Down Syndrome

Richard A. Feely, D.O., FAAO, FCA, FAAMA

One might wonder what the value of osteopathic manipulative treatment could be for a genetic syndrome. Osteopathic medicine is based on the principle that body structure and function are dynamically interrelated. When one improves the anatomic interrelationships of structural elements of the body (bones, muscles, membranes, tissues, fluids), one sees improvement in the function of the body. This holds true whether the causes of the structural abnormalities are genetically based or not. It is clearly evident in looking at the face of a typical child with Down Syndrome that there is a lot about structure that is less than optimal. Let's look at what improvements in functions might be seen by improving the structure.

Down Syndrome, or Trisomy 21, occurs in about one in 800 births. It is almost always the result of a third copy (trisomy) of some or all of the genetic material on chromosome 21. Intellectual developmental disorder and low muscle tone are probably the two most common hallmarks of Down syndrome. There is also a much higher than normal incidence of heart and gastrointestinal tract defects which often require surgical correction.

Many external body features are characteristic of the syndrome. These include among others, an upward slant to the eyes; skin folds at the inner edges of the eyes; a flat, wide bridge of the nose; small, low-set ears; a shortened front to back dimension of the skull; a recessed midportion of the face and a protruding and often furrowed tongue. Some of these features contribute to the health complications seen in Trisomy 21, and some may plat a role in the common neurodevelopmental problems.

Changes in most features are possible through osteopathic manipulative treatment, and the improvements made structurally are likely to result in better functioning.

Infections

It is commonly accepted that most children with Down Syndrome have more severe respiratory infections, especially of the ears and sinuses. There are two reasons for this. One is the genetics of Down Syndrome causes abnormalities in the immune system which make it more difficult to resist an illness once exposed and harder to heal from it once ill. The second reason lies in the structure of the facial features which makes drainage of these areas more difficult.

The midportion of the face (the area between the eyes and mouth) is small and typically set further back in the child with Down Syndrome. This means that the sinus cavities are smaller than normal and sometimes absent entirely. The wide, flat bridge of the nose blocks the openings through which the sinuses drain. The problem is compounded by the low-set position of the ears and the smaller than normal diameter of the eustachian tube which drains the middle ear to the back of the throat. When fluids fill the ears and sinus–spaces that should be occupied by air-infections are likely to occur.

Drainage is further compromised by the differential growth of the upper and lower jaw bones. The upper (maxilla), being part of the midface, is small in comparison to the lower (mandible). This also promotes the mouth breathing, protruding tongue and difficulty enunciating language often see in trisomic children.

Through a very gentle touch, an osteopathic physician trained in the cranial concept, can help to normalize the relationships of the bones and membranes of the of the facial area. By assisting the midface structures to come forward, one can see a cosmetic change in eye shape, cheekbones, tongue/mouth relationship and bridge of nose. Usually the frequency of upper respiratory infections are reduced as well.

Growth Concerns

Almost all children with Down Syndrome show delays in gross motor, fine motor developmental and language development. These skills often lag four months behind at one year of age and eight to ten months behind at two years of age. Language is frequently not gained until the fourth to sixth year. Though these delays are assumed to be genetically predetermined, let's look at the role that body structure might play.

Osteopathic theory asserts that neural pathways in the brain are designed to lay themselves down in precise geometric relationships. When the cranium (skull) is distorted in its shape, it is not possible for these pathways to develop normally.

There are several factors contributing to the distorted cranial shape. The sutures, where one bone meets another, are often positioned abnormally in Down Syndrome. The membranes that encase the central nervous system and lie between the brain and the cranium have a powerful effect on the growth of the developing skull. These dural membranes usually demonstrate very poor mobility in the trisomic child. The front to back dimension of the cranium is typically shortened in Down Syndrome and is one more factor dictating distorted geometry for the developing neural pathways.

Osteopathic treatment can effect significant changes in the shape of the cranium through addressing the sutures and the tensions in the dural membranes. The distortion of the cranial mold appears to contribute significantly to the difficulty in performing coordinated motor tasks such as grasping and crawling. Most agree that mastery of these tasks is a necessary foundation for later learning. Osteopathic treatment, therefore, is an important part of the health plan for a child with Down Syndrome.