Dyspraxia in general chiropractic practice

Introduction 

One in every five children suffers from some form of developmental delay—dyslexia, dyspraxia, attention deficit disorder (ADD), attention deficit hyperactivity disorder (AD/HD), obsessive compulsive disorder (OCD) or a tic disorder. There is good evidence that these conditions always appear in patterns of comorbidity, to a point that it has been suggested that they should be considered as symptoms as opposed to actual conditions in their own right. Within the patterns of comorbidity dyspraxia is the most common of the presenting comorbid symptoms. Untreated the developmental delay will continue into adult life and may impact upon not only the development of social skills and academic success but also the physical health of the individual. It is therefore essential that the chiropractic general practitioner has an awareness of dyspraxia and the means at their disposal to test for it.

Comorbidity rates have been found at incidences of up to 95%, representing an increase on the expected prevalence in a general population of 160–2300%. Within these patterns of comorbidity dyspraxia was the most prevalent finding, occurring in up to 89% of children with a primary diagnosis of AD/HD.1

Although once considered a self-limiting condition, AD/HD, along with the other primary symptoms of developmental delay, is now known to continue into adulthood in a high percentage of cases, impacting adversely on the individual's ability to cope in society and frequently leading to criminality.2 As dyspraxia is primarily a disorder of the motor system, practitioners who treat conditions of the musculoskeletal system need to be not only aware of the various presentations that dyspraxia may take but also familiar with the diagnostic tests available to them and treatment options open to them.

Definition 

The Dyspraxia Foundation (UK) defines dyspraxia as follows—developmental dyspraxia is an impairment or immaturity of the organisation of movement. It is an immaturity in the way that the brain processes information, which results in messages not being properly or fully transmitted. The term dyspraxia comes from the word praxis, which means ‘doing, acting’. Dyspraxia affects the planning of what to do and how to do it. It is associated with problems of perception, language and thought.3

History 

In the past, dyspraxia has been thought of as primarily a condition of childhood and at one time was called the ‘Clumsy Child Syndrome’. The first mention of dyspraxia in terms of a developmental motor disorder is attributed to Collier who used the term ‘congenital maladroitness’.4 In 1937, Samuel Orton suggested that this abnormal clumsiness was one of the six most common developmental disorders showing distinctive impairment of praxis—normal motor control/movement.5 Since then it has been described and labelled by many, including A. Jean Ayres, who in 1972 called it a ‘disorder of Sensory Integration’,6 and Sasson Gubbay who in 1975 called it the ‘Clumsy Child Syndrome’.7 Other labels include ‘developmental awkwardness’, ‘sensorimotor dysfunction’, ‘minimal brain dysfunction’, ‘motor sequencing disorder’ and, most recently, ‘developmental coordination disorder’.8 The World Health Organisation currently lists it as a specific developmental disorder of motor function.

The Dyspraxia Foundation UK3 lists nine categories of symptoms under general headings. Under gross motor skills they include poor balance, poor posture, fatigue, poor muscle tone, flat feet, poor motor integration, poor hand-eye coordination and clumsiness leading to a tendency to be accident prone. Reduced fine motor skills can impact upon manual dexterity and thereby poor manipulative skills when writing, eating and using tools. Poorly established hand dominance may further exacerbate the reduced level of manual dexterity. Speech and language difficulties – verbal dyspraxia – may slow the development of language, may make pronunciation difficult and speech unclear. Eye movements may be involved causing poor tracking (reading fluency) and a reduced ability to make saccadic (fast) movements of the eyes.9 Lack of awareness of body position in space can result in numerous accidents. All of the above may impact upon learning, thought, memory and emotionality.

Of the possible presenting symptomatology of the adult form of dyspraxia, pes planus, poor balance, poor posture, reduced muscle tone and poor motor integration would appear to be significant and may predispose the sufferer to a variety of spinal related conditions.10, 11, 12

Testing for dyspraxia 

Any history of developmental delay should alert the practitioner to the possibility of dyspraxia being present and should lead to direct questioning concerning problems with latching-on if breast fed, speech delay, being accident prone, being clumsy, being a messy eater and having poor spatial awareness.3 Any delay in learning to read or a dislike of reading may indicate that a visual dyspraxia is present and the patient may mention when questioned that they were treated as a child for a lazy eye.9

Before testing the patient it is essential to add to the details drawn from the history and observations made during the consultation, which should include postural notes as well as how the patient approaches everyday tasks such as sitting, dressing, and physical compliance during the consultation/examination process.

