THE POSTURAL INTERVENTION
Alexandre Frey Pinto de Almeida, MD., PhD.
Scientific Coordinator of the Bachelor in Speech Therapy of the
Faculty of Health Sciences – University Fernando Pessoa
Medical Doctor of the Health Services of the University Lusíada
Director of Serralves Medical Clinic (Oporto / Portugal)
Defined as a specific reading disability, dyslexia is a syndrome which includes, beyond the reading and writing disorders, a constellanation of several manifestations and variants of a psychological scope (some cognitive styles and some ways of compensing deficits and coping with emotions) or of a somatic scope as well (e. g. some psychomotor defects), many times several neurological soft signs (laterality disturbances, for instance, are very common). In this set of clinical manifestations, Pinto de Almeida (1993) noticed the very frequent association of the dyslexic syndrome with a clinical background of postural deficiency. The associated Postural Deficiency Syndrome can be treated by means of the postural reprogramming, eventually in combination with the use of low power prismatic lenses. Pinto de Almeida (ibd.) demonstrated that this treatment can occasion very noticeable effects on the performances of reading themselves, and afterwards some other authors also let us know about good results of this therapeutic intervention on the writing alterations in a great number of disorthographical children.
The major question is to know which is the place of this postural intervention in the management of dyslexia and disorthography. Serrano and Alves da Silva already affirmed that dyslexia can be faced as a manifestation of the Postural Deficiency Syndrome, hence they defend that the postural intervention has to be the treatment of election for most of the cases, attributing the effects on reading to the rehabilitation of the proprioceptive dysfunctios conditioned by those vices of position, which could tend to create some cognitive blockades responsible for the compromise of reading. Conversely, Pinto de Almeida (2004) considers dyslexia, as much as the P.D.S. itself, both as “dyslaterality syndromes”, descending from a general disharmony of the hemispheric functions: it is this disharmony that the treatment in question is supposed to correct. There are however several other successful interventions that also are able to compensate laterality disturbances and that could be of first choice in many situations.
I. INTRODUCTION: POSTURAL SEMIOLOGY IN THE DYSLEXIC SYNDROME
Despite of all the discussions taking place, there is a reasonable international consensus about dyslexia as a nosological entity: as much the DSM-IV as the World Federation of Neurology and now the CIM-10 of the O.M.S., they all allow us to define it very simply, as a specific difficulty in learning to read. The major problem is just that a trustworthy diagnosis is usually extremely hard-working (Pinto de Almeida, 2002): it requires namely the application of a reading scale, not always conveniently surveyed for all the languages (cf. Pinto de Almeida, 1993 for the European Portuguese), an intelligence scale (normally a Wescheler one) very laborious in its application, as well as a medical and psychological examination that could exclude deficits of sensorial acuity, neurological and psychiatric illnesses, main problems at school or some important developmental delays of another nature, being thus well established to be about a "specific evolutive dyslexia" we are talking (Critchley, 1975), and not a difficulty in reading secondary to other causes. Everything considered, there are very rarely less than some 5 hours of evaluation in order to exclude from this result of reading difficulty any causes that could make it not-specific.
We believe this is the major drama in the assistance to the dyslexic: the prevalence is high (the most modest estimations never are below 4% of the school population, and many times numbers are higher than 8%) and the systems of health the State is able to implement do not have capacity enough to offer a so laborious evaluation to every child on suspicion; out of the State, a complete evaluation can on the other hand become impossible, because of the cost of the implied services. Here it is, from our point of view, the reason for all this inertia, all this jib, and for all the mythologies, on the other hand, around dyslexia, however they allowed to call it as the "illness of the fashion", however they lead to argue its real existence (one must have something very complicated to be considered dyslexic), when it is not defined in several wrong ways ("he is dyslexic because he changes sounds, or changes letters, or he is not because he doesn’t change", and so on). It is the kingdom of the disinformation.
The dyslexic is thus being pushed from a professional to another, nobody solving really his specific problem, because the problem pertains in fact to all of them, and therefore it belongs to no one: that’s a matter of the medical doctor, of the psychologist, of the teacher, of the educationalist, it is one of the speech therapist, of the psychiatrist, of the neurologist... - and all of them "pass the ball", many of them doubt, some others relativize the difficulties, one comes that develops successive sessions of games and activities that do not work; that one accuses the mother because of a bad communication with the child, another one medicates, a last one proceeds with sessions of psychomotor reeducation during months and months... and many times the progresses are quite modest. What is being difficult is after all the constitution of a team that could integrate the abilities of all these professionals in favour of the dyslexic. Each one of these technicians tend to find that it is not his matter, or then that it is only a matter of himself, and therefore the diagnosis fails, the evaluation fails, the therapy fails, the reeducation fails. Here it is what we are looking for at the Serralves Medical Clinic, partner of the University Fernando Pessoa (Oporto/ Portugal), by means of the constitution of a large interdisciplinary team.
