilst holding a ball was 0.45 in the 1st test and 1.33 in the 2nd test; it had therefore likewise considerably improved. It is one of the items with a medium degree of difficulty in the MOT (MV boys in MOT: 1.29; MV girls: 1.41). 2.4.2. Statistically relevant connections between standing up and sitting down whilst holding a ball and the individual diagnoses of ADS/ADHS, foot abnormality, genu valgum, postural insufficiency: The task of standing up and sitting down whilst holding a ball indicated relevant negative correlations with the individual diagnoses of ADS/ADHS, postural insufficiency and genu valgum (see Table 5), less so in the case of foot abnormality. Table 5 
The negative connection between standing up and sitting down whilst holding a ball and the initial diagnosis of genu valgum is noticeably higher in the 2nd test than in the 1st test, and has a significance in contrast to the 1st test in which a tendency was present. This was a finding that ought to be investigated further. 2.4.3 Factor analysis with the values from the 1st test only: In the factor analysis this item (values from the 1st test) loaded on factor "A" with - .52; this result corresponded with the results of the correlation calculation. 2.4.4. Comparison between the groups diagnosed with ADS/ADHS, foot abnormality, genu valgum or postural insufficiency and the remaining groups to which the respective diagnosis did not apply (Table 5) with regard to their performance in standing up and sitting down whilst holding a ball. In the 1st test the children diagnosed with either ADS/ADHS, postural insufficiency or genu valgum performed this item less well than the remainder to which the respective diagnosis did not apply – the one exception being the diagnosis of foot abnormality, which showed no significant effect. In the 2nd test the result for those diagnosed with genu valgum was much the same as in the 1st test, a little higher, in fact. 2.5. Tapping and Ducking through a hoop items Further somewhat higher absolute correlative values (between - .30 and - .37) were found in the 1st test between the tapping task (medium degree of difficulty) and the individual diagnoses of genu valgum, ADS/ADHS and foot abnormality, none of which, however, were in any way significant. The absolute value in the 2nd test showed a drop in the respective correlation values. There was, however, a noticeable correlation in the 1st test between the ducking through a hoop item (a lesser degree of difficulty) and the individual diagnosis genu valgum (-.47*) which was no longer found to any relevant extent in the 2nd test. This item also loaded on the first factor "A" with - .64. Tapping loaded on the first factor "A" with - .43 (both values from the 1st test). The results of the factor analysis revealed that despite their low correlation values, both items bore a strikingly close connection to the diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency. 2.6 Gripping a cloth with the toes item Examination of the gripping a cloth with the toes item produced quite different and striking results (the child stands with both feet on the floor. A fully unfolded textile handkerchief is placed on the floor at a distance of 20cm from its feet. Within 5 seconds the child is supposed to grip the handkerchief with its toes and pass it over to the test supervisor, who takes the handkerchief when it has been lifted to the height of the child´s knee. The task is then repeated with the other foot). 2.6.1. Change in values from the 1st to the 2nd test: The median values of the gripping a cloth with the toes item improved from 0.70 in the 1st test to 1.22 in the 2nd test. It is one of the items with a low degree of difficulty in the MOT (MV boys in MOT: 1.59; MV girls 1.68) 2.6.2 Statistically relevant connections with the individual diagnoses of ADS/ADHS, foot abnormality, genu valgum, postural insufficiency: Table 6 
In the 1st test the gripping a cloth with the toes item showed high positive ! correlations with postural insufficiency and genu valgum but not with foot abnormality. The high positive correlations here mean that the task of gripping a cloth with the toes was performed better by children diagnosed with genu valgum or postural insufficiency than by those from the remaining groups to which this diagnosis did not apply. In the case of ADS/ADHS the correlation figure, albeit at .315, was still too low to be significant. In the 2nd test correlations were insignificant across the board, meaning that there had been a decline in the performance of the task among those children who had initially performed better compared to the remaining groups to which the diagnosis did not apply. The question as to why there was a substantial improvement in the median value nevertheless, could not be clarified. 