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births .Accounts for over 55% of India’s under 5 mortality rate(U5MR).The U5MR currently is 59 deaths/1000 live births and Neonatal mortality rate is around 33 deaths/1000. Neonatal mortality is a very serious problem as rate is not decreasing while IMR and U5MR have been steadily declining. Millenium Development Goal is U5MR of 38/1000 by 2015. 12th plan seeks to reduce U5MR to 33 by 2017. IMR (Infant Mortality Rate) : Number of infant deaths/1000 before the age of 1.IMR is presently 44/1000 down from 47/1000 live births. Basic Reasons for high Neonatal Mortality rate Absence of steps to propagate basic healthy practices like breastfeeding, prevalence of child marriage, anaemia among young women, lack of focus on sanitation and also the lack of care to most mothers during the critical phases of pregnancy and post delivery are responsible for several diseases and neonatal and child deaths. Solutions:
Breast feeding: Practising exclusive breastfeeding for the first six months of a child’s life and complementing that with soft foods in the following period could prevent 210,000 Indian children from dying each year, a new report by Save the Children has said. Research also revealed that 22 per cent of all newborn deaths can be prevented if infants were breastfed within the first hour. Across the country, just 40 per cent of babies are given colostrum, the first milk produced by a mother that is full of vital antibodies that strengthen a baby’s immune system. In examining the barriers to breastfeeding in India, Save the Children found that family and religious customs dictate giving newborns other liquids before breast milk to remove their first stools. Studies in India also showed that over two-thirds of those who discard the colostrum cited religious beliefs, while others said it was thick, unclean and its removal helps children suckle more easily. Breastfeeding is one of the best ways to tackle malnutrition; a simple, natural way to boost a baby’s immune system. The report says that if babies receive colostrum within an hour of birth, they are three times more likely to survive. And if the mother continues feeding for the next six months, then a child growing up in the developing world is up to 15 times less lily to die from killer diseases like pneumonia and diarrhoea.
2.According to national surveys, adolescents (15-19 years) contribute a sixth of total fertility in the country. The substantial unmet need of contraception leads to unplanned pregnancies and also places a high risk of contracting STD’s impacting child mortality rate s. Thus need of awareness and increasing the availability of contraceptives to prevent both STDs and unplanned pregnancies.
low birth weight and Asphyxia. Maharashtra and Kerala have achieved MDG’s so far. which together account for a significant propotion of these deaths. and congenital diseases like HIV. which are actively dividing. This causes the body to respond in such a manner that there may be organ dysfunction. They will also have to register the births and both the mother and child will have to be safe at the end of the 42nd day to get the money. most importantly.zinc supplementation on time to address severe cases of diarrhoea. herpes. Sepsis in new-borns refers to a serious bacterial infection like meningitis. Under this scheme. The ASHAs are being paid Rs 250 for every home visit but get the money only after the completion of 42 days. Choking and hyperventilating are everyday examples that cause lack of oxygen to . etc later) Primary cause of neonatal deaths in India are mainly neonatal infections(Sepsis.Good sanitation and hygiene and access to clean drinking water can prevent many cases of pneumonia and diarrhoea. etc). It leads to a serious overdrive of the body’s immune system and leads to a series of reactions that can lead to widespread inflammation and blood clotting. chicken pox.depression of the heart. pneumonia. Neonatal sepsis is a grave entity leading to millions of infant deaths worldwide. National average is 212 and Millennium Development Goal (MDG) is 109. etc. or no. (Detailed Govt interventions to tackle IMR. While main causes of child death(or other under 5 child deaths) are Pneumonia. Sepsis or septicaemia is a life-threatening illness that can occur when the whole body reacts to an infection. Accredited Social Health Activists (ASHAs) will have to visit new mothers six times in 42 days to encourage safe newborn care practices and early detection and free referral of sick newborn babies. For the first time. increased metabolic rate and abnormalities or organ function and thus sepsis is not considered to be a mere infection alone. Septicaemia or sepsis is defined as the presence of numerous bacteria in the blood. MMR. the ASHAs will have to record the birth weight of the child in the maternal and child protection cards (MCP). There may be a collapse of blood circulation (shock). Only TN. Asphyxia is a condition in which the body and. Maternal Mortality Rate (MMR) : Number of maternal deaths /100000 live births. the brain receives inadequate. meningitis. Simple health interventions like providing Oral Rehydration Therapy (ORT). Within this timeframe. oxygen supply. India last year rolled the home-based newborn care scheme under the country's National Rural Health Mission. immunize newborns with BCG vaccine and administer the first dose of oral polio and DPT vaccine. Measles and Malaria. Diarrhoea and in some cases Meningitis.