But with everything this against, many dyslexic go on in any case, making progresses more or less slowly, with more or less compensations, and they all go on doing, in one way or another, some of them faster and others more slowly, the long journey of the mandatory schooling. Sometimes they realize to perform oral reading with a strong vivacity, even if they do not understand what they read. It is clear that they do not like to read, that they avoid reading. As a general rule, disorthography associates to dyslexia, and it is – jointly with disgraphy – the compensation in writing of the difficulties observed when reading. Many cases also associate, beyond that, an attention deficit disorder.
More confusing are the frequent difficulties in the relationships dyslexics use to establish, their compensatory strategies, the bizarre behaviours that sometimes they develop in consequence of their mechanisms of defense: the scan of the stimulus is frequently less effective, not only regarding the written text as also regarding the symbols in general, at the point of being able to disturb their spatial integrations, their rhytms and so on; in face of this not deciphered and misunderstood universe, lacking to achieve a good integration, it happens many times that the dyslexic appeals quite systematically to a “fly to the fantasy” as a strategy of coping with a hostile world, a teacher that looks at him as a diminished individual, a mother that complaints he isn’t being dedicated … - consequences that give many diversities to the syndrome in each particular case.
In addition, this specific learning difficulty in reading is a point of arrival, a resultant of a set of several small deficits of very diverse nature. We would say that dyslexia as one only entity does not exist; there are in fact several ways of being dyslexic. The capacity of reading is extraordinarily complex (cf. Pinto de Almeida, 2005), demanding a perfect integration of many diverse neural systems: reading presumes the integrity of the afferent pathways, regarding sight and hearing (this one especially in the oral reading) as well as the sense of proprioception, of the efferent pathways and of the regulation of the eye mobility, the primary cortical sensitive and motor areas and the association ones, as well as the intermodal areas at the confluence of the three lobes of reception in each side; cerebral lateral dominances should be minimally defined, and the brain commissures (specially the corpus callosum) should be developed in a certain extension, since reading requires the integration of the strategies of both hemispheres, as well as the maturity of the areas involved in language processing should have been achieved at the point of being able to deal with a metaphonological conscience (cf. Van Haout and Estienne, 1998, for example).
Castro Caldas and Reis (2002) present several neuropsychological studies comparing literate with illiterate women, and they show a quite different cerebral processing of the stimuli as a result of literacy - all an entire dynamics that comes from neural plasticity: the brain that reads perceives the world, analyzes and treats it in a very different way, when compared with the brain that never learned to read. The ascending reticular system provides the level of vigil activity and the necessary attention to an efficient reading performance, and is sensible to the motivation, namely by influence of the limbic processing of the emotions. The action of reading requires beyond of this a good relation with the space – the spacialization itself as much as the body scheme and the equilibrium, from which the posture results as an outcome, being to this regard very important the role of the cerebellum, that great integrator of the several sensibilities and regulating device of motricity and posture.
Hence, it is not surprising that the dyslexic brain can show the most diverse alterations, small or great deviations, as much in its structural as its functional organization: according to the techniques they are using, different authors evidenced different kinds of findings, such as uncommon cases of symmetry of the plana temporale (Galaburda and Geschwind, 1980), a deviant geometry of the corpus callosum (Hynd & Semrud-Clikeman, 1989), disorders of the neuronal migration with disorganization of the cytoarchitecture, including cortical ectopias on the peri-Sylvic regions of the dominant hemisphere (see for example in Galaburda et al., 1989; Habib, 2000; etc.), undefined or even inverted patterns regarding the usual predominance of magnocells on parvocells at the left, in the thalamic lateral posterior nuclei and medial and lateral geniculate bodies (Galaburda et al., 1989; Livingstone et al., 1991), an increased time of Inter-hemispheric transmission when one reads (Davidson et al., 1990), a marked asymmetry in the activity of the two cerebral hemispheres during reading - as much in electrophysiological (cf. Duffy, 1984; Bakker et al., 1987; etc.) as in functional neuroimagiological studies (cf. Wise et al., 1991, for PET scan), and at a peripheric level a set of many alterations that we interpret as coming from a very similar dysfunction of the central processing, such as a right ear / left hemisphere less discriminative for the sounds of the language (cf. Tomatis, 1972), a directional predominance of one side in the vestibular functions (Levinson, 1990), a frequently increased visual peripheral sensibility (Grosser and Spafford, 1991), or on the contrary a decline in these sensibilities, including very frequent functional scotomas in the peripheral visual fields (Pinto de Almeida, 1993), and so on - what we use to summarize as a general dyslaterality or dysharmony in the coordinated functioning of the cerebral hemispheres (Pinto de Almeida, ibd.).
