Informing Clinical Practice Guidelines for Children and Youth With Down Syndrome: A Survey of Key Partners.

PURPOSE: The purpose of this work was to describe input from key partners to inform the scope and priorities for a clinical practice guideline (CPG) pertaining to physical therapy services provided to children and youth with Down syndrome (DS). METHODS: A 68-item survey was completed by interventionists and parents (n = 296) of children and youth with DS. RESULTS: The most prevalent physical therapy interventions currently being performed included tummy time, postural control activities, activity-based interventions, and play-based interventions. Key partners agreed on the importance of specific clinical outcomes, needing guidance on frequency and dosage of interventions, common barriers to physical therapy intervention, and needing information for discharge criteria in a future CPG. CONCLUSIONS: The results of this survey have given the CPG committee the necessary information to inform the CPG process for children and youth with DS.

Leg Movement Rate Pre- and Post-Kicking Intervention in Infants with Down Syndrome.

AIM: Children with Down syndrome (DS) have delayed development and atypical movements including kicking. We hypothesized that a kicking intervention would significantly increase leg movement rate. METHODS: Nine infants, 3-5 months old, with DS used a commercially available toy that encouraged kicking. The intervention was administered in their home for 20 minutes, 5 days a week, for 8 weeks. Leg movement rate was measured using Opal wearable sensors before and after the intervention. At post-test, a secondary analysis compared infants with DS to infants with typical development (TD). RESULTS: Average leg movement rate increased significantly from pre to post intervention, from 2253 to 2645 movements per hour of awake time (p = 0.049). Compared to data from nine infants with TD, infants with DS had a significantly lower movement rate post intervention (p = 0.002). CONCLUSION: The infants with DS demonstrated a higher leg movement rate following an in-home kicking intervention.

Current Trends in Pediatric Physical Therapy Practice for Children With Down Syndrome.

BACKGROUND: Physical therapists (PTs) have a broad range of approaches to the management of Down syndrome (DS). PURPOSE: To examine the breadth of physical therapy practice for children with DS. METHODS: A survey was distributed to 1000 randomly selected members of the Academy of Pediatric Physical Therapy. DATA ANALYSIS: Responses were categorized into 13 thematic subcategories and 3 International Classification of Functioning, Disability and Health (ICF) subcategories. RESULTS AND DISCUSSION: One hundred eight PTs participated. Joint stability and alignment were the most common physical therapy-related problem. Functional movement was the most common physical therapy intervention. Most clinicians identified and treated at the ICF level of body functions and structure. Multiple assessment tools were used and tended to include norm-referenced tests. There was diversity of interventions with varying amounts of supporting evidence. CONCLUSIONS: PTs manage children with DS for a wide variety of needs with a variety of interventions.

Low-Intensity vs High-Intensity Home-Based Treadmill Training and Walking Attainment in Young Children With Spastic Diplegic Cerebral Palsy.

OBJECTIVE: To compare the effect of low-intensity (LI) vs high-intensity (HI) treadmill training (TT) on walking attainment and overall walking activity in children with cerebral palsy (CP). DESIGN: Prospective, multisite, randomized controlled trial. SETTING: Homes of the participants. PARTICIPANTS: Children with spastic diplegic CP, Gross Motor Function Classification System Level I and II, ages 14-32 months (N=19; male, n=8). INTERVENTIONS: The children were randomized to LI TT (2×/wk for 6wk) (n=10) and HI TT (10×/wk for 6wk) (n=9). The TT was carried out by the families with weekly instruction by the researchers. MAIN OUTCOME MEASURES: Children were assessed at study onset, post intervention, and 1 and 4 months post intervention with the Gross Motor Function Measure Dimension D/E (GMFM D/E), average strides per day and percentage of time spent walking with accelerometers, the Peabody Developmental Motor Scales-2 (PDMS-2), Pediatric Evaluation of Disability Index Mobility Scale, timed 10-m and 1-minute walk test, and Functional Mobility Scale. Blinding was conducted for GMFM D/E and PDMS-2. Linear mixed effects regression models were applied to all outcomes. RESULTS: No significant between-group differences were found in any outcome measure at any of the time points. Children in the HI group did not show significant improvement immediately following the intervention in GMFM E (P=.061), while children in the LI group did (P=.003), but no statistically significant differences were detected over time (P=.71). Children in the HI group showed better walking independence on the Functional Mobility Scale at all postintervention assessments. CONCLUSIONS: A twice-weekly dosage was equally effective in improving skills related to walking compared with a 10×/wk program and can be more readily implemented into clinical practice.