As the body sends white blood cells to attack the infection. almost 60. It is characterized primarily by inflammation of the alveoli in the lungs or by alveoli that are filled with fluid (alveoli are microscopic sacs in the lungs that absorb oxygen). In addition to its impact on human health. and is a pathogen of livestock. rotavirus caused about 2. its importance is still not widely known within the public health community. It was once thought that asphyxia due to complications at birth was the cause of cerebral palsy. However. bacteria. Now it is estimated that asphyxia accounts for only 6-8% of all cerebral palsy cases.causing pneumonia. viral. Pneumonia is an infection of the lungs that is caused by bacteria. parasites. fungal. rotavirus also infects animals. Rotavirus is usually an easily managed disease of childhood. fungi. It infects and damages the cells that line the small intestine and causes gastroenteritis (which is often called "stomach flu" despite having no relation to influenza). In the United States. the sacs become filed with fluid and pus .meningitis means inflammation of the meninges. but worldwide more than 450. and people with other diseases or impaired immune systems. Meningitis is generally caused by infection of viruses. some non-infectious causes of meningitis also exist.the brain. fungi. before initiation of the rotavirus vaccination programme. At times a very serious condition. Bacteria and viruses are the primary causes of pneumonia. Pneumonia has bacterial. and around 37 deaths each year. . it is most dangerous for older adults. In the majority of cases the cause is a virus.000 children under five years of age still die from rotavirus infection each year most of whom live in developing countries.000 hospitalizations.7 million cases of severe gastroenteritis in children. Public health campaigns to combat rotavirus focus on providing oral rehydration therapy for infected children and vaccination to prevent the disease. Although the disease can occur in young and healthy people. The virus is transmitted by the faecal-oral route. pneumonia can make a person very sick or even cause death. Anatomical defects or weak immune systems may be linked to recurrent bacterial meningitis. the organisms settle in small air sacs called alveoli and continue multiplying. and other primary causes. viruses. The incidence and severity of rotavirus infections has declined significantly in countries that have added rotavirus vaccine to their routine childhood immunisation policies. particularly in developing countries. and certain organisms. babies. and almost two million more become severely ill. Although rotavirus was discovered in 1973 and accounts for up to 50% of hospitalisations for severe diarrhoea in infants and children. When a person breathes pneumoniacausing germs into his lungs and his body's immune system cannot otherwise prevent entry. Rotavirus is the most common cause of severe diarrhoea among infants and young children. Meningitis: The membranes that surround the brain and the spinal cord are collectively known as the meninges . or parasites.
In medicine acute means it comes on abruptly. ie. also known as Rubeola or morbilli. of abrupt onset. Antibiotics are not effective against viruses. mental retardation. If untreated.a viral infection caused by the rubeola virus. and usually requires urgent care. meaning it is continually present in a community and many people develop resistance. Acute Encephalitis is acute inflammation of the brain resulting either from a viral infection or when the body's own immune system mistakenly attacks brain tissue. But when the population of such mosquitoes increases exponentially (during rainy season). Encephalitis occurs in 1 in every 1. If measles enters an area where the people have never been exposed the result can be devastating. (also water birds) Culex mosquitoes are the principal vectors.000 cases of measles . The most common cause is a viral infection. the leading cause of viral encephalitis in Asia. pneumonia. human biting rate increases. Pigs are amplifying hosts. Infected mosquitoes then transmit the Japanese encephalitis virus to humans and animals. Mosquitoes become infected by feeding on do mestic pigs and wild birds infected with the Japanese encephalitis virus. There is no specific treatment for Japanese encephalitis. convulsions. . These species are prolific in rural areas where their larvae breed in ground pools and especially in flooded rice fields These Mosquitoes usually prefer to drink the blood of such pigs. and no effective anti-viral drugs have been discovered. and even death. paralysis Mental retardation or death. The virus comes in the air or water through open defecation and circulates mainly through shallow hand pumps in the area. Measles can be complicated by ear infections. Caused by Flavivirus. Japanese encephalitis virus cannot be transmitted from person-to-person. Claimed over 1000 lives in India last year. Measles infection of the brain (encephalitis) can cause convulsions. is a highly infectious illness caused by a virus . Caused by Entero virus. Can be prevented through vaccination. it can result in to Coma. The treatment is targeted at symptomatic relief.Measles: Measles. develops rapidly. Japanese encephalitis (which also causes an inflammation of the brain) is a mosquito-borne viral infection. The Japanese encephalitis virus is amplified in the blood systems of domestic pigs and wild birds. Measles is an endemic disease. Flavivirus reproduces in pigs but doesn’t infect them. or encephalitis. higher body temp. Symptoms: Headache. So.