2.6.3 Factor analysis with the values from the 1st test only: In the factor analysis this item loaded on factor "A" with .53 !, a positive loading of some relevance in line with the correlations. 2.6.4 Comparison of the groups with the individual diagnosis of ADS/ADHS, foot abnormality, genu valgum and postural insufficiency and the remaining groups to which this diagnosis did not apply (Table 6) with regard to their respective performance of the gripping a cloth with the toes item: In contrast to the correlations and loadings found in the more striking of the MOT items in the 1st test, which showed a tendency for children diagnosed with ADS/ADHS, foot abnormality, genu valgum or postural insufficiency to perform less well than the remaining group to which the diagnosis did not apply, those diagnosed with postural insufficiency or genu valgum tended to perform the gripping a cloth with the toes task better in the 1st test; even those diagnosed with ADS/ADHS performed somewhat better in terms of the absolute value. One exception here was the foot abnormality item which bore no relevant correlative connection to the gripping a cloth with the toes item, neither in the 1st nor the 2nd test. 3. Connection between the individual diagnoses of ADS/ADHS, foot abnormality, genu valgum, postural insufficiency and the social and emotional state variables: Only few relevant connections could be found to the remainder of the items measured. Examination of correlative connections between the four individual diagnoses ADS/ADHS, foot abnormality, genu valgum, postural insufficiency and the other data collected brought to light no correlations with the social variables and only minor ones with the emotional state variables. The one exception was postural insufficiency, which appeared to adversely affect the mother´s emotional state (cor. -.40*) and enhanced parent cooperation (cor. .43*) The only connections of interest to be found were those with respect to assessment of school marks, whereby there was a high negative correlation of assessment of school marks with foot abnormality (see Table 7). Table 7 
The high negative correlation in Table 7 means that where foot abnormality was diagnosed, assessment of school marks produced lower values than in cases in which this diagnosis had not been made. The probability value (significance) ascertained confirms this connection. Discussion: 1. Results show improvements in performance between the 1st and 2nd test, in particular in those tasks rated between easy and medium. It can be assumed that the therapy undertaken contributed to this effect. 2. The close connection between the four individual diagnoses of foot abnormality, postural insufficiency, genu valgum and ADS/ADHS is striking in view of the fact that only few connections were to be found to the other eight diagnosis categories. This could be an indication of an important recurrent symptom complex that comes to light in the diagnosis, in which a diagnosis of an ADS/ADHS disorder is perceived as being closely associated with problems with the feet and with posture. Other diagnoses were not connected with this complex to any statistically relevant degree. Up till now, too little attention has been paid, and wrongly so seemingly, to the possibility of the existence of such a connection. There is an urgent need for further investigation. As this was initially intended to be no more than a preliminary study, many questions could not be answered. It would have been very important, for example, to establish whether ADS/ADHS, foot abnormality, postural insufficiency or genu valgum would still have been diagnosed after therapy. As these medical diagnoses were only made once before the commencement of therapy, it could not be established whether these same diagnoses would have applied to the same extent at the time of the 2nd test as they had at the beginning. 3. Of all the items tested, the balancing backwards item in the MOT bore the closest connection to this diagnosis complex. Where individual diagnoses of ADS/ADHS, foot abnormality, postural insufficiency or genu valgum applied, performance in this item tended to decline. This item would be one of particular informative value in a screening test. 4. There was a statistically significant connection between the foot abnormality item and estimation of school performance. This is interesting in that, up to now, very little attention has been paid to the condition of the feet in discussion of school performance. This would need to be looked into further. 