With such a diversity of the implied neural systems, it does not surprise that the cases of dyslexia present quite often a wide constellation of associated soft neurological signs, small immaturities, small handicaps, besides the difficulties in reading and writing themselves (Pinto de Almeida, 2002): a contradicted left handedness, a misdirected laterality, crossed lateralities, ambidexterity; bizarre visual complaints, including visual stress, astenopia, metamorphopsias...; a dominant eye at the perceptive level that does not coincide with the dominant eye at the motor level; increased peripheral visual sensibilities, diminished peripheral visual sensibilities...; an exophoric deviation at near; a vergence dysfunction; slow, inexact, irregular ocular movements, with changeable latencies, very prolonged fixations and a higher number of verification saccades; a visuo-spatial disorganization; various disturbances of the rhytm(s); a "director ear" not well established; a very incipient processing of the rapid sequences of sounds; disturbances of the linguistic development, phonological processing deficits, deficits of the phonological memory, difficulties in the verbal organization of the thought; several defects at the level of the metaphonological conscience; a subtle persistence of primitive reflexes; a lateral directional superiority affecting the vestibular functions; more or less severe alterations of the static equilibrium, of the dynamic equilibrium; an incipient dysmetria; a motor discoordination in relatively simple tasks; a gait in zigzag; difficulties in going up or going downstairs... – in our experience we can find all those clinical manifestations, and we really find, in diverse combinations, plenty of those soft neurological symptoms and signs, giving to each dyslexic syndrome its particular profile (cf. Pinto de Almeida, 1993; Pinto de Almeida, 2002; etc.).
The author of these lines has investigated especially certain subtle ophthalmological, postural and proprioceptive factors that many times are altered in the dyslexic, and whose manipulation has been shown very efficient in order to improve the performances of reading, but that does not signify that one could reduce the dyslexic syndrome to a mere resultant of one of such factors, or have them as only determinants of the clinical picture. In an exploratory study with a small number of cases, dated of 1993, Pinto de Almeida discovered indeed that Dyslexia associates quite frequently with a Syndrome of Postural Deficiency first described by the physiatrist Henrique Martins da Cunha (1979). It is a persistent dysfunction of the muscular tonus coming from a deficit of the perceptive integration with regard to the equilibrium and proprioception. This syndrome includes a certain number of symptoms considered as “cardinal” – pain (especially rachialgias, retro-ocular pain, arthralgias and cephaleas); disturbances of the equilibrium (many times including a history of frequent falls); alterations of the visual perception (often astenopia, intermittent diplopia, metamorphopsias…); disturbances of the proprioception and of the somatognosis (with frequent shocks against tables and seats, shoulder collisions against the doors, etc.), and occasionally a lot of other numerous and disparate, said “non-cardinal symptoms”, that do not make the diagnosis – which, beyond of the depressive, pseudohisterical complaints, beyond of the agoraphobia, the insomnia, bruxism, tinnitus, respiratory, vasomotor alterations and so many other, Martins da Cunha (1987) admitted since soon they could include difficulties in reading; and a characteristic physical semiology, including frequently facial assimetria; adoption of a preferential direction of the gaze; ocular vergence dysfunctions; cervical blockades; limitations of the rank of mouth opening; a stereotypical asymmetrical ciphoscoliotic postural attitude, with axial rotation and privileged support on one foot, with characteristic pressure algical points – a semiology that in his cases of dyslexia Pinto de Almeida (1993) did confirm in different services of the University Hospital where he developed this pioneer research with dyslexic subjects who presented in association a S.P.D.
II. PLACE OF THE POSTURAL INTERVENTION IN THE DYSLEXIC CLINICAL MANAGEMENT
What Pinto de Almeida (1993) established, and what henceforth he could confirm in its clinical activity (cf. Pinto de Almeida, 2004a), was that the handling of this associated S. P. D. by means of the postural reprogramming and the proprioceptive correction with low power prismatic lenses tends to be effective on the reading performances themselves in a quite short delay (one month elapsed from the beginning of the intervention, in a test-retest protocol with a broad battery of tests, the treated subjects showed evident, statistically significant progresses, as well in reading speed and accuracy than in reading comprehension, this result not being due to a simple training or learning effect, since in control cases no significant differences were registered one month later).
