Multidisciplinary health care for dyslexic patients
Prodys is a French medical center dedicated to children and adults suffering from acute learning disabilities. The Center opened in 2006 and has thus far provided over 8,000 examinations to 3,000 patients. Physicians use a multidisciplinary innovative approach to diagnose and treat proprioceptive impairment routinely associated with learning disorders. The staff conducts longitudinal research on large samples using multivariate patient record analysis.
Dyslexia and related learning disabilities
According to the U.S. Department of Education statistics, dyslexia is a high-prevalence syndrome affecting 5 to 9 percent of school-aged children, though some have put the figure as high as 17 percent. The U.S. dyslexic population numbers at least 20 million, including adults who struggle with the handicap. While comprising about 80 percent of learning disabilities, dyslexia is often associated with other learning disorders such as dysgraphia, dyscalculia, dyspraxia and attention deficit disorders.
Public health programs targeted to children affected by learning disabilities have been launched in the U.S.A. (No Child Left Behind Act), Britain (British Disability Discrimination Act), and France (Loi Handicap) with various successes.
Researchers have found comparable frequency rates of dyslexia in other countries, cultures, and language systems. Learning difficulties know no boundaries, neither geographic nor ethnic nor social.
DefinitionsDevelopmental dyslexia is a specific reading disability whose cause remains controversial, although generally regarded as a neurological and genetic disorder. Dyslexic readers have trouble with accurate and/or fluent word recognition and with poor spelling and decoding abilities. These difficulties result from a deficit in the phonological module of language, meaning that people with the condition have trouble detecting or manipulating the sound structure of oral language. This in turn leads to problems in mapping speech sounds onto letters.
The trouble is independent of other cognitive or higher-level abilities or effective classroom instruction: dyslexia is not due to a lack of intelligence, lack of effort, lack of education, disease, attention issues, or emotional problems.
Functional magnetic resonance imaging (fMRI) developments in the 1990s allowed neuroscientists to identify the areas of the left side of the brain that play key roles in reading. This noninvasive technology played a key part in visualizing cerebral zones activated during the reading process, and in understanding how dyslexic children struggle to transform letters (the written code) into sounds (the linguistic code).
Despite increased research, scientists have yet to find a unified theory explaining why a child suffers from developmental dyslexia. There is still considerable debate over the origins of slow reading, and its is unlikely that a unique causal model will ever emerge, as it would be very dangerous to assume that every child with reading problems is uniform and has the same kinds of breakdowns preventing him from learning to read.
The phonologic model explains how a phonologic weakness at the lowest level of the language system impairs decoding, which in turn interferes with word identification. This hampers a dyslexic reader from applying his/her cognitive or higher-level skills to get at a word’s meaning. However, Neuroscientists are still looking for brain structures responsible for fluent reading, namely nerve cells and nerve fibers, or “wiring”. Different and sometimes conflicting studies pinpoint to genetic, neuronal, but also physiological explanations, ultimately leaving parents and adults looking for answers puzzled.
For this reason, dyslexia may not be reduced to a severe reading disorder. It is a complex syndrome of many and varied symptoms including reading, writing, calculating, spelling, but also difficulties with balance and coordination functions, psychosomatic ailments, lack of concentration, behavior disturbances, phobias, sleep disorders, and low self-esteem.
Identification and DiagnosisIdentification generally happens at school, but depends largely on teachers’ training, ability and patience in assuming that a child faces a specific learning disability. Despite large-scale public initiatives in North America and Europe, many dyslexic children remain unnoticed and finally fall behind their classmates.
Once involved, treating doctors will ask about children or adults’ symptoms and their medical history, and do a physical exam including hearing and vision tests. Patients are then referred to speech therapists, school psychologists or learning specialists for additional testing. These may include cognitive processing and IQ tests, and specific tests to measure reading, spelling and writing skills.
TreatmentsMost people with learning disabilities need help from a trained professional over an extended period. Usual treatment options include remediation, a way of teaching dyslexic patients to learn language skills, and compensatory strategies, to work around the effects of dyslexia. As Dr. Sally Shaywitz, a Yale neuroscientist put it: “The data we have don't show any one program that is head and shoulders above the rest”. The most successful programs emphasize the same core elements: practice manipulating phonemes, building vocabulary, increasing comprehension and improving the fluency of reading. As might be expected, early intervention gives the best results.
Alternative methods based on computer exercises, or acoustical training have been touted without being endorsed by the scientific community.
No “medical” treatment exists yet, whether in the form of drug taking or surgery. Conventional treatments rely on speech therapy and special education services, the results of which vary considerably from one patient to another. Little if any coordination exists between care providers and parents or adults often feel isolated and frustrated.