Embedding Play to Enrich Physical Therapy.

Play is an active process by which an individual is intrinsically motivated to explore the self, the environment, and/or interactions with another person. For infants and toddlers, engaging in play is essential to support development across multiple domains. Infants and toddlers with or at risk of motor delays may demonstrate differences in play or challenges with engaging in play activities compared to typically developing peers. Pediatric physical therapists often use play as a modality to engage children in therapeutic assessment and interventions. Careful consideration of the design and use of physical therapy that embeds play is needed. Following a 3-day consensus conference and review of the literature, we propose physical therapy that embeds play should consider three components; the child, the environment, and the family. First, engage the child by respecting the child's behavioral state and following the child's lead during play, respect the child's autonomous play initiatives and engagements, use activities across developmental domains, and adapt to the individual child's needs. Second, structure the environment including the toy selection to support using independent movements as a means to engage in play. Allow the child to initiate and sustain play activities. Third, engage families in play by respecting individual family cultures related to play, while also providing information on the value of play as a tool for learning. Partner with families to design an individualized physical therapy routine that scaffolds or advances play using newly emerging motor skills.

What to measure when determining orthotic needs in children with Down syndrome: a pilot study.

PURPOSE: To compare the effects of off-the-shelf foot orthoses and supramalleolar orthoses on the gait of children with Down syndrome (DS), and establish criteria for determining orthoses prescription for a child with DS. METHODS: We assessed the gait of 6 children (aged 4-7 years) with DS using the GAITRite system, and obtained height, weight, leg length, hypermobility, calcaneal eversion, navicular drop, and tibial torsion measurements. RESULTS: Supramalleolar orthoses lead to a longer cycle time than foot orthoses (P = .05) and barefoot walking (P = .03) and a lower cadence than barefoot walking (P = .04). Significant strong correlations with gait parameters were obtained for height, leg length, and hypermobility. Biomechanical measurements showed no significant correlations with gait parameters. CONCLUSIONS: The role of physical examination data, including anthropometric and biomechanical measurements in the prescription of orthoses requires further investigation.

Does orthotic use affect upper extremity support during upright play in infants with down syndrome?

PURPOSE: To determine whether supramalleolar orthoses use during upright play contributes to decreased upper extremity support in infants with Down syndrome. METHOD: Seventeen children with Down syndrome were assigned to 2 groups. Infants in the control group received treadmill training. Infants in the experimental group wore supramalleolar orthoses in addition to treadmill training. The participants were followed every other month from pull to stand until independent walking. Each child was videotaped playing at a table for 20 minutes. Researchers coded the tapes to determine whether the child's trunk was leaning or not and whether he or she was using 0, 1, or 2 hands for support. RESULTS: No group differences were found in hand support during time in the upright position. All children decreased the amount of 2-hand support over time (P = .05). CONCLUSION: The use of supramalleolar orthoses may improve upright stability but it does not decrease upper extremity support in infants with Down syndrome.

Promoting Participation in Physical Activity in Children and Adolescents With Down Syndrome.

Children with Down syndrome (DS) often have lower physical activity (PA) levels compared with their peers with typical development, and face challenges to being physically active such as medical comorbidities, access issues, and societal stigma. Physical therapists are experts in exercise prescription and PA and are thus uniquely qualified to successfully promote participation in children with DS, in spite of inherent challenges. Our perspective is that a shift in physical therapy service delivery is needed. We suggest that physical therapists change the focus of their interventions for children with DS from underlying impairments such as low tone or joint laxity or from developing motor skills in isolation and "correct" movement patterns. Instead, physical therapists should allow the PA preferences and the environmental contexts of the children and adolescents they are working with to direct the treatment plan. In this way, physical therapist intervention becomes more child centered by concentrating on developing the specific skills and strategies required for success in the child's preferred PA. In this article, we consider the role of pediatric physical therapists in the United States, as well as in low- and middle-income countries, in promoting and monitoring PA in children with DS from infancy through adolescence. Examples of physical therapist interventions such as tummy time, movement exploration, treadmill training, bicycle riding, and strength training are discussed, across infancy, childhood, and adolescence, with a focus on how to successfully promote lifelong participation in PA. LAY SUMMARY: Physical therapists are experts in exercise and physical activity and are thus uniquely qualified to promote participation in children with Down syndrome. Instead of focusing on impairments or "correct" movement patterns, physical therapists are encouraged to allow the child and the child's environment to direct the treatment plan.

