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The practice of pediatric physical therapy has experienced significant growth in recent years, especially with regard to the care of children with Down syndrome.
Down syndrome is a genetic condition that can influence motor development, muscle tone and coordination in affected children.
The estimated incidence of Down syndrome is between 1 in 1,000 and 1 in 1,100 live births worldwide . Approximately 3,000 to 5,000 children are born with this chromosomal abnormality each year. *1
Palisano et al. *2 established motor growth curves for children with DS and estimated the probability of children achieving motor skills at specific ages.
They found that the odds of children with DS sitting up at 12 months and walking at 24 months were 78% and 40%, respectively. This is about twice the age at which these skills are typically seen in typically developing children.
Research suggests that children with DS require more time and practice to learn more complex motor skills, particularly movements requiring speed, postural control, and balance, which explains these delays. * 2,3 Because of these common motor limitations, pediatric physical therapists are frequently involved in providing early services for children with DS.
Current scientific literature provides limited evidence to guide physical therapy assessment and intervention in children with Down syndrome (DS). However, available studies support the effectiveness of physical therapy in improving activity impairments and limitations in individuals with DS .
For example, specific exercise programs for people with DS have been observed to result in increased muscle strength, improved balance, greater motor coordination, and improved cardiovascular fitness. * 4, 5
Furthermore, the use of sensorimotor play groups in combination with physical therapy services has been shown to promote greater overall motor development in young children with DS. Despite these positive findings, the selection of the most appropriate interventions for individuals with DS is often based primarily on the experience and preferences of the treating therapists.
In a research study conducted by Johnson, Rebekah at the *6 found that physical therapists used 39 rating scales when assessing children with a diagnosis of Down syndrome, of these 39 tools they found that 23 of them were used by more than one therapist.
The assessment scales most commonly used by therapists to evaluate children diagnosed with Down syndrome are:
Motor development scale (Peabody developmental motor scale – Peabody/PDSM-2)
Gross motor function measurement (GMFM)
Alberta Children's Scale (AIMS)
Bruinninks-Oseretsky test of motor proficiency-2 (BOT-2)
Hawaii Early Learning profile (HELP)
Battelle scale – II
Bayley scale
Developmental Assessment of Young Children-2 (DAYC-2)
Pediatric Evaluation of Disabilities (PEDI)/PEDI-Computerized Adaptive Testing (PEDI-CAT)
Balance Scales (Pediatric Balance Scale, Berg Balance Test, Pediatric Stand and Reach, Single Limb Stance)
Timed Up and Down stairs
Timed walking test (30-s walk test, 2-min walk test, 6-min walk test, timed 50-ft walk/run)
According to scientific evidence, the most reliable assessment scales for evaluating children diagnosed with Down syndrome are:
PDMS 3
According to Palisano and colleagues *7 who examined the validity of the PDMS-Gross Motor Scale (PDMS-GM) for use as a screening measure in children receiving physical therapy, including children with Down syndrome. Results indicate that the minimum clinically important difference on the PDMS-GM is 10 scale points. The authors concluded that the PDMS-GM should not be used to assess the direct effects of physical therapy intervention, but may be useful when included as a global measure of development over time when combined with other measures.
GMFM-88
The Gross Motor Function Measure-88 (GMFM-88) was the second most commonly identified assessment measure for children with DS. The GMFM-88 is a criterion-referenced measure that is intended to assess change over time in gross motor skills. Although originally developed as a measure for children with cerebral palsy, the GMFM-88 has been reported to be valid, reliable, and sensitive to change in gross motor function in children with DS *9
BOT-3
Connolly and Michael *8 concluded in their study of BOT scale performance that children with DS had significantly lower scores than children without DS on running speed, balance, strength, and visual motor control, as well as composite scores for gross motor and fine motor skills.
6 minute march
According to Boer PH, et al *10 the 6-minute walking assessment scale is a valid and reliable tool for use with individuals with Down syndrome.
According to Johnson, Rebekah at *6 most commonly identified issues related to Physical Therapy were functional motor skills, joint stability, and muscle performance.
