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\begin{document}


\def\RunningAuthor{Monisha R and Ganapathy Sankar U}
\firstPage{6327}
\articleType{Original Article}
\receivedDate{04 Feb 2020}
\acceptedDate{09 Mar 2020}
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\title{\textbf{Evaluation of Gait and Quality of Movement Analysis in Children With Developmental Coordination Disorder}}
\author{Ganapathy~Sankar~U, 
            Monisha~R\textsuperscript{*}~\\[5pt]{SRM College of Occupational therapy, SRM Institute of Science and technology, SRM Nagar, Kattankulathur, 603203, Kanchipuram, Chennai, Tamil Nadu, India}}

\begin{abstract}
A Child with developmental coordination disorder will have a higher incidence of movement difficulties and challenges to participate in activities of daily living. There is no exploration of the Gait pattern and the quality of movement exhibited by children's of developmental coordination disorder in Tamilnadu context. Children's of age 5 to 10 years were included, and after baseline screening with Diagnostic and statistical manual for mental disorder-5 criteria, children were allowed for further examination. MABC-2 and DCDQ were used to screen and rate the movement skill. Of the total sample of 100, 80\% exhibited difficulties in Gait initiation, progression and integration of motor skills. Results proved that sensory integration difficulties experienced by the children with DCD were not related to motor coordination. One hundred children included in the study experiences difficulties in participation with a peer group, awareness of body position sense, balance, and activity integration and planning. The current study concludes and adds evidence that each child with DCD is unique but presented with difficulties in gait initiation and integration. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Developmental Coordination Disorder,\newline Sensory Integration,\newline Participation,\newline Gait Analysis
\end{keywords}
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Monisha~R~\\ Phone:\ ~\\  Email:\ dreamsfuture000@gmail.com
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\section{Introduction}
Developmental coordination disorder (DCD) manifests as difficulty in the acquisition and execution of movement skill to accomplish activities of daily living. Everyday life is challenging for a child with DCD. When there is no appropriate early diagnosis for this disorder, there will be a long term negative consequences like social isolation, negativism, suicidal tendency and other behavioural disorders \unskip~\citep{895071:20423633}.

The Royal College of Occupational Therapists (COT) elaborates that therapeutic strategies deliver strategies to strengthen the movement skill and to master development and acquisition of gait pattern. It also reduces long-term costs by facilitating social participation and develops a dynamic environment for the child. Suppose difficulties addressed by the children with DCD in every activity of daily living skills are left unaddressed without early diagnosis and treatment. In that case, there are high-risk failures on education, mental health illness, reduced participation in daily living skills. Interventions scheduled for children should direct towards personal and environmental factors which hinder the participation in daily living skills \unskip~\citep{895071:20423635}. There is a growing need to address the burden of disease on caregivers. This study aims to examine the gait pattern and the quality of movement in children with DCD. This Gait analysis will improve understanding among parents and caregivers of children with DCD. A greater understanding of DCD and its clinical manifestations will have an impact on related sensory processing accurate diagnoses and also enhances the future evaluation of intervention in both health and wellbeing \unskip~\citep{895071:20423626}. Children with DCD are facing innumerous challenges in performing the task, which is easy and convenient for other typically developing children's of the same age. Activities like brushing, bathing, walking are considered essential, and all children's acquire those skills easily without much effort. However, children with DCD fail to acquire these skills, and they were identified as having challenges in everyday activities, school performance and social participation \unskip~\citep{895071:20423632}. Parents of those children with DCD fail to identify the appropriate therapy needed for their children, and they waste their time and money by roaming behind the services and care which is not needed for their children with DCD. Because of the lack of awareness and identification of DCD at the earlier stage by the caregivers and teachers of children, they are referred to occupational therapy services at the later stage of their primary schooling.

To address these challenges faced by children with DCD, there is a need for consistent gold standard norm-referenced assessment tool which analysis children face all the domains of motor incompetence with DCD \unskip~\citep{895071:20423631}. DCD is described as a condition which is manifested as delay in motor skill acquisition, but all those children's were presented with IQ of more than 70. However, marked by motor skill defect, those are substantially lower than the children with MR. (DSM-5). These motor skill deficits significantly and persistently interfere gait pattern and all other daily life skills and all these difficulties were present in children with DCD, which is not due to general medical conditions like cerebral palsy, muscular dystrophy or degenerative disorder, pervasive developmental disorder, intellectual impairment or a visual deficit \unskip~\citep{895071:20423634}. It is also evident through observation that more significant variability in the movement would occur in more distal limb segments. Difference encountered in gait pattern between children with DCD, and normal developing child is seen in the stance phase. This deference might be due to variability in the movement of the distal limb segment. Children with DCD may exhibit more significant variation in ankle control during stance phase as compared to normal developing peers, the reason behind this difference is still in debate, and further research is needed to test this hypothesis \unskip~\citep{895071:20423627}. 