Strategy adoption and locomotor adjustment in obstacle clearance of newly walking toddlers with Down syndrome after different treadmill interventions.

This study investigated how newly walking toddlers with Down syndrome (DS), after different treadmill interventions, adopted clearance strategies and modified anticipatory locomotor adjustment patterns to negotiate an obstacle in their travel path. Thirty infants with DS (about 10 months of age) were recruited and randomly assigned to either a lower-intensity, generalized (LG) treadmill training group, or a higher-intensity, individualized (HI) treadmill training group. Thirteen in each group completed a one-year-gait follow-up after the treadmill intervention. Initially, both groups chose to either crawl or walk over an obstacle. However, walking over the obstacle became their preferred clearance strategy over the course of the gait follow-up even though the height of the obstacle increased from visit to visit. The HI group used the strategy of walking over the obstacle at a considerably higher percentage than the LG group within 6 months after the training. When approaching the obstacle, both groups started to show consistent anticipatory locomotor adjustments about 6 months after the training. Both groups decreased velocity, cadence and step length, and increased step width at the last three pre-obstacle steps. It was concluded that the retention of the HI training effects led the HI group to predominantly walk over an obstacle earlier than the LG group within 6 months after treadmill intervention, and the two groups produced similar anticipatory locomotor adjustments in the last three steps before negotiating the obstacle.

Effects of intensity of treadmill training on developmental outcomes and stepping in infants with Down syndrome: a randomized trial.

BACKGROUND AND PURPOSE: Infants with Down syndrome (DS) are consistently late walkers. The purpose of this investigation was to test the effects of individualized, progressively more intense treadmill training on developmental outcomes in infants with DS. SUBJECTS: Thirty infants born with DS were randomly assigned to receive lower-intensity, generalized treadmill training or higher-intensity, individualized training implemented by their parents in their homes. METHODS: Research staff members monitored implementation of training, physical growth, and onset of motor milestones of all infants on a monthly basis. RESULTS: Infants in the higher-intensity, individualized training group increased their stepping more dramatically over the course of training. Infants in the higher-intensity training group attained most of the motor milestones at an earlier mean age. DISCUSSION AND CONCLUSION: Treadmill training of infants with DS is an excellent supplement to regularly scheduled physical therapy intervention for the purpose of reducing the delay in the onset of walking.

Changes in step variability of new walkers with typical development and with Down syndrome.

Models of human gait are based on adult locomotion. C. E. Bauby and A. D. Kuo (2000) proposed that adults rely on passive mechanisms at the spinal level to control motion in the anteroposterior direction and rely on direct monitoring of postural control in the lateral direction. The authors' purpose in this study was to determine if that model applies to control at the onset of walking in typically developing toddlers (n = 9) and in toddlers with Down syndrome (n = 6). Their longitudinal data suggested that toddlers control gait in a distinctly different manner than adults do. An adult pattern of control emerges with experience. In addition, the effect of experience on the emergence of that pattern is magnified by task-specific early intervention. The present data support the emergence and discovery of efficient patterns of control in this fundamental human behavior.

The relationship between transitional motor skills and locomotion.

This study explores whether transitional skills and sitting correlate with locomotion onset. The development of eight infants was followed. Most transitional skills correlated with locomotor skills. Sitting and rolling did not. Transitional skills may resemble the control needed for locomotion more closely than sitting.

How do toddlers increase their gait velocity?

This study examines the components of the development of velocity during early walking. Eight children with typical development were followed during their first 5 months of walking experience. Velocity, cadence, and step length were measured. Normalized step length did not change over this time, however, normalized cadence increased. This indicates that an increase in cadence is contributing to early increases in walking velocity.

Effect of treadmill training and supramalleolar orthosis use on motor skill development in infants with Down syndrome: a randomized clinical trial.

