1. Art and Diseño

Pediatrics International (2003) 45, 68–73
Clinical Investigations
Comparison of different therapy approaches in children with
Down syndrome
MINE UYANGK, GONCA BUMIN AND HÜLYA KAYGHAN
Hacettepe University School of Physical Therapy and Rehabilitation, Occupational Therapy Unit,
06100 Samanpazarı-Ankara, Turkey
Abstract
Background: Children with Down syndrome have sensory integrative dysfunction as a result of limited
sensory experience from lack of normal motor control. The aim of the present study was to compare the
effects of sensory integrative therapy alone, vestibular stimulation in addition to sensory integrative therapy
and neurodevelopmental therapy, on children with Down syndrome.
Methods: The present study was carried out at the Occupational Therapy Unit, School of Physical Therapy
and Rehabilitation of Hacettepe University. Forty-five children who were diagnosed as having Down
syndrome by the Departments of Paediatric Neurology and Medical Genetics at Hacettepe University were
assessed and randomly divided into three groups. Sensory integrative therapy was given to the first group
(n=15), vestibular stimulation in addition sensory integrative therapy was given to the second group (n=15)
and neurodevelopmental therapy was given to the third group (n=15). All children were evaluated with
Ayres Southern California Sensory Integration Test, Pivot Prone Test, Gravitational Insecurity Test and
Pegboard Test. The hypotonicity of extensor muscles, joint stability, automatic movement reactions and
locomotor skills were tested. Treatment programs were 1.5 h per session, 3 days per week for 3 months.
Results: When these groups were compared, statistically significant differences were found in subjects’
performance of balance on right foot-eyes open, pivot prone position–quality score and locomotor skills-front
tests (P<0.05). There were no significant differences in the other tests (P>0.05).
Conclusion: The results of the present study showed that sensory integration, vestibular stimulation and
neurodevelopmental therapy were effective in children with Down syndrome. It was concluded that when
designing rehabilitation programs for children with Down syndrome, all treatment methods should be applied
in combination, and should support each other according to the individual needs of the child.
Key words
Down syndrome, occupational therapy, physical therapy.
Down syndrome is a type of mental retardation that has an
effect on motor development of children. Neuromuscular
abnormalities in children with Down syndrome, which have
been observed to be coincident with developmental delays,
include generalized muscular hypotonia, the persistence of
primitive reflexes beyond their normal disappearance with
age, and slowed reaction times during voluntary movement.1,2
Children with Down syndrome have a predominance of
primitive, spinally controlled muscle response patterns over
more centrally integrated and co-ordinated movement
patterns. This is due to poor myelination of the descending
Correspondence: Gonca Bumin, PT, PhD, Assist. Prof. Hacettepe
University, School of Physical Therapy and Rehabilitation, 06100
Samanpazarı-Ankara, Turkey. Email: [email protected]
Received 10 July 2001; revised 12 June 2002; accepted 12 July
2002.
cerebral and brain stem neurones, and a reduction in both
the number and connections of neurones in higher nervous
centers, such as the motor cortex, basal ganglia, cerebellum
and brain stem. Based on behavioral observations of developmental delay, clinicians have conducted a number of research
projects involving early therapeutic intervention for children
with Down syndrome. These studies have attempted to
facilitate normal mental and motor development through a
variety of stimulation techniques, with mixed results.2–4
Automatic postural reactions are considered to be essential
components of motor behaviors. Postural reactions work
together as a unified system to maintain body alignment and
proper posture during movement.5 Infants with Down
syndrome have delayed motor development, including a
delay in postural reactions.6
When motor development of a child with Down syndrome
is compared with that of a developmentally normal child, a
Down syndrome
consistent delay is observed in the acquisition of both
postural and voluntary components of motor control.7,8
The vestibular system plays a major role in the expression
of early motor behavior. Previous research has cited extensive
neural connections between the vestibular apparatus and the
motor system.9
Children with Down syndrome have sensory integrative
dysfunction as a result of limited sensory experience from
lack of normal motor control. Physical, cognitive and
sensory integration problems decrease the functional ability
of children in activities of daily living.9–11 Neurodevelopmental approaches, sensory integrative therapy and vestibular
stimulation have been used to improve function in children
with Down syndrome.8,12–16
The aim of the present study was to compare the effects
of sensory integrative therapy alone, vestibular stimulation in
addition to sensory integrative therapy and neurodevelopmental therapy in children with Down syndrome.