The formal examination should include muscle testing; the Provoked Romberg's test; the Finger-to-Nose test; looking for dysdiadochokinesia (the inability to make rapid alternating movements of the upper limbs), both with the arms outstretched and flexed at the elbow; and a test designed to bring out any dyspraxic tendencies, e.g. walking upstairs with the hands by the side, head in the normal upright position and eyes closed. These tests, although used on a daily basis by the chiropractic neurologist, may not be familiar to the general chiropractic practitioner and will therefore be described in detail.

The Provoked Romberg's test 

The patient should stand with their feet together, their hands by their side and their head in the neutral position. The patient is then instructed to close their eyes and remain in this position for a few seconds. Note if the patient begins to sway or if the eyelid begins to flicker (blepharoclonus). Then tap the patient firmly on the upper arms in a random pattern so that they cannot predict and therefore resist the tap. Note any movement of the hands, feet or if the patient loses balance and falls to one side or the other.

Finger-to-Nose test 

This test is usually performed with the patient seated but if the results are equivocal, should be repeated with the patient standing with their feet together thus increasing the level of difficulty. The practitioner should demonstrate the test to the patient and be sure that they know what it is they are expected to do. The patient is then instructed to stretch their arms out in front of them with the index finger pointing at the examiner. Then with the eyes closed they should bring the tip of each finger to the tip of the nose alternatively. This should be carried out for at least ×10.

Testing for dysdiadochokinesia 

With the patient seated they should be asked to stretch their arms out in front of them with the palms uppermost. They should then be instructed to rotate the arms inwards so that the palms are facing downwards. The speed of these alternating movements should then be slowly increased. The patient should be instructed not to bend the arms at the elbows as the principal movement should take place at the shoulders. The patient should then be asked to bend the arms at the elbows, tuck the elbows in to their side and repeat the test, rotating the forearms from the elbows.

Stair walking test 

Have the patient attempt to walk up 3 steps of the stairs with their head in the neutral position, hands by their side and eyes closed. They should walk backwards down the stairs keeping only one foot on a step at a time.

Treatment 

Verbal dyspraxia is generally detected and treated at an early age with the intervention of speech therapy. Visual dyspraxia – convergence insufficiency and tracking problems – can be tested for by the use of an isopter brought in towards the nose from a distance of 16 inches and repeated 3 times. If convergence insufficiency is suspected, the patient should be referred to a more experienced colleague or an optometrist for further testing and treatment. General dyspraxia can be treated in general chiropractic practice by addressing the specific problems, e.g. pes planus or more generally by prescribing a simple exercise regime that the patient can complete at home on a daily basis.

The exercise regime 

Based on the results of the test results non-specific and specific exercises can be prescribed that will address cerebellar based problems in general or lateralised to specifically afferentate an under-functioning hemisphere. The treatment regime will be familiar to the practitioner with a postgraduate education in chiropractic neurology but may provide a novel exercise programme to the general chiropractic practitioner.16, 17, 18

Discussion 

Although awareness of dyspraxia is growing amongst the general population and it is commonly cited in educational psychologists’ reports, its impact in general practice may be overlooked and as a result the patient presenting with a variety of neuromuscular complaints may be slow to respond to treatment.

The setting of tone, control of posture, locomotion and motor planning are multifaceted and beyond the scope of this paper but the role of the cerebellum and brainstem are well established, as are the functions of central pattern generators in repetitive rhythmic movements such as walking and swimming.19

Until recently it was generally considered that the learning and behavioural problems were incurable. However, with the discovery of the epigenome and its control of morphogenesis, it is now possible to consider treatment regimes that can have a significant impact upon these conditions.20 Also, with increasing knowledge of the postnatal development of the brain and the negative impact stressors may have upon it, the likelihood of the epigenome as the prime factor in developmental delay seems probable and would go a long way towards explaining why the geneticists to date have not found a purely genetic underlying cause for these common conditions.21, 22

Conclusion 

As dyspraxia is thought to affect up to eight per cent of the adult population in varying degrees and sometimes runs in families, an increased awareness and a better understanding of its various presentations are essential to anyone working with children with learning and behavioural disorders but also to those addressing conditions of the musculoskeletal system. It is known to have profound effects upon learning ability but it may also present as a latent/underlying predisposing factor in many common complaints, and it is suggested, may cause the treatment of such conditions to respond poorly or potentially lead to recurring relapses.