5. By and large, the negative connection found initially between the balancing backwards, balancing forwards, placing tennis balls in boxes, standing up and sitting down whilst holding a ball, tapping and the ducking through a hoop items in the MOT and the individual diagnoses of ADS/ADHS, foot abnormality, genu valgum, postural insufficiency declined following the period of therapy. This indicates that, barring a few exceptions, the difference found between the group of children originally diagnosed with ADS/ADHS, foot abnormality, genu valgum, postural insufficiency and the remaining groups, to which these did not apply, diminished. 6. Contrary to expectations and in contrast to all the other connections examined, the gripping a cloth with the toes item was performed better in cases where one of the four individual diagnoses applied, especially by those diagnosed with postural insufficiency, but also somewhat better by those diagnosed with genu valgum and ADS/ADHS. Should this finding be further corroborated, it would give rise to much debate, even though foot abnormality was not in the frame. This poses several questions: Does instability of posture induce an increased compensatory activity of the toes, thus enhancing the toes´ ability to grip? Or are residual reactions of a persisting gripping reflex still active in the foot, or could there be other reasons for this surprising finding? This connection is not found in the 2nd test, which means that performance of this item, too, has approximated to the overall level of the group as a whole. 7. The deviant performance in the gripping a cloth with the toes item described in Point 6 above might explain why no statistically relevant connections could be found to the total score of the MOT. Further work on the inner consistency of the MOT for the continued use of its total score should take account of this result. Conclusion: These results call for a more profound and thorough investigation of the connections brought to light, especially since they confirm many observations made in practice that point in the same direction. Considering that an increasing number of children are being diagnosed with ADS/ADHS, it would be important to focus more on that. The hitherto largely unheeded posture component, which would be taken more into account as part of this disorder complex, would provide starting points for treatment and other conducive measures, and offer some new insights into aspects of the inner structure of this type of disorder. To this extent, this study, notwithstanding its underlying limitations, has produced some important results. What is more, these results cannot be seen as artefacts because the 2nd test of the same patients that had originally been diagnosed with ADS/ADHS produced different results from the 1st test. A further pointer is that the results corresponded credibly to the theoretical assumptions of there being a connection between body posture and coordination, although this was not the actual concern of the preliminary study; moreover, a demarcated structure emerged. In view of the small number of patients, the uneven distribution of the individual ADS/ADHS, foot abnormality, genu valgum and postural insufficiency diagnoses and the select clientele, these results should be understood primarily as an indication of the need for further investigation in this direction. However, should these connections be confirmed in further studies on this subject, one would in future have to conclude that many cases of ADS/ADHS will also call for physiotherapeutic treatment of foot and posture abnormalities. A desirable course of action would be follow-up studies with additional orthopaedic testing procedures on a larger number of patients as well as studies with random samples. A big thank you to all colleagues and practice teams who took part in the preliminary work. Appendix 1: Medical diagnoses: postural insufficiency, scoliosis, genu valgum, hip dysplasia, coordination disorder, diplegia, balance, others, perception disorder, ADS/ADHS, foot abnormality (talipes valgus, fallen arches, splayfoot, pigeon toes), speech disorder. Appendix 2: Gender, multiple birth, type of school, social status, school marks. Appendix 3: Mother feels bothered by her child´s impairment, child´s motivation to cooperate, parents´motivation to cooperate, reliability in doing homework, the child´s ability to concentrate, social skills, self-reliance, school marks, enjoyment of physical exercise, emotional state. Literature: (1) Clauß, G./ Ebner, H.: Grundlagen der Stastistik. Frankfurt a.M. / Zurich 1971 (2) Kiphard, E.J. /Schilling, F.: Körperkoordinationstest für Kinder KTK. Beltz Test. Weinheim 1974 (3) Hildebrandt, H.: Pschyrembel. Walter de Gruyter. Berlin New York 1998 258 (4) Überla, K.: Faktorenanalyse. Springer-Verlag. Berlin Heidelberg New York 1971 2 (5) Zimmer, R. / Volkamer, M.: MOT – 4-6. Beltz Test. Weinheim 1987 2 |