on core health from 1. Government of India launched a Rs. .04 per cent in the corresponding year of the Twelfth Plan. Dengue and Chikungunya. The Plan envisages substantial expansion and strengthening of the public health systems both in rural and urban areas. with robust provision of primary health care. OSELTAMIVIR—antiviral drug for H1N1 virus which is no more a pandemic but will continue to circulate for some years as a seasonal influenza virus. National Vector Borne Disease Control Programme is a comprehensive programme for prevention and control of vector borne diseases namely Malaria. regulation in drugs and food system and developing Health information system.5 and 15.provide safe drinking water to the affected persons by replacing shallow tubewells with deep tubewells (To prevent Acute Encephalitis Syndrome (AES)) Provide proper sanitation facilities . Kala-azar. Filaria. the projections for the Twelfth Plan envisage increasing total public funding by the Centre and States. plan and nonplan.cent of GDP in 2011-12 to 1. Dengue : Aedes Mosquito As per the 12th Five Year Plan document of Planning Commission.87 per cent of GDP by the end of the Twelfth Plan. with robust provision of primary health care.In Oct 2012. It is covered under the overall umbrella of National Rural Health Mission.4000 crore plan to tackle JE problem which included vaccination of children between 1. the total Government expenditure as a proportion of GDP in the Twelfth Plan is likely to increase from 1. JEEV is the brandname of India’s first indigenously developed vaccine for Japanese Encephalitis (JE). Other focus areas include strengthening human resources in health.etc.94 per cent of GDP in the last year of the Eleventh Plan to 3. When viewed in the perspective of the broader health sector. The Plan envisages substantial expansion and strengthening of the public health systems both in rural and urban areas. Japanese Encephalitis (JE). UNIVERSAL HEALTHCARE : THE VISION The Twelfth Plan strategy seeks to strengthen initiatives taken in the Eleventh Plan to expand the reach of health care and work towards the long term objective of establishing a system of Universal Health Coverage (UHC) in the country.Provide alternative means of livelihood for pig-rearing farmers.04 per.
Weekly Iron-Folic Acid Supplementation with deworming (WIFS). free vaccination (TT) to pregnant women. affordable and accountable health services to the poorest households in the remotest rural regions. free spectacles to children. ASHA is a major strategic intervention under the NRHM. free cornea transplant. Dengue. which include free investigation and treatment for Malaria. which include antenatal check up including free investigations and Iron-Folic Acid (IFA) supplementation. Control of Non-communicable diseases. linked to availability of adequate financial resources. Recent initiatives in this regard include the Janani Shishu Suraksha Karyakaram(JSSK) Free Child Health Services which include home based new born care. post-natal care. Diarrhea management including free Oral Rehydration Solution (ORS) and Zinc. Control of Communicable and Non-communicable Diseases. filarial. Control of Communicable diseases. have the features of universal coverage through public health facilities for the target population. which include free cataract surgery for blindness control.Several of the on-going initiatives like Reproductive and Child Health. Tuberculosis and Leprosy etc. An ASHA(Accredited Social Health Activist) is envisaged as a trained woman community health activist who is trained in dealing with health related issues such as . pneumonia management including antibiotics. Kala-azar. guidelines have been developed and shared with the States and the Schemes are operational. New Initiatives in this direction are Rashtriya Bal Swasthya Yojana(details later) Universal Immunization Programme which guarantees free vaccination of children against 7 diseases. Family planning activities. safe abortion services and Reproductive Tract Infection (RTI)/ Sexually Transmitted Infections (STI) services including investigations and treatment. Nutritional rehabilitation. which encompass the following: Free Maternal Health Services. For these schemes. These are important steps towards achieving UHC which is an incremental process. which include free services including providing information. supply of contraceptives and other family planning interventions. facility based new born care. Adolescent Health Services which include adolescent friendly services through Adolescent Reproductive and Sexual Health (ARSH) Clinics. National Rural Health Mission was started in 2005 to bridge the gap in Rural Health Infrastructure and aimed at providing accessible. Japanese Encephalitis and Chikungunya. glaucoma/diabetic retinopathy. Implement through the ASHA.