Dr.U.Ganapathy Sankar elaborates that walking from place to place without tripping or falling over is an essential skill needed in everyday life. Some children have difficulty in achieving this task, and they find walking as a challenging and complex task in life. Amongst these are children with Developmental Coordination Disorder (DCD). DCD children's have difficulties with fine and gross motor skill without the marked neurological disorder, and they don't have any intellectual impairment. Common Skills those DCD children's finds complexity in achieving are tying up shoelaces, playing with their peer group, driving a bicycle and the most problematic skill cited as for this Children are handwriting. Majority of research work has highlighted that these children without proper evaluation they have the persistent difficulty in motor skills in adolescence and early adulthood \unskip~\citep{895071:20423637}. Teachers and parents who are the first population, to rule out the clinical features observed in children with DCD. They were commonly referred by the teachers as clumsy, awkward in walking. Therapist working with these children have identified different gait pattern as compared to typically developing children. When gait pattern is evaluated in detail, they found to have difficulty in walking, when a particular new object has interfered in their walking space in a familiar environment. They reported having frequent sway, stumbling and hitting to objects in the pathway. It is noteworthy that, these researches on Indian children with DCD highlighted the gait deviations and postural instability and the correlates of a sensory and visual perceptual skill.
    
\section{METHODOLOGY}
The research was conducted in a therapy Centre in Chennai, Tamilnadu, Special schools in rural and urban areas in and around Chennai with a mixed socioeconomic profile, was evaluated. After getting the consent form signed by the parents of children with DCD, The occupational therapist provided the baseline assessment and screening for the area. Ethical permission was granted by the Institution, SRM Institute of Science and technology, SRMIST, Kattankulathur. All the data scoring sheets were numbered consequently, and the children's identity was hidden, and a unique identifier colour code was given for all 100 children. Confidentiality was maintained by not sharing the information and assessment sheet to other parents and researchers. Inclusion criteria included the children of age group five to 10 years, who met the criteria for the diagnosis of DCD as per the DSM-5 (American Psychiatric Association, 2013) and Movement Assessment Battery for Children (MABC-2) (Henderson et al., 2007) children attending special schools in and around Chennai were included in the study. Children with ASD and attention deficit disorders (ADD) were included. Children with neurological impairment, such as cerebral palsy, were excluded. The reported prevalence of DCD in and around Chennai is 6\%{\textendash}8\% \unskip~\citep{895071:20423629}. The required sample size is calculated with the approval of statistician at a 95\% confidence interval and a 10\% margin of error. 

\textbf{Procedure}

Samples were collected from 2018 January to 2019 January based on inclusion and exclusion criteria. Children secured a total standard score of 6 in the total MABC-2 were enrolled in the study. Data were collected for age, gender, level of functional difficulties, scores on MABC-2 and six-minute walk test (6MWT). Both the 6MWT and MABC-2 were used at the baseline and into occupational therapy services. The two variables under evaluation were gait pattern and quality of movement. The independent variable measured was motor coordination as assessed by MABC-2 total and subsection scores. This is a norm-referenced test, and each age band task is completed by the child and scored by the occupational therapist. MABC-2 is divided into three sections under three age bands: manual dexterity, aiming and catching, and balance. Inter-rater reliability is between 0.94 and 1.00. Test-retest reliability is good, and the intraclass coefficient was 0.88, with a 95\% confidence interval of 0.79 to 0.93. There is a lack of evidence on discriminative validity. However, criterion, content and face validity are supported. Objective assessment is executed by the therapist for quality of movement examination during the gait cycle, cadence, and step length, stride length, toe-out were the parameters assessed to ensure the quality of movement. This objective assessment guidelines devised in the current trial is yet to be standardized on age group 5- 10 years old.

\textbf{Statistical Analysis}

Time sampling is used to select and enrol subjects with random selection is preferred by the investigator; the calculation of sample size designed by the statistician reduces bias. However, the risk of examiner bias is present at the level of the assessment of the quality of movement pattern executed by the children with DCD. The therapist who is elected for the collection of data is blinded to the study criteria. Standard scores for MABC-2 and t-scores for the quality of movement measures were used. The analysis was undertaken using the Statistical Package for Social Sciences (SPSS) version 20 workbook. To test the objectives of the study (Do children with DCD have reported Gait difficulties?), a one-sample t-test was selected to compare objective assessment scores of gait parameters to the specific population.
    