Proprioception and dyslexia
Proprioception refers to the unconscious perception of movement and spatial orientation arising from stimuli within the body itself. As an example, even when blindfolded, a person knows through proprioception if her arm is up in the air or hanging by her side.
The awareness of the orientation of the body in space and the direction, extent, and rate of movement of the limbs depend in part upon information derived from sensory receptors in the joints, tendons, skin, and muscles including oculomotor muscles. Information from these receptors, called proprioreceptors, is normally integrated with that arising from vestibular receptors including the inner ear, as well as from visual, auditory, and tactile receptors. Sensory information from certain proprioreceptors can be used by the motor system as feedback to guide postural adjustments and control of well-practiced or semiautomatic movements such as those involved in walking.
Postural deficiencyIf any of these functions are irregular, patients either have a diminished sense of body-in-space or place greater reliance on another system such as vision to compensate, which in turn causes them to use their eyes inefficiently for higher-level visual functions. Proprioception impairment results in irregular muscle tone, back and neck pain, improper dental occlusion, deficits in gait and balance control, spacio-temporal confusion of the orientation, and sensory and cognitive disorders, the above symptoms being combined under a generic syndrome known as “Postural Deficiency Syndrome” (P.D.S.).
P.D.S. symptoms include:
- No transition from baby slept position to the upright posture (no phase on all fours)
- Persistent immature or baby talk
- Unusual need to have physical contact with another person
- Worried child, always moving
- Confuses left for right
- Clumsiness, tripping over own feet, bumping into things
- Aversion to crowds
- Motion sickness, nauseas
- Swinging between pieces of furniture
- Frequent tongue and cheek bites
- Cannot concentrate for a long period
- Defective immediate memory
- “Automatic” reading, no understanding
- Forgetting words and syllables
- Slow reading
- Difficulty grasping mathematical concepts
- Avoidance of eyes closed activities
- Discomfort or disorientation in closed environments
- Difficulty falling asleep and staying asleep
- Sleep walking
- Falling out of bed
- Feeling as if he/she is floating in space or tipping in space while in bed
- Extreme restlessness while sleeping
- Difficulty getting up and moving after sleep
- Need to have the light on to sleep
- Avoidance of team sports
- Unusual degree of stretching and yawning
- Inability to accept physical (and social) boundaries
Clinical research has also established interference between postural control and cognitive processing in patients with surgically confirmed vestibular lesions.
Dyslexic patients frequently display a hypertonic oculomotor system (eye muscles) which produces malfunctioning eye movements such as inconsistent saccadic eye tracking, erratic pursuit convergence and motility disorders. These results suggest disturbances of both acceleration of eye movement in the initial state and maintenance of velocity in minimizing retinal slip in steady state.
The Postural Deficiency Syndrome may be regarded as a pivotal cause in reading disorders, since dysfunctional eye movements prevent a dyslexic reader from identifying, acquiring, assembling and retrieving phonemes or basic building blocks of all spoken and written words.
Tying it all togetherEvidence that dyslexia is a neurological or brain-based condition is substantial. Advances in imaging technology may lead one day to understand the nature and activity of brain tracts and cells involved in reading. However, the neural theory does not conflict with the proprioceptive explanation.
Reading actually goes beyond mapping letters with sounds: a proficient reader still relies on phonetic codes to decipher unknown words, but he has also developed a large lexicon of words over time. Fluent reading uses “pattern recognition” strategies to retrieve spelling and meaning of words, and requires long practice.
Remediation treatments such as speech therapy and special education depend on teaching the same words and concepts many times. This is consistent with what Neuroscientists know about neural circuits that can be created, reactivated or strengthened by repetition.
Likewise, reprogramming vestibular sensors and other proprioreceptors such as ocular muscles ultimately contribute in rewiring defective neuronal structures, especially among children whose brain is still very malleable.
Restoring appropriate eye muscle tone allows correct eye pursuit when reading. Fixing postural impairment eliminates physical ailments and lessens psychological suffering. Patients can eventually apply their cognitive skills such as attention, reasoning and memory.
Finally, speech therapists experience stronger results with children who have followed a postural treatment.
Prodys Medical Center
Since its opening in 2006, Prodys’ physicians have designed an integrated model of care to diagnose and treat proprioceptive impairment and the Postural Deficiency Syndrome related to dyslexia and other learning disabilities.
The treatment relies on a three-pronged method:
1.Prismatic glasses to restore appropriate ocular muscle tone;
2.Custom-made postural soles to stimulate podal proprioreceptors;
3.Daily exercises including workout, training for proper work and sleep positions to better use proprioception.