Among the treatment strategies with the greatest scientific evidence we find:
Tummy Time:
Wentz *11 reported in a study that increasing tummy time decreases the rate of motor delay in children with Down syndrome.
Treadmill:
Body weight supported treadmill training for children with DS prior to the onset of walking has several benefits, such as decreasing the time it takes to learn to walk, *12 improved gait patterns, * 1 3-14 and improved physical activity. *15
The use of orthoses:
The use of lower extremity orthoses to improve foot and ankle alignment is an effective intervention for children with Down syndrome after they have learned to walk, as it improves gait parameters, 16 improves balance, *17 improves gross motor skills, and participation. *18
It is important to emphasize that the use of orthoses on the lower limb should be used once children have learned to walk, since orthoses can alter the neuromotor development of the foot and ankle. *19
Muscle strengthening exercises and functional activities:
The use of progressive resistance training has been shown to produce significant improvements in muscle strength in children and adolescents with Down syndrome, which may result in improved physical activity levels.
It has also been observed that core training can contribute to improving functional balance and stability in this population. Regarding power, that is, the ability to quickly generate muscle force, specific studies have been carried out in children with Down syndrome using jumps as a form of assessment . *20, 21
Aerobic exercise:
In a case study conducted by Lewis and Fragala-Pinkham, *22 it was observed that the implementation of an aerobic and strength training program resulted in significant improvements in submaximal heart rate, respiratory rate, aerobic performance, as well as measures of strength and power in a child with Down syndrome.
Furthermore, a meta-analysis based on 4 studies revealed that performing low-impact cardiovascular exercise for 30 minutes, 3 times per week, over a period of 10 to 16 weeks, led to improvements in maximal oxygen consumption, maximal minute ventilation, time to exhaustion, and maximal workload in individuals with Down syndrome. *23
Other tools commonly used as therapeutic intervention are:
Dynamic orthoses such as:
Kyriossuit
Hip Helper
SPIO
Theratogs
Activities such as:
Adaptive sports such as dance, soccer, gymnastics and swimming
Yoga
Hippotherapy
Children's playgrounds
In conclusion, it is of utmost importance to recognize and utilize reliable, evidence-based assessment and treatment tools when working with patients who have Down syndrome. By doing so, we can ensure that we are providing the best care and treatment possible.
The availability of evidence-based assessment and treatment tools allows us to gain a more accurate understanding of the individual needs of each patient with Down syndrome. This helps us develop personalized and effective treatment plans that address each individual's specific impairments and limitations.
Furthermore, by basing our treatment approaches on scientific evidence, we can be confident that we are using proven, research-backed methods. This gives us confidence that our interventions are supported by solid data and have the potential to generate positive, meaningful outcomes for our patients with Down syndrome.
In summary, recognizing and using reliable, evidence-based assessment and treatment tools is essential to providing the best possible treatment for patients with Down syndrome. In doing so, we are committed to providing quality care and promoting the development and well-being of individuals with Down syndrome.
Resources
Peabody chart
Gross Motor Skills Scoring Sheet (GMFM-88)
6 minute test
Kyrios suit page (Dynamic orthosis)
References:
*2 Palisano RJ, Walter SD, Russell DJ, et al. Gross motor function of children with Down syndrome: creation of motor growth curves. Arch Phys Med Rehabil. 2001;82(4):494–500. doi:10.1053/apmr.2001.21956.
*3 Cardoso AC, de Campos AC, dos Santos MM, Santos DCC, Rocha NACF. Motor performance of children with Down syndrome and typical development at 2 to 4 and 26 months. Pediatr Phys Ther. 2015;27(2):135–141. doi:10.1097/PEP.0000000000000120.
*4 Shields N, Taylor NF, Dodd KJ. Effects of a community-based progressive resistance training program on muscle performance and physical function in adults with Down syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2008;89(7):1215–1220. doi:10.1016/j.apmr.2007.11.056.
*5 Wang WY, Ju YH. Promoting balance and jumping skills in children with Down syndrome. Percept Mot Skills. 2002;94(2):443–448. doi:10.2466/pms.2002.94.2.443.