immunization. treatment of diarrhoea. in need of prompt medical attention. are referred to the Primary Health Centre or its sub-centre. morbidity and related malnutrition. Presently around 8 lakh ASHAs working in rural areas.physical and social development of the child. the Anganwadi attempts to bridge the caloric gap between the national recommended and average intake of children and women in low income and disadvantaged communities. Health Check-ups: This includes health care of children less than six years of age. Immunization of pregnant women against tetanus also reduces maternal and neonatal mortality. severely malnourished children are given special supplementary feeding and referred to medical services Immunization of pregnant women and infants protects children from six vaccine preventable diseases-poliomyelitis. include regular health checkups. Improved nutrition 4. to enhance the capability of the mother to look after the normal health and nutritional needs of the child through proper nutrition and health education and lay the foundation for proper psychological. diphtheria. Growth Monitoring and nutrition surveillance are two important activities that are undertaken. Besides. These are major preventable causes of child mortality. 2. pertussis.1. Referral Services: During health check-ups and growth monitoring. disability. By providing supplementary feeding. recording of weight. today. to identify children below the age of six and pregnant & nursing mothers. and prophylaxis against vitamin A deficiency and control of nutritional anaemia. sick or malnourished children. Objectives: To tackle malnutrition. deworming and distribution of simple medicines etc. Services: Nutrition including Supplementary Nutrition: This includes supplementary feeding and growth monitoring. antenatal care of expectant mothers and postnatal care of nursing mothers. tuberculosis and measles. Weight-for-age growth cards are maintained for all children below six years. She enlists all such . Universal immunisation etc It is proposed to have 1 ASHA per 1000 population. tetanus. All families in the community are surveyed. They avail of supplementary feeding support for 300 days in a year. The anganwadi worker has also been oriented to detect disabilities in young children. reduce the instances of child mortality. The various health services provided for children by anganwadi workers and Primary Health Centre (PHC) staff. Safe Delivery 2. Integrated Child Development Services (ICDS) Scheme Launched on 2nd October 1975. 1. management of malnutrition. Children below the age of three years of age are weighed once a month and children 36 years of age are weighed quarterly. The The care of the new born 3. This helps to detect growth faltering and helps in assessing nutritional status. ICDS Scheme represents one of the world’s largest and most unique programmes for early childhood development. Promotion of household sanitary toilets 5.
Health and Education (NHED) is a key element of the work of the anganwadi worker. Its programme for the three-to six years old children in the anganwadi is directed towards providing and ensuring a natural. since all its services essentially converge at the anganwadi – a village courtyard. This is also the most joyful play-way daily activity.cases in a special register and refers them to the medical officer of the Primary Health Centre/ Subcentre. The early learning component of the ICDS is a significant input for providing a sound foundation for cumulative lifelong learning and development. focuses on total development of the child. visibly sustained for three hours a day. as envisaged in the ICDS. in the age up to six years. It brings and keeps young children at the anganwadi centre . It also contributes to the universalization of primary education. with emphasis on necessary inputs for optimal growth and development. 2 Nutrition and Health Education: Nutrition. joyful and stimulating environment. The concept of providing a package of services is based primarily on the consideration that the overall impact will be much larger if the different services develop in an integrated manner as the efficacy of a particular service depends upon the support it receives from related services. nutrition and development needs as well as that of their children and families. This has the long term goal of capacity-building of women – especially in the age group of 15-45 years – so that they can look after their own health. The Non-formal Pre-school Education (PSE) component of the ICDS may well be considered the backbone of the ICDS programme. Services Supplementary Nutrition Target Group Children below 6 years: Pregnant & Lactating Mother (P&LM) Immunization* Children below 6 years: Pregnant & Lactating Mother (P&LM) Health Check-up* Children below 6 years: Pregnant & Lactating Mother (P&LM) ANM/MO/AWW ANM/MO Service Provided by Anganwadi Worker and Anganwadi Helper . by providing to the child the necessary preparation for primary schooling and offering substitute care to younger siblings. Anganwadi Centre (AWC) – a village courtyard – is the main platform for delivering of these services. thus freeing the older ones – especially girls – to attend school. These AWCs have been set up in every village in the country. This forms part of BCC (Behaviour Change Communication) strategy. PSE.an activity that motivates parents and communities. mainly from the underprivileged groups.