Methods
Participants
This study was carried out at the Occupational Therapy
Unit, School of Physical Therapy and Rehabilitation of
Hacettepe University. Forty-five children with Down syndrome
diagnosed by the Departments of Paediatric Neurology and
Medical Genetics were included in the study. They were
assigned into three groups according to the date of admittance to our clinic. Pre-school children were not included in
the study because it may be difficult for these children to
cooperate with the sensory integration and other tests. To
provide homogeneity between groups and to ensure cooperation of the children with these tests, an age range
between 7 and 10 years was selected.
Children with complications were examined. None of the
children had a history of epilepsy. There were two children
with congenital heart disease in the first group, two in the
second group and three in the third group. All children with
congenital heart disease had been previously operated on.
The children’s complications were not severe, so their
developmental skills were not influenced. There was one
child with atlantoaxial instability in the second group;
however, there were no neurological signs. There was no
spinal cord compression in his computerized tomography
and developmental milestones of skills were not influenced.
Sensory integrative therapy was applied to the first group,
vestibular stimulation and sensory integrative therapy were
applied to the second group and neurodevelopmental therapy
was applied to the third group. We did not establish a control
group in this study because withholding treatment from
these children would not be ethical.
69
Ayres Southern California Sensory Integration Tests
(SCSIT) was used to assess sensory integration problems.
Design copying (DC), imitation of posture (IP), and standing
balance on right and left foot–eyes open and closed (BEORL, BECR-L) subtests of SCSIT were used.17 Pivot prone
position test (PPP), hypotonicity of extensor muscles, joint
stability (co-contraction) and gravitational insecurity tests
were used to assess the vestibular system.18 Automatic movement reactions were used to assess reflex development.
Locomotor skills, ten step forward walking (LS-f) and ten
step sideways walking (LS-s), were tested. A pegboard test
was used to assess fine motor skills of the hand.19
Test definitions
Pivot prone position test (PPP)
While in the prone position, the child was asked to perform
head, trunk and hip extensions. The maintenance time of
this position was recorded with a stopwatch. The quality of
response was graded, with the following responses each
receiving one point using the following parameters:
(Children aged 6 years and older who were able to maintain
the position for 30 s would obtain a quality score of 6)
• Position assumed smoothly, quickly, and nonsegmentally
• Head position held steadily and within 45º of vertical
• Upper trunk (shoulders, chest and arms) raised off floor,
arms abducted and externally rotated approximately 90º,
elbows flexed approximately 90º
• Distal one third of thigh raised far enough off floor to
allow examiner to place fingers between distal thigh and
floor, knees can be flexed
• Knees flexed 30º or less, thighs do not have to be off
floor, but feet cannot touch floor
• Able to talk in this position
Hypotonia of extensor muscles
Hyperextensibility of distal joints, hypotonic posture in
standing, including lordosis and hyperextended and/or locked
knees and muscle tone by palpation were tested.
Joint stability (co-contraction test)
Quadripedal position was used for this test. Head neutral,
hip, shoulder and knees 90º flexion, fingers extension,
elbows semiflexion and straight back were accepted as the
normal position. While the children were in this position, the
presence of lordosis, hyperextension, rising medial side and
inferior angulus of scapula and excessive scapular adduction
were assessed.
70
M Uyangk et al.
Gravitational insecurity
Table 1 The demographic characteristics of all subjects
Gravitational insecurity was assessed according to the
emotional reactions to vestibular stimuli on the tilt board.
Groups
Automatic movement reactions
Total
Group 1
Group 2
Group 3
15
15
15
No. subjects
Female
Male
7
6
7
8
9
8
Age (years)
(mean~SD)
9.60~0.51
8.67~0.45
8.53~0.50
Protective extension and equilibrium reactions were scored
as negative or positive in standing and kneeling position.
Locomotor skill tests
The time of ten step forward walking (LS-f) and ten step
sideways walking (LS-s) on a straight line were recorded.