Subsequently, in 1996, Graciete Serrano and Orlando Alves da Silva revealed to have obtained very convergent results applying the same therapeutic approach in an appreciable number of disorthographic children, probable dyslexic ones; we say probable because of the lack of evidences, since it does not look that some leximetric evaluation was done, neither before, nor after the therapeutical intervention, and the progresses were simply documented by means of the best performances they could register in handwriting, directional coordimetry, cortical cartography, and in psychological tests such as the complex figure of Rey, this last used by the way, with many other, since Aura Montenegro (1974), but of course, the diagnosis not being done in such a way, as these procedures import very especially if we want to obtain a characterization of the particular cases with regard to perception, organization of the space and so on (at this level, the improvements seem in fact to be undeniable). Only very recently (cf. in Quercia et al., s/d) we did have notice of reading tests in French language being methodically applied in dyslexic subjects which present some associated postural signs; not intending to analise right here the detail of the tests in question, some of them by the way very similar to our own battery in the first exploratory study about this association (Pinto de Almeida, 1993), we couldn’t fail to notice that the statistical norms published are absolutely insufficient for a capable leximetric evaluation, and as such they do not securely permit to quote the reading performances observed in each concrete clinical case; any way, it looks therefore very early for having a correct estimation of the epidemiology of the two syndromes in association – what does not allow right now any generalization of the therapeutic results.
Serrano and Alves da Silva (1996) defend that postural (and proprioceptive) approach as the treatment of first line for the cases of dyslexia in general, since it is going to correct the underlying proprioceptive dysfunctions occasioned by vices of position they assume as constituting the main cause of the dyslexia itself, since these proprioceptive dysfunctions generate, in their opinion, cognitive blockades able to compromise the reading process. The hereditary substrate, Quercia, Alves da Silva and Robichon (Quercia et al., op. cit., s/d) continue to devaluate it or any way they subordinate it to a supposed postural / proprioceptive real origin of the dyslexia, which is not proved after all. The interferences of the proprioception with other sensibilities can explain some difficulties of the multimodal integration in the dyslexic and some difficulties of spatial location in certain dyslexias; they might be able to clarify certain alterations of the spaciality or of the visuo-motor coordinations in some dyslexic subjects, but they do not explain the cognitive and psycholinguistic alterations that integrate the dyslexic syndrome, the disturbances of the linguistic development and Dyslexia as such.
Altough there isn’t any doubt on the existence of sensori-motor general coordinations since a very tender age, despite of a large consensus about the unity of the visual perception and proprioception with the movements of the gait while performing intelligent decoding tasks, and being certain on the other hand that reading requires a multimodal continued integration, there’s a big distance between this level of the perception and a level of cognition and language. First of all, nothing tells us that the perceptive dysfunctions (proprioceptive, visual or any other) do condition a “cognitive blockade”, and not the inverse: having in consideration the numerous feedback relying input, output and processing, it seems more probable that both circuits could be possible (the final result can be very similar, but it is clear that we should ponder case to case the most adapted therapeutic plan, not accepting without a critique any panacea, any general treatment supposedly of first choice, without the precaution that is due to the clinical case in particular of each dyslexic subject). It is not difficult for us to admit, with Zaichkowsky et al. (1980), and others, a triangulation of cognition with affection and psychomotricity, an alteration in one of the vertices of this triangle having necessarily repercussions on the remainders; this idea is quite often latent in diverse other authors (cf. Vítor da Fonseca, 1992, for example). But it is in fact a somewhat mysterious connection, still lacking a demonstration in detail.
Pinto de Almeida (1993; 2004) advances in alternative, as the essential physiopathological explanation and as an attempt to comprehend the mechanism of action of this postural handling, a conception of Dyslexia and of the S.P.D. itself while “syndromes of dislaterality” (we should have in mind the neuroanathomofunctional deviations already described in the dyslexic brain, and the very analogous deviations that have been found in brains of individuals with postural alterations – cf. Martins da Cunha, 1988): both syndromes would settle after all in a general disharmony of the joint functioning of the two cerebral hemispheres – what of course can be extended to the proprioception without being reduced to it, affecting therefore other sensibilities, as well as cognition and motricity itself. It would exist, in sum, a dislaterality of base or an underlying hemispherical dysharmony, able to affect at once all of these different domains, and also responsible for dyslexia.
By means of the postural reprogramming, the individual becomes conscious of his vices of position, continually cares of a more correct positioning and performs batteries of daily exercises aiming to correct such postural deviations; the proprioceptive correction by means of the low power prismatic lenses is going to support this trial, supplying changes in the tension degree of the extrinsic muscles of the eye and in the hole system of postural support, making the informations compatible in the different channels – the visual, the proprioceptive and even the vestibular one – whose will be present as the input of the system of postural regulations (Gagey, 1993); one obtains in this way an improvement of the postural and motor output, leading to a correspondingly adjustment of the diverse actions that depend on these different systems of entrance and processing of the information. That’s the reason why the Syndrome of Postural Deficiency improves, changing in the direction of a more symmetrical and adjusted postural attitude, which is obtained by means of this kind of therapeutic approach, registering also apparent benefits at the level of the equilibrium, the vestibular functions and the visual fields themselves.
