Influence of a Foot Insole for a Down Syndrome Patient with a Flat Foot: A Case Study.

Background and Objectives: Patients with Down syndrome have many orthopedic problems including flat foot. Insertion of an insole for a flat foot provides support to the medial longitudinal arch; thus, insole therapy is often used to treat a flat foot. However, the influence of an insole insertion on the knee joint kinematics for a patient with Down syndrome is unknown. This study aimed to elucidate the influence of an insole for a flat foot on the knee kinematics during gait for a patient with Down syndrome. Materials and Methods: The subject was a 22-year-old male with Down syndrome who had a flat foot. The knee joint angle during the gait was measured using a 3D motion capture system that consisted of eight infrared cameras. Results: The gait analysis demonstrated a reduction in the knee flexion angle during double knee action. The knee valgus and tibial internal rotation angles also decreased during the loading response phase while wearing shoes that contained the insole. Conclusions: As the angle of the knee joint decreased during the gait, it was considered that the stability of the knee joint improved by inserting the insole. In particular, there was a large difference in the tibial internal rotation angle when the insole was inserted. It is thus hypothesized that the insole contributes to the rotational stability of the knee joint. This study suggests that knee stability may improve and that gait becomes more stable when a Down syndrome patient with a flat foot wears an insole.

Use of malleoli as an indicator for flatfoot in patients with Down syndrome: development of a simple and non-invasive evaluation method through medial longitudinal arch.

[Purpose] Flatfoot often presents in patients with Down syndrome, and it can be diagnosed using a simple radiograph. Consequently, due to radiograph limitations, alternative non-invasive testing must be determined. Conventionally, arch height ratio can be used for evaluation of the medial longitudinal arch, where the foot is evaluated by detecting the navicular bone on the foot surface. However, detection of the navicular tuberosity is difficult and even though the detection is relatively straightforward for patients without intellectual disability, measuring navicular bone is more difficult in patients with intellectual disability, such as those who have Down syndrome and are uncooperative with a tester. Therefore, we evaluated arch height ratio using the malleoli instead of the navicular bone to determine whether malleoli testing was appropriate for patients with Down syndrome that have an intellectual disability. [Participants and Methods] We conducted a retrospective study of 16 pairs of feet in 16 patients with Down syndrome, diagnosed with flatfoot. The height to the centre of the talo-navicular joint and that of the malleoli from the sole were measured on radiographs using weight-bearing conditions. [Results] The age range was 5.2 to 25.3 years. There was a correlation between the height of the navicular bone and that of the medial and lateral malleoli. [Conclusion] We conclude that the medial and lateral malleoli can substitute navicular bone as a landmark diagnosis test for flatfoot. Considering the close physical distance between the medial malleolus and navicular bone, and the association between the tibia and medial longitudinal arch, the medial malleolus may provide a better landmark in patients with Down syndrome with it being potentially less invasive for uncooperative patients.

Differences in skill level influence the effects of visual feedback on motor learning.

[Purpose] No previous studies have confirmed whether the effects of visual feedback on motor learning vary according to learner skill level for a learning task. The purpose of this study was to clarify whether differences in skill influence the effects of visual feedback on motor learning. [Participants and Methods] Sixty-four participants were assigned to one of four different feedback groups (concurrent-100%, concurrent-50%, terminal-100%, or terminal-50%). The learning task was to adjust the load amount continuously to the left lower limb in accordance with sound stimulation at intervals of 1 Hz. The four groups performed a pretest, practice sessions, and a retention test 24 hours after practice. After completing these measurements, the participants were classified as either high- or low-skilled based on the results of the pretest. [Results] Only the groups of low-skilled participants who used concurrent feedback showed lower root mean square errors in the retention test compared to in the pretest. [Conclusion] Differences in skill level for the same task influenced the effects of visual feedback on motor learning. Furthermore, concurrent visual feedback can help improve motor learning in low-skilled learners for the same task.

Intra-rater reliability of arch height ratio measurement using the navicular tuberosity on the surface of the body in children with Down syndrome.

[Purpose] Flat feet frequently present in children with Down syndrome, necessitating a clinical evaluation and diagnosis. Therefore, a simple, low cost diagnostic method that can avoid radiation exposure is needed. This study was performed to investigate the intra-rater reliability of arch height ratio measurement using bone markers of the foot on the surface of the body in children with Down syndrome. [Participants and Methods] In total, 27 feet of 27 children with Down syndrome (16 male, 11 female) were included. We measured the length of each foot and the height of the navicular tuberosity on the surface of the body. The arch height ratio was calculated using the length and height. The same examiner performed three consecutive measurements of each of the two parameters. We calculated the arch height ratio using each of these measurements. The intraclass correlation coefficient [ICC(1,3)] of the length of the foot, height of the navicular tuberosity, and arch height ratio among the three measurements was obtained. [Results] The ICC of the height of the navicular tuberosity, length of the foot, and arch height ratio were quite high at 0.998, 0.999, and 0.997, respectively. [Conclusion] This study showed high intra-rater reliability of arch height ratio measurement using the length of the foot and height of the navicular tuberosity on the surface of the body in children with Down syndrome.

External focus training for reacquisition of knee function in a Down syndrome patient after surgery for recurrent patellar dislocation: a case report.