Pegboard test
The time of placing 20 pegs was recorded for both hands.
While the treatment program was applied, a sequence of
normal motor development was followed. The therapy
progression was done step by step, from simple to complex,
and until the skills at one stage were achieved, there was no
progression to the next stage.
Groups
Group 1: Sensory integrative therapy
The following activities were completed by group 1:
1. Visual perception activities: Block design, finding shapes
in pictures, puzzles, matching geometric shapes and letters,
numbers, and classification.
2. Body awareness: Pointing to the body parts, life-size
drawing, turning left and right side and awareness of the
body parts through touch.
3. Tactile perception: Feeling various textures, touching
boards and feeling shapes.
4. Visual-motor co-ordination training: Ocular-pursuit training,
moving ball and pegboard activities.14,20,21
3. Reducing gravitational insecurity: Self-initiated linear
vestibular stimulation in non-threatening positions with
speeds and durations tolerable to the children.18
Group 3: Neurodevelopmental therapy
Included following activities:
1. Tonic postural extensor muscle strengthening: Push-pull
scooter board games against resistive tubing strips, move
different ways using dowels, and basketball drop games.
2. Developmental movement patterns training: Obstacle
crawl, hold swing’s ropes in kneeling and half kneeling
position, throw balls to targets in kneeling and standing
position.
3. Walking activities: Forward, backward and sideways walk,
animal walks (like crab and cat), line walks and steppingstones.
4. Fine motor activities: Cutting with scissors, copying
designs, chalkboard activities, working different cubes and
pegboard designs.22,23
Treatment programs were applied for 1.5 hours a day, 3
days per week for 3 months. The home program was given
to all groups. All subjects were assessed at the beginning of
the therapy and after 3 months.
Statistical analysis
Descriptive statistics, ANOVA and McNemar Test were applied
to gained scores in order to compare the three groups. The
differences between the pre-test and post-test mean were
compared by paired t-test.
Group 2: Sensory integration therapy and vestibular stimulation
Results
In addition to the sensory integration therapy applied in the
first group, vestibular stimulation was applied to the second
group. These included:
1. Linear swinging: With platform swing in standing and
kneeling position, with T-swing and platform swing in
sitting position, with platform swing quadruped position and
with platform swing in prone and supine positions.
2. Developing equilibrium reactions: Push-pull and movement of the support surface on tilt board on sitting and
standing position, activities on therapy ball in prone
position, active maintenance of balance on stairs and ramps.
Table 1 summarizes the demographic characteristics of the
subjects. The children’s age range was between 7 and 10
years. The mean~SD age of the children was 9.60~0.51
years in the first group; 8.67~0.45 years in the second
group; and 8.53~0.50 years in the third group.
In order to investigate whether there was a difference
among groups pre-treatment, ANOVA was performed. When
compared to pre-treatment test values, there was no
significant difference between the three groups in all tests
(Table 2).
Down syndrome
Table 2 Comparison of pretreatment evaluations
Score
Tests
mean
Balance eyes closed (right)
Group 1
2.00
Group 2
2.47
Group 3
2.46
Balance eyes closed (left)
Group 1
1.27
Group 2
1.35
Group 3
1.40
Balance eyes open (right)
Group 1
6.93
Group 2
7.20
Group 3
8.00
Balance eyes open (left)
Group 1
5.80
Group 2
6.13
Group 3
6.40
Pivot prone position (time)
Group 1
21.06
Group 2
20.86
Group 3
22.73
Pivot prone position (score)
Group 1
4.20
Group 2
4.00
Group 3
3.60
Design copying
Group 1
4.00
Group 2
3.40
Group 3
3.26
Imitation of posture
Group 1
10.27
Group 2
13.20
Group 3
10.67
Locomotor skills (front)
Group 1