There is something very interesting in these dyslexic subjects treated in this way: many times, one can observe a best cognitive performance and they often refer spontaneously, in relation with the intervention, better outcomes namely in functions as the attention, the memory and even the verbal organization of the thought – something that the evaluation of some of those parameters permit in fact to assess.
In our opinion, the postural intervention (reprogramming and prisms), beyond of getting a reorganization of the entrances for the sensory information, would permit – not only in the presentation as in the subsequent processing – to obtain, since the input, a better harmony and tuning in the joint activity of both cerebral hemispheres, with a more adjusted output also, and this mechanism would explain as much the improvements in the somatic plan as in the psychological plan, which apparently responds in a very positive way to the postural handling. Doing justice to the oriental conception of the unity of body and mind, we are here, more than in the psychosomatic domain, in the domain of the somatopsyche. With regard to the attention and the relation with the space, for example, it is admissible that a dysfunction of the vergencies could be translated in attentional and visuo-spatial alterations – what would explain the apparent benefits of this handling, in certain cases, touching the attention deficit, the visuo-motor coordination and the spatiality of the dyslexic (about the relations of the vergence control, see Riddell et al., 1990; Pinto de Almeida, 1993); it explains also different aspects of the so-called “dyslexic personality”, as a resultant of such a dysharmonia, what equally would let us understand the changes that the patients relate at this level, in relation with the postural handling: Richard Davidson (1984), for example, presented electrophysiological evidences of a relative brain lateralization in the processing of the moods, the positive at left, and the negative at right – it is not difficult to admit they could become more stable when one harmonize the general functioning of both hemispheres; this would explain namely the action of prisms upon the depressed mood that many cases of S.D.P. and of dyslexia really document.
The team of Bakker et al. (1987) showed up by the way a quite stable relation between certain reading / writing errors and the dysfunction of one or another hemisphere, according to the case, thus proposing a basic distinction between two main types of dyslexia, the perceptive or the linguistic ones, whether fail the strategies of reading / writing characteristics of one or another side of the brain – what is congruent with our interpretation of dyslexia as a syndrome of dyslaterality, and with the obtaining of therapeutic results by this means. For such cases, the group of Bakker proposes a set of exercises of specific hemispheric stimulation with the aid of a tachistoscope that is going to work selectively each quadrant of the visual fields, or of devices that are going to work specifically with the upper member of one side (cf. Bakker et al., 1990).
It seems also excessive the conception of Alves da Silva (cf. once again in the foreword dated of 2004 in Quercia et al., s/d, recently published), for whom dyslexia would not exist like an isolated clinical entity, since it would figure always in the context of a S. P. D., even if it was in a very discrete manner (but then, does any cervical blockade always reveal a postural syndrome???). Although the association can be frequent, it is far from being an absolute rule: in our experience, there are many subjects affected of a S.P.D. that do not develop dyslexia, as well as many dyslexic do not develop a S.P.D. Only in a case we remember it was indubitable that the clinical picture might have begun with sustained vicious positions, and even so in consequence of a marked anisometropia – i. e., with ophthalmologic complications that created an obstacle to the reading and were also able to affect the equilibrium of the entrances of the postural system. In the remainder, there is a much more frequent family history which indicates, in most of cases of dyslexia, an hereditary disturbance, essentially genetic in its origin, something almost consensual and widely described in the literature. But even if it was that the case, our casuistic shows that the postural symptoms can also develop in two dyslexic subjects of the same family. Would a gene in common, make dyslexic subjects more exposed to develop the S.P.D., or would they develop vicious positions because of their dyslexic handicaps when reading? – That’s something we would like to study ourselves. Right now, we only feel able to advance that both the syndromes could result of a same neurobiological dyslaterality of base. That a well succeeded postural treatment could revert the disorders of neuronal migration, an eventual dysplasia of the planum temporale in the dominant hemisphere, the alterations of the geometry of the corpus callosum, as we already said (Pinto de Almeida, 2004 a and b), there is something that is not difficult for us to believe, if we consider the presumable active trials of brain selective synaptization and mielinization (or even some trials of neurogenesis) in the course of a so complex learning activity as reading.