[Purpose] This case study describes the reacquisition of knee joint function in a patient with Down syndrome after surgery for patellar dislocation using external focus training. [Participant and Methods] The patient was a female aged 24 years with Down syndrome and a low Intelligence Quotient, who suffered from right patellar dislocation. The range of motion in the right knee while walking was 2 to 23 degrees at 3 weeks after surgery. A compensatory gait while walking was confirmed, with her right leg fixed in extension. Her range of motion while lying was 0 to 155 degrees. A task in which the patient reached and touched a ball was performed with the lower extremities while lying down, according to simple instructions from a therapist. Instructions were given using a simple directive phrase. The intervention started with a single-joint exercise and progressed to a multi-joint exercise. [Results] The range of motion was 0 to 68 degrees at 9 weeks after surgery. Her compensatory gait disappeared and she was able to walk more than 2 km. [Conclusion] Even though the patient's low cognitive function made it difficult for her to complete some tasks, training based on external focus enabled her to acquire adequate knee joint function. External focus training was found to be effective for a patient with a low Intelligence Quotient.

Relationship between the use of lower extremity orthoses and the developmental quotient of The Kyoto Scale of Psychological Development in children with Down syndrome.

[Purpose] The Kyoto Scale of Psychological Development is an evaluation scale developed in the field of psychology. The initial aim of this study was to determine whether the quotient of the Postural-Motor area in the scale was correlated with the use of orthosis in patients with Down syndrome. The second aim was to examine a correlation among Postural-Motor, Cognitive-Adaptive, and Language-Social areas in the participants. [Participants and Methods] Patients with Down syndrome who had received a developmental examination, the Kyoto Scale of Psychological Development, were retrospectively investigated. The sample included 78 participants. Data on the participants' calendar ages ranged from 4.1 to 6.0 years, and the mean age was 4.9 at the examination. The investigated parameters were the number of participants who used an orthosis or insole and the mean developmental quotient for the Postural-Motor, Cognitive-Adaptive, and Language-Social areas. [Results] Twenty participants who completed the exam used an orthosis, and 18 of these had an insole as a first orthosis. The mean Postural-Motor quotient was significantly lower in participants who used an orthosis than in those who did not (52.3 ± 14.7). [Conclusion] The mean quotient of the Postural-Motor area was significantly lower in patients with Down syndrome who were prescribed some kind of orthosis than in those who were not. There was a significant correlation among the quotients of the three areas. The use of orthosis was expected to positively influence the Cognitive-Adaptive and Language-Social areas through the future in people with Down syndrome who have some difficulty with posture and movement.

The prevalence of the flat foot condition and insole prescription in people with Down's syndrome: a retrospective population-based study.

[Purpose] The general approach for flat foot (FF) treatment in people with Down's syndrome (DS) is the use of insoles. However, the appropriate timing of the first insole prescription remains unclear. An aim of this present research was to investigate the status of prevalence of FF and orthosis prescription in the DS population. [Subjects and Methods] Two hundred fifteen subjects with DS who were seen at our hospital were retrospectively investigated. Investigated parameters were: prevalence of FF and other foot diseases, ratio and timing of orthopaedic consultation, ratio and timing of orthoses prescription, and mean age at the time of orthosis prescription. [Results] The prevalence of FF was 27.0% (58 subjects), and 50 subjects (23.3%) consulted an orthopaedic surgeon. An orthosis was prescribed for 54 subjects; 88.9% of these orthoses were insoles. Foot and leg orthoses other than insoles were prescribed significantly more frequently for females than males. The mean ages at the time of the first prescription of all types of orthoses and an insole were 7.3 years and 6.4 years, respectively. [Conclusion] The prevalence of FF was low, and the age at which subjects with DS were prescribed an orthosis was relatively high at our institution compared to previous reports. Since physical therapists see patients who could potentially have FF, those with suspected FF should then be referred to an orthopaedic doctor, which would enable the earlier orthosis prescription.

Effects of temporal constraints on medio-lateral stability when negotiating obstacles.

If an obstacle suddenly appears during walking, either the crossing step can be lengthened or the precrossing step shortened to avoid the obstacle. We investigated the effects of temporal constraints on dynamic stability during step adjustments. Twelve healthy young adults avoided a virtual white planar obstacle by lengthening or shortening their steps under free or constrained conditions. When constrained, participants had only one step to avoid the obstacle. The results indicated that center of mass (COM) displacement in the mediolateral (ML) direction and the COM velocity toward the swing-leg side during the crossing step were significantly increased in the long-constraint compared with the long-free condition. Consequently, the extrapolated COM (XcoM) position at the swing foot contact was also located further toward the swing-leg side. However, the distances between the XcoM and base of support (BOS) at the swing foot contact in the ML direction was unchanged because of greater lateral foot placement. In the anteriorposterior (AP) direction, temporal constraints led to greater AP COM displacement. The XcoM-BOS distance in the AP direction was unchanged in the long-constraint condition because of greater step length. However, the value became negative in the short-constraint condition, violating the conditions for dynamic stability, because step length adjustments were obstructed by the spatial constraints of the obstacles. These results suggest that temporal constraints affect postural stability in the AP and ML directions during step adjustments. AP and ML stability at swing foot contact are maintained through adjustments of step length and lateral foot placement, respectively.