What about the PDS?

Report from a Round Table at the Aix-les-Bains 2005 APE Congress
Discussing the Postural Deficiency Syndrome by H. Martins Da CUNHA

Only the interventions of P.M. Gagey and D. Pérennou, as well as the synthesis made. by Philippe Thoumie are reported.

P.M. GAGEY's intervention

     In 1979 first, then in 1987, Henrique Martins Da Cunha published about the same paper on what he called the "Postural Deficiency Syndrome" (PDS). Twenty six years later, in the groups interested in postural pathology, we still speak about this paper, it did not fall in the neglect as so many other papers!. But it does not arouse consensus… the least that can be said!... What does this paper hide behind such a stormy survival?

The clumsiness of Da Cunha's paper
How was Da Cunha able to gather under the same concept so different realities and, worse, realities which himself sets as different? There is the "That" and the "Not-That", the "Cardinal" and the "Not-cardinal" which, together, build the totality of the concept and the author does not make any effort to explain by which virtue this contradiction is magnificently resolved in the ideal unity of the concept of postural deficiency! In front of so much clumsiness, the reader can find in this paper only a jumble of signs and symptoms collected, confusedly , by a delirious imagination. Only the convincing heat of Henrique's verb was able to help his pupils to think that, maybe, there was other things to read in this paper that an inventory of what one cannot make head or tail.

Both Da Cunha's clinical intuitions
To move on, the first thing to be done is to distinguish the "That" and the "Not-That".
The "That" of the postural Patient
Da Cunha's idea is simple: These functional chronic patients which practitioners knows well, who have difficulty in standing upright because either they stagger, or they suffer in this posture, Da Cunha says to us: please, look as they are standing up and you will discover abnormal asymmetries of their postural tone which disappear at once as soon as you find how to manipulate their tone by treating one or the other input of their postural system. If you manage to reduce their asymmetries, you will reduce their sufferings.
"That" is quite clear and simple; only a matter of clinical observation, without needing the support of a long neurophysiological speech. And besides. "That" works!

The "Not-That" of the postural Patient
Contrary to the simplicity and clearness of the postural Patient, it is impossible to understand anything in the "Not-That" of the postural Patient! Da Cunha stretches out a list of signs and symptoms from which the coherence escapes us; what is sure: they have nothing to do with posture, it is their only common point. Please , rather see: Raynaud's phenomenon, Palpitation, Dyslexia, Dysgraphia, Defect of concentration, Anxiety, Depression, Paresis, Paresthesia, Scotoma, Lipothymia, Dyspnoea, Fatigue, Agoraphobia, Defect of orientation, Defect of spatial localization, Losses of memory, Asthenia, etc. Bizarre!. Nevertheless so it is.

Da Cunha's intuitions: what interest?
What is the interest of describing the "That" of the postural patient, how to examine him, how to treat him? The question does not even arise... Or rather it is transformed and becomes: 'How to validate a so simple, so coherent, so effective description? '
     But the "Not-That" of the postural patient, what's its interest?. The answer is not evident today!. It may be towards what Da Cunha does not say openly: looking after the "That" looks also after the "Not-That". The pupils of Da Cunha, even today, tell that they cure dyslexias by looking after SDP. In any cases, the communication between the "That" and the "Not-That" is announced in this crossed efficiency of manipulations of a system that is known capricious, because it is a dynamic non-linear system. Maybe the "Not-That" of the postural patient opens a strangely interesting track? But there is certainly a lot of work to be done before ascertain that.
All the work which remains to be done, on the postural patient as on the "not-postural-patient", should it be made under the sign of the "Postural Deficiency Syndrome"? The matter is not so sure. Far from us the idea not to recognize pioneer's role of Da Cunha, but one can, maybe, not steer at once the readers towards the inevitable clumsiness of the first papers. In that case, we are short of an alternative naming. How to name, at least, the "That" of the postural patient?
DA CUNHA H.M. — Syndrome de déficience posturale, In: Actualité en rééducation fonctionnelle et en réadaptation, 4° série Masson, Paris, 27-31, 1979.
DA CUNHA H.M. — Le syndrome de déficience posturale (SDP). Agressologie, 28, 941-943, 1987.

D. PERENNOU's intervention
The reflection which was proposed to me by the APE consisted in analyzing objectively the literature concerning the "Postural Deficiency Syndrome".
An interrogation of the international data base MEDLINE with keywords "Syndrome de déficience posturale" or " postural deficiency syndrome " allows to find these four papers:
Da Cunha H.M., Da Silva O.A. (1986). Le syndrome de déficience posturale. Son intérêt en ophtalmologie. Journal Français d’Ophtalmologie, 9 : 747-755.
Da Cunha H.M., Da Silva O.A. (1986). Disturbances of binocular function in the postural deficiencysyndrome. Agressologie, 27 : 63-67.
Da Cunha H.M. (1987) Le syndrome de déficience posturale (SPD), Agressologie, 28 : 941-943.
Da Silva O.A. (1987) Directional scotometry and prismatic correction in postural deficiency syndrome Agressologie 28: 945-46
An interrogation by the names of the two authors cosigning these papers (Da Cunha H.M., Da Silva O.A.) did not find any other paper.

Comments on these results
If, in fact, the "postural deficiency syndrome" is referenced in the international data base, there are very few papers.
And these four papers were written by the same authors, affiliated to the same department of Rehabilitation Medicine (Da Cunha) or to the same department of Ophthalmology (Da Silva) of the hospital Santa-Maria in Lisbon.
These four papers are ancient, published 20 years ago in French reviews (Agressologie, and a French review of ophthalmology), written in French for three of them and in English for one of them.
The words "Postural deficiency syndrome" or "syndrome de déficience posturale " are found in no other posterior international publication, though thousands of papers on the theoretical and clinical aspects of the postural control are referenced. We think that this lack of interest of the international community finds its origin at two levels: the inadequacy of the terminology used by Da Cunha and Da Silva and the character purely descriptive and subjective of the clinical observations which they reported..