and free transport from home to institution including during referrals. free drugs. Deficiencies. Development Delays including Disability and follow-up management. In addition.Referral Services Children below 6 years: Pregnant & Lactating Mother (P&LM) AWW/ANM/MO Pre-School Education Nutrition & Health Education Children 3-6 years Women (15-45 years) AWW AWW/ANM/MO *AWW assists ANM(Auxillary Nurse Midwife) in identifying the target group. Rashtriya Bal Swasthya karyakram launched(February 2013) The purpose of Rashtriya Bal Swasthya Karyakram is to improve survival. · The teams will screen children in the age group 0 – 6 years at Anganwadi centres besides screening of all children enrolled in Government and Government aided schools from class1to class12.The scheme is now covered under the Direct Benefit Transfer (DBT) programme with nine districts being included in the first phase. is also in operation Indira Gandhi Matritva Sahyog Yojana (IGMSY): The IGMSY is a conditional cash transfer scheme for pregnant and lactating women implemented initially on pilot basis in 53 selected districts in the country from October 2010. Janani Suraksha Yojana (JSY):The JSY launched in 2005 aims to bring down the MMR by promoting institutional deliveries conducted by skilled birth attendants. blood and diet. Diseases.MO is probably Monitoring Officer :-P Three of the six services namely Immunisation. a new initiative to eliminate out of pocket expenses for pregnant women and sick neonates. · The newborns will be screened for birth defects in health facilities where deliveries take place and during the home visits by ASHA · . · The child health screening services builds on the existing school health services and will be provided through dedicated mobile health teams placed in every block. development and quality of life of children in the age group of 0 to 18 years through early detection of Defects at birth. It which entitles all pregnant women delivering in public health institutions to an absolutely no expenses delivery covering free delivery including Caesarean. Janani Shishu Suraksha Karyakram (JSSK). diagnostics. Health Check-up and Referral Services delivered through Public Health Infrastructure under the Ministry of Health & Family Welfare. The block level dedicated mobile medical health teams would comprise of trained doctors and paramedics.
diseases and deficiencies specific to childhood which. · Existing services offered by Ministry of Women and Child Development. if unattended. Many children suffer from developmental delays. Other diseases in the news and PIB .· RBSK envisages to cover 30 common health conditions prevalent in children for early detection and free intervention and treatment. · There is a provision for District Early Intervention Centres at the district level for management of cases referred from the blocks and further referral to tertiary level health services in case of need. The programme would cover all States and UTs in the country in a phased manner. Around 15 lakh children are born with defects. Regular health screening and early intervention can yield rich dividends. which contributes to 10% of neonatal mortality in our country. become severely debilitating and a source of suffering for the entire family. Social Justice and Empowerment and Education will also be optimally utilized.