*7 Palisano RJ, Kolobe TH, Haley SM, Lowes LP, Jones SL. Validity of the Peabody Developmental Gross Motor Scale as an evaluative measure of infants receiving physical therapy. Phys Ther. 1995;75(11):939–948; discussion 948–951. doi:10.1093/ptj/75.11.939.
*8 Connolly BH, Michael BT. Performance of retarded children, with and without Down syndrome, on the Bruininks-Oseretsky Test of Motor Proficiency. Phys Ther. 1986;66(3):344–348. doi:10.1093/ptj/66.3.344.
*9 Russell D, Palisano R, Walter S, et al. Evaluating motor function in children with Down syndrome: validity of the GMFM. Dev Med Child Neurol. 1998;40(10):693–701. doi:10.1111/j.1469-8749.1998.tb12330.x.
*10 Boer PH, Moss SJ. Validity of the 16-meter PACER and six-minute walk test in adults with Down syndrome. Disabil Rehabil. 2016;38(26):2575–2583. doi:10.3109/09638288.2015.1137982.
*11 Wentz EE. Importance of initiating a “tummy time” intervention early in infants with Down syndrome. Pediatr Phys Ther. 2017;29(1):68–75. doi:10.1097/PEP.0000000000000335.
*12Ulrich DA, Ulrich BD, Angulo-Kinzler RM, Yun J. Treadmill training of infants with Down syndrome: evidence-based developmental outcomes. Pediatrics. 2001;108(5):E84. doi:10.1542/peds.108.5.e84.
*13 Wu J, Looper J, Ulrich DA, Angulo-Barroso RM. Effects of various treadmill interventions on the development of joint kinematics in infants with Down syndrome. Phys Ther. 2010;90(9):1265–1276. doi:10.2522/ptj.20090281.
*14 Angulo-Barroso RM, Wu J, Ulrich DA. Long-term effect of different treadmill interventions on gait development in new walkers with Down syndrome. Gait Posture. 2008;27(2):231–238. doi:10.1016/j.gaitpost.2007.03.014.
*15 Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev. 2008;31(2):255–269. doi:10.1016/j.infbeh.2007.10.003.
*16 Selby-Silverstein L, Hillstrom HJ, Palisano RJ. The effect of foot orthoses on standing foot posture and gait of young children with Down syndrome. NeuroRehabilitation. 2001;16(3):183–189.
*17 Martin K. Effects of supramalleolar orthoses on postural stability in children with Down syndrome. Dev Med Child Neurol. 2004;46(6):406–411.
*18 Looper J, Martin K. The effect of supramalleolar orthotic use on activity and participation skills in children with Down syndrome. J Prosthet Orthot. 2020;32(4):222–228. doi:10.1097/JPO.0000000000000308.
*19 Looper J, Ulrich D. Does orthotic use affect upper extremity support during upright play in infants with Down syndrome? Pediatr Phys Ther. 2011;23(1):70–77. doi:10.1097/PEP.0b013e318208cdea.
*20 Shields N, Taylor NF. A student-led progressive resistance training program increases lower limb muscle strength in adolescents with Down syndrome: a randomized controlled trial. J Physiother. 2010;56(3):187–193. doi:10.1016/s1836-9553(10)70024-2.
*21 Shields N, Taylor NF, Wee E, Wollersheim D, O'Shea SD, Fernhall B. A community-based strength training program increases muscle strength and physical activity in young people with Down syndrome: a randomized controlled trial. Res Dev Disabil. 2013;34(12):4385–4394. doi:10.1016/j.ridd.2013.09.022.
*22 Lewis CL, Fragala-Pinkham MA. Effects of aerobic conditioning and strength training on a child with Down syndrome: a case study. Pediatric Phys Ther. 2005;17(1):30–36. doi:10.1097/01.pep.0000154185.55735.a0.
*23 Dodd KJ, Shields N. A systematic review of the outcomes of cardiovascular exercise programs for people with Down syndrome. Arch Phys Med Rehabil. 2005;86(10):2051–2058. doi:10.1016/j.apmr.2005.06.003.
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