This medical approach to dealing with dyslexia is in no way opposite to traditional remedial treatment including speech therapy and special education. Our patient records indicate that children and adults who took on postural treatment quickly recovered their proprioceptive sense, an appropriate gait and posture, improved their cognitive skills, and were willing and able to follow speech therapy again. The latter observation is the more significant as 37 percent of incoming patients had stopped all remedial treatment for lack of results. Patients experienced higher scores in speed of reading, fared better in word recognition, reading and writing and increased their cognitive skills noticeably.
Multidisciplinary CareProdys relies on a multidisciplinary clinical examination using medical doctors and paramedics (Ophthalmologists, Pediatricians, Optometrists and Physiotherapists) co-located under the same roof. Patients follow a medical route taking them through individual examination rooms. Medical excellence is attained when physicians reach a consensus: prismatic glasses are systematically tested by Physiotherapists to ensure their effect do not interfere with that of postural soles. Not all patients get prescriptions for glasses and soles. Prodys integrated model eliminates time lags between separate appointments, and provides a seamless coordination of care delivery. Physicians can also better monitor patient progress over time. This patient-centric model provides a blueprint for other complex diseases requiring a coordinated approach (i.e. Diabetes).
Patient follow-upThe medical protocol starts with a 3-hour initial multidisciplinary diagnosis. Pediatricians start with a thorough examination to eliminate dysfunctions and organic lesions which could have passed unnoticed and are not related to the specific learning disability. Patients bring a comprehensive questionnaire sent previously to guide physicians though their examination. Ophthalmologists carry out an eye checkup up to control patient vision, but also ocular muscles tone.
Optometrists perform various reading and eye convergence tests with and without prismatic glasses, and measure speed of reading.
Physiotherapists identify deficits in balance control following vestibular or proprioceptive loss using posturographic analysis of stance tasks. Pelvis and shoulder sway are measured with patients standing with their eyes closed then opened. Physiotherapists also measure the effect of proprioceptive loss on the triggering of postural and gait movements.
Physicians convene for a wrap-up meeting to determine whether and to what extent patients suffer from a postural disorder syndrome. When P.D.S. diagnosis is confirmed, they prescribe a tailor-made protocol typically extending over three years and comprising seven to ten examinations. Patients walk in every six months to assess cognitive and proprioceptive developments. Prodys physicians also coordinate with outside care providers (teachers, speech therapists, treating doctors, optometrists, and psychologists…).
Clinical research has been at the cornerstone of medical procedures from the onset. In 2008, the French Ministère de la Recherche endorsed Prodys research program and granted the Center favorable fiscal terms. Physicians design longitudinal studies over large patient cohorts to assess and measure the relationships between proprioceptive impairment and learning disabilities over time.
Students and professors of French’s prestigious école nationale de la statistique (ENSAE) perform multivariate analysis based on patient records.
The results confirmed clinical observations and paved the way for additional research on learning disorders in relation to postural syndromes.
Clinical research also influenced individual diagnosis and the overall multidisciplinary organization over time.
2007 and 2009 StudiesIn 2007, an in-house 4-month clinical study was conducted on a sample of 320 patients. In 2009, physicians led an additional study on a larger sample of 685 patients observed over a one-year period totaling five examinations.
After only four months, measures showed and average increase in speed of reading by 35%, or a word count rise from to 82.7 to 106.11 per minute. Postural ailments symptoms and cognitive disorders decreased by 65% and 36%. The first study also analyzed improvement in subjective signs such as children behavior, focus, attention, memorizing and quality of writing.
The second study exhibited stronger results in every category, with noticeable improvements in higher-levels skills such as attention and memory. Over 90% of patients increased fluency and speed of reading between their first and third examination, as measured by the number of words correctly spelled and understood per minute. Another 70% of patients scored higher between the third and fifth examination. The dramatic step up during the first 4 months suggests that patients quickly came close to their normal speed of reading, the following 8 months of treatment bringing marginal improvements.
Both studies provided ample evidence of postural deficiencies decreasing across the board. In the first months, children experienced fewer muscular and joint pains, gait and posture unbalances, and recovered a stronger sense of spatial orientation.
Children’s progress along cognitive items was linear over one year, indicating that the postural treatment yielded steady benefits with regard to attention and memorizing.
Cluster analysis allowed statisticians to arrange patients along homogeneous groups regarding treatment components (prismatic glasses, postural soles, and daily exercises) observance modes (“not observed”, “sporadic”, and “continuous”), and locations (“at home” and “at school”).
Output provided patient profiles and treatment strategies. Children benefiting the most from the postural treatment followed their exercise plans daily. Intermittent wear of glasses or irregular exercise practice proved detrimental and in some cases harmful.
Results also demonstrated the overall effectiveness of the postural treatment on patients affected by learning disabilities. Despite their limitations, results provide a foundation for future research to be conducted with Neuroscientists and speech therapists.
Table 1: Speed of reading distribution between 1st & 5th examination (one year period)