A problem of terminology
By definition in medicine, a syndrome is an association of symptoms, signs, or deficiencies if one wishes to take place within the framework of Wood's trilogy which privileges the classification of the disorders in term of deficiencies, incapacities and handicap. A syndrome cannot be "monodeficient". Unless writing deficiencies in the plural, what was never done by Da Silva and Da Cuhna. The terminology which they propose is inappropriate.

An empirical approach
These four analyzed papers say the same thing. They describe a syndrome which associates, to different degrees, cardinal and not cardinal signs. The four cardinal signs are pains, postural instability, visual disorders and confusions of body schema. Pains are very variable and can include headaches, retro-orbital pains, thoracic or abdominal pains, joint and\or spinal pains. Instability includes sensations of instability, dizzinesses, sicknesses, and also balance disorders with falls. The ophtalmological signs are very varied including blurred vision, monocular or binocular diplopia, directional scotoma. These cardinal signs are really only varied complaints being able to be found in numerous domains of medicine, without any objective criterion. Numerous errors of disorders classification can also easily be found, the dysmetria being considered as a proprioceptive disorder. The not cardinal signs include a procession of signs in which all the medicine can meet itself... It is for example mentioned dyslexia, agoraphobia, loss of memory, fatigue, palpitation, Raynaud phenomenon, low back pain, sprain, disorders of the temporo-mandibular joint… In fact Da CUNHA and Da Silva only report some reflections stemming from their clinical observations. At no time an analysis of prevalence of the PDS it is proposed. They do not clarify diagnostic criteria, nor postural disorders physiopathology is approached.
Treatment or Miracle?
In a surprising way, Da CUNHA mentions the spectacular improvement of his patients by manœuvres including a prismatic correction, sometimes associated to other manœuvres little clearly explained, or the bearing of some plantar orthosis. No objective measure of the incapacity of the patients comes to support these observations of cure, the spectacular character of which is suspect.

     The practices of care (evaluations and treatments) entered on Evidence-Based Medecine (Medicine by the proof), and the medical and paramedical activities are now valued by a naming bearing a precise price scale. It is henceforth unreasonable and counterproductive for an association as the APE to support the practices of care based on a vague terminology even absurd, and for which the subjectivity is the queen. It would be even more crazy to maintain myths as the postural deficiency syndrome.

     On the contrary the APE has everything to gain to accompany this inevitable evolution that concern also balance and postural disorders, one of the most frequent motives for consultation in daily practice. These postural problems can have numerous causes as sensory somesthesic disorders, vestibular or visual, deficits of the driving command or tone disorders, certain innate or acquired scrawny deformations, coordination disorders, confusions of the vertical orientation, or still incapacity to manage vigilance resources. All this is understood henceforth better and better thanks to a high-level, physiological, biomechanical, technological international research. All this can and should be henceforth quantified, as well as the severity of the postural incapacity and its consequences in term of risk of fall, fear of falling and reduction of autonomy. We have numerous tools the place of which in private hospital can be again refined. In a near future, new, more innovative tools will come to strengthen this arsenal. We shall have to analyze their contribution to care practice. The main wealth of the APE results from interactions among researchers and clinicians. This permanent stimulation spurs us and urges us to look forwards. The PDS belongs to the past.

Ph. THOUMIE's synthesis

     The successive statements of P.M. Gagey and D. Pérennou had us touch difficulties of an exercise which aims to structure under a word, still to define (syndrome seems the most close to consensus), a clinical experience in the field of posture.
     The actual absence of validation of the PDS, in spite of its sketch of description more than 25 years ago, testifies the lack of precision in the comments: what clinical signs are indispensable to the diagnosis, what additional exams must be done, what is the therapeutic approach?
     Our practices, so different, teach us that all the signs can be brought back to a secondary postural disorder: balance disorders after the wearing of badly adapted corrective lenses, cervical pains of mandibular origin, low back pain due to some pathology of lower limbs.
     The idea defended here is that of a primitive syndrome whose symptomatology would be associated to disorders of the paraspinal muscles tone, abnormalities of postural investigations and sensibility to a specific way of therapy, called "postural". Actually there is an agreement among clinicians on none of these three points.
     The synthesis of such an expertise is that it would be necessary for the future to fix the situation from a new clinical analysis, the progress of which would be the following one:

- What are the signs which a postural patient is pushed to ask help for? (Statistics opened right now on x patients but not review)
- What do we hold as postural cardinal parameter? (Its absence eliminates the diagnosis)?
- Do we need a complementary exam to assert the diagnosis?
- What exams eliminate the diagnosis?
- If the success of the treatment is a part of the "syndrome" how can we assert postural treatment efficiency? (Immediate, secondary).

     From this approach several situations can be born: either the revealing of a federative global syndrome, or the revealing of differences of appreciations according to the concerned input, showing many secondary postural demonstrations.
     To answer this question we need an analysis of the practices of all the therapeutists in the field of posturology. Such a study could be driven within the APE.
     A second approach based on a reduction of the field of investigation to a dominant symptomatology (pains of the body axis, balance disorders, cognitive disorders) with its own evaluation criteria, would reduce certainly the federative concept of the PDS but would certainly offer the possibility of a validation of the postural approach, in a definite clinical situation. This would correspond then to the current standards of the Evidence Based Medicine which, whatever besides one thinks of it, will impose itself upon all of us, for the institutional recognition of our practices.

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