The etiology of the dyslexic syndrome is extremely varied, including from genetic causes (according to a mendelian pattern, autossomic dominant in principle, or then a polygenic multifactorial heredity of variable expressiveness, involving the chromossome 15 and others), to embryological causes and peri-natal ones (fetal suffering, prematurity, low weight for birth, a diminished index of Apgar, neo-natal jaundice…), and including developmental and ambiencial causes (ex. sustained vicious positions?) or even scholar ones (in France for example, the global method in the teaching of reading increased the incidence of dyslexia during the eighties). We believe that all these different possible causes result in a same general picture of a “minimal cerebral dysfunction” (cf. Touwen, 1982), which regarding dyslexia consists essentially for us in a dysharmony of the hemispherical functioning. In this consists, from our point of view, the essential physiopathological connection in the comprehension of dyslexia.
There is certainly a preexisting syndrome, before the scholar age, determined by this cerebral immaturity, rich of mild neurological symptoms or signs that translate those deficits in the hemispheric processing: a language disturbance, some defect of the phonological processing or the metaphonological integrations, a disorganization of the space (cf. e. g. Pinto de Almeida, 1993 and 2002), a persistence of reflexes usually considered as "archaic" (cf. McPhillips et al., 2000), some form of motor discoordination, a discrete ataxia or other "soft-signs" that sometimes we only are able to detach by means of some special tests (ex. the monopedal Romberg), could be in this phase the only manifestations (cf. Vítor da Fonseca, 1992). They can already include or not some sort of postural incipient symptoms, and they will be able or not to evolve, according to the case, in the direction of a definite postural syndrome. It is rare that such symptoms and signals organize as a complete picture of S. P. D. before the puberty, and generally we only are able to do the positive diagnosis of this one in full adolescence.
But more often, what happens is that, in some forms of dyslexia, the postural symptoms are lacking in the terms Martins da Cunha (1979) defined them. The syndrome will be able namely to be disclosed in this case in a sensorial manner, the visual or even the cognitive background, for example, can be in evidence more than the proprioceptive, motor and postural functions. A sort of dyslexia relative to the visual sensibility could correspond, for example, to the so-called "syndrome of scotopic sensitivity", that Helen Irlen (1991) recognized in dyslexia, attention deficit disorder as in other learning difficulties: intense and gradual visual stress - with symptoms that include visual fatigue, blurred vision, glare, metamorphopsias, chronic headaches – a picture that becomes more and more troubling all along the continuation of school tasks and daily activities of reading, finally hindering their continuity, these ones shortening and shortening each time. It has been advanced in this case an underlying deficit of the magnocellular system (cf. e.g. Galaburda et al., 1989; Evans et al., 1996 and Skottun, 2005) as the essential physiopathological basis of the clinical picture: the magnocellular system is responsible for the processing of stimuli in fast presentation and with low contrast, as much in the visual modality as in the auditory modality: we find the two contingents well distinct, magnocells and parvocells, with clearly defined specific functions, since the first synapses in each one of these two neural pathways. What happens in the vision is that, from a fixation to the following one, this magnocellular system would have to be capable to inhibit the image caught in the first one to give place to the next one; here it is what would have to be transferred in a fraction of second, during each saccadic movement that we carry on through the continuation of the reading, and here it is what does not arrive when the image of the previous fixation persists. If we inquire them, many dyslexics will reveal complaints of this type. We only can understand this, in our opinion, in relation with a real problem in this fast processing magnocellular pathway; the electrophysiological studies with visual and verbal evoked potentials allow to assume that the dysfunction affects, in dyslexia, the early components (related with the sensorial input itself, and appearing so early as a N50 wave that comes behind the components at 20 to 40 mseg. in dyslexic subjects according to Livingstone et al., 1991) as well as the most delayed components (diverse alterations, including a higher latency of the waves N200 and P300 already evidenced in dyslexic subjects by Taylor and Keenan, 1990, in relation with the cognitive processing) along the work of visual decoding, in different tasks. The neural circuit of reading is found disrupted in different points.
Bizarre complaints appear now, letters that jump or change of position in the graphical spot, graphemes that appear and disappear, groups of letters that seem to persist from a fixation till the following one; graphic characters, entire lines that seem to oscillate, to move in diverse degrees of inclination...; the copy becomes in these circumstances more difficult than the dictate. Reading becomes a torture. Cephaleas, visual stress all along reading – here is the syndrome of scotopic vision that installs, in which case diverse authors recommend sessions of stimulation (the so called ”syntonic phototherapy") on eventually non stimulated functional areas of the visual fields (in certain learning difficulties Hussey, 1990, admits an intermittent central suppression); the stimulation will be done with coloured lights (cf. Kaplan, 1983; Karu, 1989; Gottlieb and Wallace, 2001; etc.), as a complement of the visual classic optometric therapies (cf. for example in Scheiman and Rouse, 1994). Others defend that one should improve the contrast by means of the use of coloured lenses that act as filters regarding certain selected wave lengths of the visible light (cf. Irlen, 1991; Harris and MacRow-Hill, 1999; Lightstone et al., 1999): improving not only the contrast but also the quality of the vision itself, a barrier is won that seemed unsurmountable before, the ocular movements improve their precision and reading becomes immediately quicker (cf. also Wilkins, 2002).