BACKGROUND: Children with Down syndrome (DS) often display delayed onset of independent walking. Treadmill training is an effective intervention that leads to an earlier walking onset. In addition, orthoses often are provided to infants with DS to increase stability and promote earlier independent walking. However, this early use of orthoses has not been scientifically verified in infants with DS. OBJECTIVE: The purpose of this study was to provide insight into the developmental outcomes of early orthosis use in combination with treadmill training in infants with DS compared with treadmill training alone. DESIGN: This study was a randomized controlled trial. SETTING: This study was conducted in participants' homes and in the motor development laboratory. PARTICIPANTS AND INTERVENTION: Seventeen infants with DS entered the study when they could pull themselves to a standing position. They were randomly assigned to either a control group (which received treadmill training) or an experimental group (which received treadmill training and orthoses). During monthly visits to the infants' homes, 3 minutes of treadmill stepping was recorded and each child's motor development skills were tested. The treadmill training ended once the child took 3 independent steps. One month following walking onset, developmental tests were readministered. MEASUREMENTS: The Gross Motor Function Measure (GMFM) was used to test motor skill development. RESULTS: The average (SD) time in the study was 268 (88) days for the control group and 206 (109) days for the experimental group. All infants showed significantly increased GMFM scores over time. At 1 month of walking experience, the control group had higher GMFM scores than the experimental group, with higher standing and walking, running, and jumping subscale scores. LIMITATIONS: Limitations of this study included a small sample of convenience, a statistical model that may have reduced validity at the tail end, and a lack of blinding in the GMFM scorer. CONCLUSIONS: Orthoses may have a detrimental effect on overall gross motor skill development.

Effects of various treadmill interventions on the development of joint kinematics in infants with Down syndrome.

BACKGROUND: Infants with Down syndrome (DS) have delayed walking and produce less-coordinated walking patterns. OBJECTIVE: The aim of this study was to investigate whether 2 treadmill interventions would have different influences on the development of joint kinematic patterns in infants with DS. DESIGN: Thirty infants with DS were randomly assigned to a lower-intensity, generalized (LG) treadmill training group (LG group) or a higher-intensity, individualized (HI) treadmill training group (HI group) and trained until walking onset. Twenty-six participants (13 in each group) completed a 1-year gait follow-up assessment. METHODS: During the gait follow-up assessment, reflective markers were placed bilaterally on the participants to measure the kinematic patterns of the hip, knee, and ankle joints. Both the timing and the magnitude of peak extension and flexion at the hip, knee, and ankle joints, as well as peak adduction and abduction at the hip joint, in the 2 groups were compared. RESULTS: Both the LG group and the HI group showed significantly advanced development of joint kinematics at the gait follow-up. In the HI group, peak ankle plantar flexion occurred at or before toe-off, and the duration of the forward thigh swing after toe-off increased. LIMITATIONS: Joint kinematics in the lower extremities were evaluated in this study. It would be interesting to investigate the effect of treadmill interventions on kinematic patterns in the trunk and arm movement. CONCLUSIONS: The timing of peak ankle plantar flexion (before toe-off) in the HI group implies further benefits from the HI intervention; that is, the HI group may use mechanical energy transfer better at the end of stance and may show decreased hip muscle forces and moments during walking. It was concluded that the HI intervention can accelerate the development of joint kinematic patterns in infants with DS within 1 year after walking onset.

Exploring effects of different treadmill interventions on walking onset and gait patterns in infants with Down syndrome.

Two cohorts of participants were included to investigate the effects of different treadmill interventions on walking onset and gait patterns in infants with Down syndrome (DS). The first cohort included 30 infants with DS (17 males, 13 females; mean age 10 mo [SD 1.9 mo]) who were randomly assigned to either a lower-intensity-generalized (LG) training group, or a higher-intensity-individualized (HI) training group. A control (C) group from another study, who did not receive treadmill training, served as the control (eight males, seven females; mean age 10.4 mo [SD 2.2 mo]). Mean age at walking onset was 19.2, 21.4, and 23.9 months for the HI, LG, and C groups respectively. At walking onset the HI group was significantly younger than the C group (p=0.011). At the gait follow-up that was conducted between 1 and 3 months after walking onset, three groups significantly different in overall gait patterns (p=0.037) were examined by six basic gait parameters including average velocity, stride length, step width, stride time, stance time, and dynamic base. Post-hoc analyses demonstrated that stride length was the gait parameter largely contributing to this overall group difference (p=0.033), and the HI group produced a significantly longer stride length than the C group (p=0.030). In conclusion, the HI treadmill intervention significantly promoted earlier walking onset and elicited more advanced gait patterns (particularly in stride length) in infants with DS.