Colorectal cancer is essentially a lifestyle cancer but with a big hereditary component. Tuberculosis: India accounts for 2. Peritonectomy. ovaries. Incidence of Multi Drug Resistant TB(MDR-TB) has increased. In most cases of rectal cancers. the cancer would have been fairly advanced.7 million cases of TB globally caused by Myobacterium Tuberculosis. pseudomyxoma peritonei. making it first among the 27 MDR-TB high burden countries. doctors at the RCC say. and a rare kind of cancer. low in fibre and vegetables. Reasons for MDR TB Many of India’s 2 million TB patients stop talking medicines once their health improves. The treatment options now available here for rectal cancers can be quite morbid. an intensive.The rates of colorectal cancers are certainly high when people pursue a Western lifestyle and diet. . this is one of the lifestyle-related cancers which seem to be on the rise here. primary peritoneal cancer. The NCC has been doing this for the past 12 years quite successfully. Also Misuse of new TB drugs could lead to more cases of drug resistant TB as it leads to bacteria developing more resistance.Oncologists from Regional Cancer Centre in Trivandrum. In this procedure. is a procedure that NCC offered patients with advanced (Stage IV) cancers of the colon and rectum. they removed all visible tumour from the abdomen and the peritoneum itself. The Health Min has constituted a committee to finalise protocols for new drug use. Singapore. followed by intraperitoneal chemotherapy. While colorectal cancer does not figure among the high prevalent cancers in Kerala. the quality of life of the patient is severely compromised after treatment. Colorectal cancer is mostly detected very late because by the time the patient begins to feel the symptoms like difficulty in passing stools or blood in the stools. high in protein and fat. the most common form of TB among adolescents and aults.which is why India is confronting the problem of drug resistant tuberculosis.2 million out of total 8. and radical procedure currently done only in a few centres across the world. It requires complex treatment. and apply chemotherapy directly to the abdomen. preparing to offer peritonectomy or cytoreductive surgery. Surgical oncologists at the RCC dealing with gastrointestinal cancers will soon be trained in the procedure at the National Cancer Centre. Acc to WHO India has 99000 number of MDR TB cases. The collaboration with the NCC could help the RCC give better options to rectal cancer patients. Vaccine used for TB since 1921 is BCG(Bacille Calmette Guerin) but it does not protect against pulmonary TB. multi-disciplinary. the only centre in south-east Asia doing the procedure.3 lakh people die of TB every year(in India itself) HIV-TB co-infection is also an increasing concern with 6% of TB patients are HIV positive. Over 3.
Its relevance in low resource setting cannot be over estimated. India has around 8 million people with autism and other developmental disorders. applied in an integrated socio-medical environment using the already existing health care delivery system in many countries. Polio was a major cause of disability. Hamid Ansari has said that in India it is estimated that over 50. The intensions include establishing a regional autism awareness campaign in South East Asia. The Ponseti method is now the standard of all National Clubfoot programs across the globe. which is not only an expensive but a less than fully satisfactory option due to relatively poor long-term results. Until two years ago. Autism is a developmental disorder which is characterized by communication difficulties. as a large number of children suffering from the disease are from the rural areas. Shri M. The intention is to identify common challenges each country is facing and form a partnership to develop solutions in a collaborating and coordinated fashion. Apparently. . The Vice President said that until recently many children with clubfoot were treated surgically. The Vice President of India. the South Asian Autism Network (SAAN) was born to combat the devastating autism public health crises. Delivering inaugural address at the “National Clubfoot Conference” organized to raise awareness on the prevalence of Clubfoot deformity here today. NGO and international partnership. With the eradication of Polio.The Revised National TB control programme(RNTCP) has developed a plan to scale up the services considerably in order to treat 40000 MDR-TB patients by 2017. It`s phenomenal success is attributable to a combination of sound scientific knowledge. social.can correct the foot deformity in children in a more cost effective and efficient manner.000 children are born with clubfoot every year making it an important factor of disability amongst our children. behavioral challenges as well as repetitive behaviours. thanks to an effective anti-polio program. based on Government. The diagnosis of autism is difficult due to the use of different diagnostic criteria. now a new method –The Ponseti Method. However. He expressed his concern that it is estimated that in India there are more than 10 million persons with locomotor disabilities. The Ponseti method is a manipulative technique that corrects congenital clubfoot without invasive surgery developed by Dr. After the adoption of Dhaka Declaration on 25 July 2011. creating joint programmes for information-sharing and professional training. it becomes logical to address the other causes of childhood disabilities. he has said that while clubfoot is easily identifiable and curable based on timely intervention. congenital clubfoot is one of them. Ignacio Ponseti of the University of Iowa. and defining national and regional strategies to advance autism public health research and policy development. they remain permanently disabled for want of access to timely cure and treatment. we have not had a single case of paralytic poliomyelitis for the last two years.
A plaster cast is applied after each manipulation to retain the degree of correction and soften the ligaments. cartilage. which respond to the proper mechanical stimuli created by the gradual reduction of the deformity. . and bone. the foot looks normal. After two months of manipulation and casting the foot appears slightly over-corrected.The manipulative treatment of clubfoot deformity is based on the inherent properties of the connective tissue. The ligaments. After a few weeks in splints however. joint capsules. The displaced bones are thus gradually brought into the correct alignment with their joint surfaces progressively remodeled yet maintaining congruency. and tendons are stretched under gentle manipulations.