Chiarenza (1990) emphasised the solidarity of the perceptual and motor functions in the reading disabled children. A nexus between the oculomotricity and the ocular sensibility exists therefore, and when this nexus fails visual stress can happen; this is no doubt a particular case of the general solidarity of the psychomotricity with the perception (cf. Lisberger, 1988; Riddell et al., 1990; Groffmann and Solan, 1994; etc.); we know that the extrinsic muscles that move the eyes are provided with proprioceptors that play an uneven role in the regulation of the equilibrium and posture, jointly with others, as the plantar surfaces of the feet and the temporomandibular joints - they all having to present to the central nervous system an information which should be coherent with the one of the receptors for the equilibrium, those regarding the localization of the body in the space (cf. tb. Gagey, 1988). However, there are cases where the starting point is probably proprioceptive, motor and postural, and conversely others where the process is predominantly visual. This would explain the fact that some respond better to an intervention centered on the input, others on the output; other cases respond especially well to (psycho)pedagogical interventions centered on the processing (cf. the proposals for a "vertical reading" from Drévillon and Drévillon, 1983; the computer games with a graduation of the speed in the presentation and processing of the stimuli, elaborated by the team of Paula Tallal et al., 1998; the activities of construction of the space and advanced cognitive general trainings proposed by the group of Helena Serra, 2002). The therapeutical change operated on any one of these levels has forcibly an impact on the others.
What we are saying about vision, we could say it also about hearing: at the level of the input, a re-education of the director ear can be justified in certain cases, training selectively the right ear/ left hemisphere with regard to the language sounds, as Tomatis (1972) considered; at the level of processing, we could mention for example the development of metaphonological abilities (cf. here Van Hout and Estienne, 1998); at the level of the output, the work of the speech therapist with the verbal language performances and articulation (ibd., ibd.).
Many times, more than the posture, more than the psychomotricity or than the sensibility in a concrete modality (hearing, vision, proprioception), it is important to work with a process, a hemispheric strategy, a cognitive style, and this would be done in different domains of sensibility or motricity. Thus, Since Orton, the classic methods of re-education (e.g. S. Borel-Maisonny, 1985) propose many times a systematic resource to the different senses, since the first acquisitions (for example, big letters made to be seen, to be felt, to be said, and so on). The specific hemispheric stimulation (Bakker et al., 1990) also appeals to different sensorial modalities. We believe that the nootropic medication can also activate non specifically the verbal, analytical and sequential processes of the left hemisphere, independently of the sensory-motor modality in concrete (cf. Wilsher, 1987). Diverse sensorial modalities tend, in a similar way, to be worked simultaneously or successively in different techniques of corrective reading (cf. Condemarín and Blomquist, 1989): we shall deal in this case with the reading strategies of the dominant hemisphere (graphophonological correspondences and sequences in deciphering reading), or alternatively with the ones of the right hemisphere (reading by global visual recognition). Finally, neurolinguistic programming (cf. Bandler and Grinder, 1979) that many authors praise as a therapeutical means in the approach of the dyslexic, also is able to equate different sensorial modalities as a way of harnessing the hemispheric synergies (figured language, for instance, would request the functioning of the right cerebral hemisphere - as the studies in PET of Frackowiak and Frith, 1994, did in fact register).
A new typology is urgent. While we have not perfectly defined it, let us keep in mind this idea: dyslexia is revealed when there are processing problems that affect such complex semiotic units as graphemes, words or texts. Beyond the processing deficits, we also find frequently problems at the the sensorial input - hearing, vision, proprioception - and at the motor and postural output, a changeable distribution of the symptoms in anyone of these spheres being found in each concrete case. At the basis, we generally find a dysharmony of the hemispheric functions. Here it is a hypothetical case: a hemisphere does not agree with the other about the position of the object, about the position of the symbol, and about the position of the body itself in the space, then this one disorganizes and the eyes wander along the text, instead of covering it in order to obtain an efficient reading; hence, the posture itself gets disorganized, the graphical gesture loses its precision and reading becomes slow, hesitant, spelled, syllabified, punctuated by errors, the intonation gets flattened, letters are not deciphered, in vain the global strategies of the right hemisphere will they try to recognize the physiognomy of the new word, this one will not be caught, the attention is lost; whispering the words while reading won’t help, neither will do it following the line with the movement of the finger: the sense is not understood. Thus, almost insensibly, we change from the sphere of the sensorial input to the one of the central processing, and from this one to the one of the motor and postural output, the entire system being submitted to feedbacks and to complex interactions, as when acting on the input is going to reverberate affecting the output, and vice versa, the central processing looking at some degree for a control of these processes, however it becomes finally influenced by both of them. In the practice, when acting upon one of these levels we will be able to affect the entire system. Here it is the explanation we defend for the fact that the different techniques complement each other in the treatment and rehabilitation of the dyslexic.