\section{RESULTS}
Table~\ref{tw-063869e729c2} outlines demographic data. When the functional activity is assessed, 10\% were reported by their parents that their children were at home only and 90\% present both at home and at school. Primary domain assessed were gait and quality of movement executed. When Exploring neurodevelopmental co-morbidity associated with DCD, no diagnosis is made other than DCD, and the standard scores on the MABC-2 are below 6. There is increased trunk flexibility reported in all the children with DCD during the gait cycle, and they have difficulty in maintaining the COM within the BOS during the initiation and execution of walking. Still, these Children shows innumerous compensatory patterns in the trunk and upper extremity to compensate for problems with balance control. On initial observation itself, it is evident that during the toe-off phase, there is plantar flexion of the ankle. Thus they have difficulty in ground clearance. Developmental Coordination Disorder (DCD) shows more significant variability of foot placement measures and movement of the centre of mass within the BOS, because of the motor coordination difficulty while walking in a new environment on the initial trial. Initially, after a trial walks to make the hallway and the environment habitual for the children, they were given instructions to walk up and down a flat 10-m-long pathway for 1 min, it is observed that they have a disproportionate movement of feet and trunk. Gait pattern of children with DCD was prominent with wider steps, walking time to cover the 10 m hallway is double the timing as compared to children without DCD, they have a higher amount of time spent in double stance and in stride time. These children have higher acceleration compared to their peers. These children have a higher incidence of fall because of difficulty in controlling the COM, and they lack the ability in coordinating the trunk and limb movements. 


\begin{table*}[!htbp]
\caption{\boldmath {Demographic Data of Children With DCD} }
\label{tw-063869e729c2}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.30630000000000003\linewidth-2\tabcolsep}p{\dimexpr.1435\linewidth-2\tabcolsep}p{\dimexpr.1502\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Age (years) & 5-6 & 7-8 & 9-10 & Total\\
\tblmidrule 
Male &
  1 &
  24 &
  20 &
  45\\
Female &
  20 &
  20 &
  15 &
  55\\
Total &
  21 &
  44 &
  35 &
  100\\
Mabc-scores &
  4.57 &
  4.23 &
  4.22 &
  4.88\\
Gait determinants score &
  5.23 &
  4.44 &
  5.23 &
  4.88\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

    
\section{\textbf{DISCUSSION}}
This study identified levels of difficulty in movement initiation and integration difficulties in execution of gait cycle in a clinical population of children with coordination difficulties. In comparison, many families with a child with DCD reported definite or at least some differences in walking speed and running accuracy. The coexistence of walking difficulties and DCD cannot be ruled out without gold standard evidence.

When difficulty exists in initiation and execution of gait is present, they have an impact on all the activities of daily life and function, and these difficulties will affect the participation and psychological well being of the child. Gait is the most mandatory part, should be considered in both the assessment and the planning of any interventions for children with DCD. In summary, the gait pattern of children with DCD showed they have higher cadence when compared to their peer groups. They have difficulty in body configuration resulted in DCD children's to appear more bent than in their typically developing children \unskip~\citep{895071:20423629,895071:20423628}. 

These differences on observing a child with DCD is due to the defect at the neuromuscular or postural control level. By observing all these children with DCD, it is proved that their lies an adaptive gait pattern, it is also shown that each child will not have the same adaptations and each one will have variation in gait pattern. Each child with DCD thus in need of tailored assessment tool/standard gold assessment.

The individual child with DCD will have their kind of adjustment to keep trunk and limb to perform the coordinated movements during walking \unskip~\citep{895071:20423636}. The present results indicate that even a fairly easy locomotors task can challenge children with DCD. Whereas they seem to have found strategies to cope with their movement difficulties in a structured, uncluttered environment, it might be clear that these strategies could fail in the daily living environment and in performing physical or sports activities. It is also evident through observation that more significant variability in the movement would occur in more distal limb segments \unskip~\citep{895071:20423630}. Difference encountered in gait pattern between children with DCD, and normal developing child is seen in the stance phase. This deference might be due to variability in the movement of the distal limb segment. Children with DCD may exhibit more significant variation in ankle control during stance phase as compared to normal developing peers, the reason behind this difference is still in debate, and further research is needed to test this hypothesis.
    
\section{Conclusion}
This result of this evaluation suggests that children with DCD not only vary from normally developing children in their overall level of stride length and cadence but that the level of variability across the two limbs is significant. This study has proved that not all the children with DCD have difficulty in producing consistent movement patterns for the right and left legs in stride to stride phase. Further research is needed in evaluating the gait pattern with increase in sample size and making the children get habituation with a treadmill. 
    
\section{Acknowledgement}
We want to acknowledge the management SRMIST for facilitating this project. We forward our heartfelt thanks to all the children and parents who participated in the study. 

\textbf{Conflict of Interest}

The authors confirm that there is no conflict of interest for this study.

\textbf{Funding Support}

The authors declare that they have no funding support for this study.
    

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