6.93
Group 2
6.27
Group 3
7.13
Locomotor skills (side)
Group 1
8.67
Group 2
8.45
Group 3
8.73
Peg right hand
Group 1
302.80
Group 2
345.06
Group 3
298.13
Peg left hand
Group 1
313.80
Group 2
329.06
Group 3
342.86
Table 3 Comparison of differences between groups
ANOVA
SD
F
71
P
3.74
2.44
2.72
0.12
>0.05
1.38
1.24
1.41
0.62
>0.05
4.28
5.44
6.24
0.52
>0.05
4.85
4.77
4.65
0.34
>0.05
12.08
15.43
18.79
0.06
>0.05
0.77
1.19
1.25
0.84
>0.05
3.54
2.66
3.36
0.59
>0.05
5.90
6.49
4.62
1.15
>0.05
1.87
2.15
1.64
0.86
>0.05
2.47
1.72
1.62
0.12
>0.05
9.61
7.56
8.66
0.96
>0.05
7.78
8.94
9.18
0.39
>0.05
Tests
Score
mean
Balance eyes closed (right)
Group 1
1.33
Group 2
2.40
Group 3
1.80
Balance eyes closed (left)
Group 1
1.53
Group 2
2.20
Group 3
2.00
Balance eyes open (right)
Group 1
2.60
Group 2
10.33
Group 3
6.13
Balance eyes open (left)
Group 1
3.47
Group 2
8.93
Group 3
4.87
Pivot prone position (time)
Group 1
5.87
Group 2
14.13
Group 3
6.00
Pivot prone position (score)
Group 1
0.33
Group 2
0.80
Group 3
1.07
Design copying
Group 1
1.93
Group 2
1.67
Group 3
2.53
Imitation of posture
Group 1
1.87
Group 2
3.27
Group 3
1.80
Locomotor skills (front)
Group 1
0.60
Group 2
1.13
Group 3
1.73
Locomotor skills (side)
Group 1
0.93
Group 2
1.33
Group 3
.20
Peg right hand
Group 1
28.40
Group 2
30.67
Group 3
24.87
Peg left hand
Group 1
17.53
Group 2
41.20
Group 3
27.40
ANOVA
SD
F
P
2.64
1.80
1.57
1.02
>0.05
2.13
1.52
1.81
0.52
>0.05
2.75
10.76
5.46
4.40
<0.05*
7.76
11.13
4.17
1.80
>0.05
12.96
13.21
6.70
2.61
>0.05
0.62
0.77
0.96
3.26
<0.05*
3.37
1.68
1.73
0.52
>0.05
1.30
2.63
1.93
2.50
>0.05
0.83
0.74
0.96
6.69
<0.05*
1.75
1.40
1.08
0.30
>0.05
35.23
40.02
17.98
0.12
>0.05
18.57
54.18
20.23
1.72
>0.05
*P<0.05.
ANOVA was performed to compare groups after treatment.
The data including mean differences (MD), standard
deviation (SD), and the ANOVA are presented Table 3.
When pre and post-test values of the first group (sensory
integrative therapy) were compared, results indicated a
statistically significant improvement only in sensory
integration subtests and fine motor skills (P<0.05).
In the second group (sensory integrative therapy and
vestibular stimulation), significant improvements were
observed in sensory integrative subtests, vestibular system,
fine hand skills, reflex development and gravitational
insecurity (P<0.05).
72
M Uyangk et al.
In the third group (neurodevelopmental therapy), there
were significant differences in all capabilities (P<0.05).
In BEOR, PPP-s and LS-f tests, there were significant
differences among all three groups, while in other tests there
was not a significant difference.
The children in the first group had lower scores in all
tests except DC and pegboard tests, than the second and
third groups. The children in the second group had higher
scores in all tests except PPP-s, DC and LS-f than the other
groups, but those scores were not statistically significant
(P>0.05). The children in the third group have higher
scores in PPP-s, DC, and LS-f tests. The differences between
this group and the other groups was significant (P<0.05).
Discussion
The results of the present study indicated that vestibular
stimulation in addition to sensory integrative therapy and
neurodevelopmental therapy was much more effective than
the sensory integrative therapy alone.
Children with Down syndrome have muscular hypotonia,
joint hypermobility and loss of balance.24–26 Connoly and
Michael examined the effects of hypotonicity on balance,
finding that the hypotonus, pelvic stability and pes planus
affect ability to balance.24 In the present study the mean
times of subjects’ ability to balance on one leg were found
to be low, at 7.73~0.87 s with eyes open, and 2.22~0.34 s
with eyes closed.24 In the present study subjects in all three
groups obtained low scores on the posture imitation test
which was used to assess praxis. In accordance with
previous studies, the results of study showed that children
with Down syndrome have motor planning impairment.