If schematically we divided the dyslexias according with the main involvement 1) of the sensorial input, 2) of the central processing or 3) of the postural and motor output, we would say that one could expect that the first ones might be especially sensible, according to the case, to the syntonic approaches or the coloured filters (audiological interventions on the "director ear " should also be considered at this level, if the primary problem was in listening); perhaps the second ones could respond better to the re-education methods; the third ones would be supposed to improve the reading performances by means of a neuropsychomotor intervention. The postural intervention (reprogramming and / or prisms) deal essentially with the proprioceptive sensibility, with the objective of adjusting the postural / motor output, and even maybe the processing, to a less uncommon pattern. There would be, in short, different forms to act on the hemispheric dysharmonies of the dyslexic brain; this one functions as a whole, and the different systems – the one of the vision, the one of the proprioception, and so on, they all are reciprocally influenced and they withhold mutual complex interconnections, with multiple feedback at different levels - the input, processing and output also intervening mutually in several ways. It isn’t hard to believe therefore that a case of dyslexia presenting at the beginning as "essentially visual" could evolve becoming rich of a proprioceptive and postural semiology, and vice versa, also being conceivable that both could develop from a previous condition they are summing right now (say, an anisometropia that favoured the loss of certain peripheral visual sensibilities, imposing sustained vicious positions, and the dyslexia evolving finally in these two contexts - cf. J. M., our inaugural case, nº 1 of Pinto de Almeida, 1993). Here it is the reason for several successful different therapeutical means that can be used many times and that are capable of complementing and of harnessing each other in the global clinical approach of the dyslexic.
III CONCLUSION: DIFFERENT COMPLEMENTARY RESOURCES IN THE TREATMENT OF THE DISLEXIA
Thus, although the cases that we have been treating are very encouraging and even if we are absolutely convict that it is one of the most promising and efficient approaches in the therapeutical management of an immense number of cases, the postural intervention in the treatment of dyslexia still remains, nowadays, in an experimental phase. The primitive exploratory study of Pinto de Almeida (1993) proved this possibility, and although relinquishing very often the question of the diagnosis of the reading level, the subsequent works had also shown the effectiveness of this same treatment on the disgraphy and the disortography itself, whose many times do in fact present in association with it, in a very appreciable number of cases. It would be necessary to improve the scientific methodology in this type of studies, searching apart the effectiveness and the cost / benefit of the each one of these various clinical measures that integrate the therapeutical proposal, first separately and later on in association, according to a set of assays and experimental protocols quite well established and duly controlled, mainly in what regards the clinical characterization and epidemiology of the dyslexias thus being treated, and finally looking for comparative results with those elapsing from the application of other therapeutical methods; however, it seems already possible to affirm that this kind of treatment will be indicated at least in the cases that course with a marked proprioceptive dysfunction. The psychomotor re-education will apparently be able to be used with some advantage as an important clinical treatment, in association of this kind of therapies, even if this would also deserve a very methodical study. In the cases of visual dysfunction itself, evidences for the success of certain visual therapies seem to give support to the syntonic stimulations and the use of coloured filters. We have reasons to believe that there are some mixing cases where both two general forms of approach - the proprioceptive and postural / psychomotor combined with the visual ones – could be used in combination with success. If there is a marked phonological and metaphonological disturbance, could be indicated, on the other hand, all the therapies centered in the auditory processing. Computer games and other computer resources will be able in the future to provide some help as much in the phase of the diagnosis as in the moment of the therapeutical intervention. Other kind of approaches, some more classical and experimented, the others most innovative, most of all they have revealed very useful, although always with a changeable success in each one of the cases, and many of them use multisensorial strategies, although most of them usually are centered on the linguistic and cognitive processing (cf. tb. Pinto de Almeida, 2004b). None of these different approaches showed 100% efficient, and all of them sum several examples of successful treatments, however many of these therapeutical means seem to harness each other, as much at the level of the therapeutical action on dyslexia as, in certain cases, on the associated S.P.D., since they increase the harmony of the different sensibilities and their respective processing in the two cerebral hemispheres in order to obtain a better reading performance (and eventually a better motor and postural output).
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* "Cortesia do Prof. Alexandre Frey Pinto de Almeida e Universidade Fernando Pessoa - artigo em publicação no colectivo de PINTO DE ALMEIDA, Alexandre Frey (org.) - Audiophonology after Bologna (in press)".