Children with Down syndrome suffer from loss of visual
motor control laterality, loss of balance and slow running
speed.3,27,28 In the present study, children in all three groups
obtained low scores on the DC test which was used to assess
visual motor co-ordination and visual perception. The mean
scores obtained were 3.22~0.60 out of a possible total of
26 points. The results of the present study support the results
of previous studies.
Studies in the published literature have shown that
different therapy programs have been used to facilitate
mental and motor developments. Sensory integrative therapy,
perceptual–motor training, neurodevelopmental therapy, vestibular stimulation and play therapy have been used either as
sole treatment programs or as combined programs according
to the necessity of the children with motor problems.4,15,29–31
Although there was a significant difference in DC and
posture imitation tests, in the first group who received
sensory integrative therapy alone there was not any
difference in locomotor skills and balance (P>0.05). In the
second group who received sensory integration and
vestibular stimulation, there was a significant difference in
all tests except for locomotor skill-side (P<0.05). In the
third group undergoing the neurodevelopmental therapy,
there were significant differences in all capabilities (P<0.05).
Kantner et al. have shown that effectiveness of the vestibular stimulation training has a positive effect on motor skills
in children with Down syndrome.12 Kelly described the effects
of rotational vestibular stimulation to increase gross motor
co-ordination in children and adults.32 Kelly showed that
rotational vestibular stimulation was effective in increasing
reflex integration, balance, intellectual functions, perception–
motor skills, hearing–language and socioemotional development.32 McLean and Baumeister examined the effects of
vestibular stimulation in two children with Down syndrome;
at the end of the training, it was seen that there was an
important improvement in arrangement and equilibrium
reactions.33 The results of the present study were similar to
the results of the other studies, showing the effectiveness of
vestibular stimulation in children with Down syndrome.
Neurodevelopmental therapy, proprioseptive neuromuscular
facilitation and sensory feedback techniques have been used
to develop the integration of postural responses.25,31 Harris
applied neurodevelopmental therapy according to the
individual needs of children with Down syndrome. Neurodevelopmental therapy was applied 3 days per week for 9
weeks. There was no significant difference between the
neurodevelopmental therapy group and the control group.15
Anderson et al. stated that play therapy in addition to
neurodevelopmental therapy developed cognitive and perceptual skills and was useful for increasing subjects’
motivation for participating in the therapy.34
Haley showed the effects of therapeutic and educational
programs and postural reactions stimulation in decreasing
motor retardation in babies with Down syndrome.35
In the present study, the neurodevelopmental therapy
group (group 3) showed an important improvement in
balance, visual motor co-ordination, praxis, fine motor and
locomotor skills after 3 months of therapy. When compared
with first and second group, the third group had much higher
scores in PPP, DC and LS. Because neurodevelopmental
therapy includes postural tonus, reflex reactions and movement patterns, the children in the third group showed greater
improvement of extensor hypotonus and joint stability. This
would have affected the PPP scores. The success in
locomotor skills and DC in the third group is due to the
inclusion of fine motor co-ordination and walking activities.
When all groups were compared, no significant difference
was found (P<0.05), except in BEOR, PPP and LS tests.
The tests have shown in that children with Down
syndrome have different problems in sensory integration,
vestibular system and motor functions. It was concluded that
each treatment program was effective in development
training of children with Down syndrome.
Down syndrome
Assessment of physical and cognitive features, improving
sensory–perceptual–motor dysfunction, developing balance,
improving fine and gross motor functions are important in
children with Down syndrome, because they can increase
independence in activities of daily living.
The results of the present study showed that sensory
integration, vestibular stimulation and neurodevelopmental
therapy were effective in children with Down syndrome.
Therefore, it was concluded that when designing rehabilitation
programs for children with Down syndrome, all treatment
methods should be applied in combination, and should support
each other according to the individual needs of the child.
Acknowledgments
The authors would like to acknowledge the contributions of
Prof. Meral Topçu, MD and Prof. Ergül Tunçbilek, MD, at
Hacettepe University, Turkey.
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