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 cerebral and brain stem neurones, and a reduction in both
effect on motor development of children. Neuromuscular the number and connections of neurones in higher nervous
abnormalities in children with Down syndrome, which have centers, such as the motor cortex, basal ganglia, cerebellum
been observed to be coincident with developmental delays, and brain stem. Based on behavioral observations of develop-
include generalized muscular hypotonia, the persistence of mental delay, clinicians have conducted a number of research
primitive reflexes beyond their normal disappearance with projects involving early therapeutic intervention for children
age, and slowed reaction times during voluntary movement.1,2 with Down syndrome. These studies have attempted to
Children with Down syndrome have a predominance of facilitate normal mental and motor development through a
primitive, spinally controlled muscle response patterns over variety of stimulation techniques, with mixed results.2–4
more centrally integrated and co-ordinated movement Automatic postural reactions are considered to be essential
patterns. This is due to poor myelination of the descending 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
Correspondence: Gonca Bumin, PT, PhD, Assist. Prof. Hacettepe syndrome have delayed motor development, including a
University, School of Physical Therapy and Rehabilitation, 06100
Samanpazarı-Ankara, Turkey. Email: gbumin@hacettepe.edu.tr delay in postural reactions.6
Received 10 July 2001; revised 12 June 2002; accepted 12 July When motor development of a child with Down syndrome
2002. is compared with that of a developmentally normal child, a
 Down syndrome 69

consistent delay is observed in the acquisition of both Ayres Southern California Sensory Integration Tests
postural and voluntary components of motor control.7,8 (SCSIT) was used to assess sensory integration problems.
The vestibular system plays a major role in the expression Design copying (DC), imitation of posture (IP), and standing
of early motor behavior. Previous research has cited extensive balance on right and left foot–eyes open and closed (BEOR-
neural connections between the vestibular apparatus and the L, BECR-L) subtests of SCSIT were used.17 Pivot prone
motor system.9 position test (PPP), hypotonicity of extensor muscles, joint
Children with Down syndrome have sensory integrative stability (co-contraction) and gravitational insecurity tests
dysfunction as a result of limited sensory experience from were used to assess the vestibular system.18 Automatic move-
lack of normal motor control. Physical, cognitive and ment reactions were used to assess reflex development.
sensory integration problems decrease the functional ability Locomotor skills, ten step forward walking (LS-f) and ten
of children in activities of daily living.9–11 Neurodevelop- step sideways walking (LS-s), were tested. A pegboard test
mental approaches, sensory integrative therapy and vestibular was used to assess fine motor skills of the hand.19
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 Test definitions
of sensory integrative therapy alone, vestibular stimulation in
addition to sensory integrative therapy and neurodevelop- Pivot prone position test (PPP)
mental therapy in children with Down syndrome.
While in the prone position, the child was asked to perform
head, trunk and hip extensions. The maintenance time of
Methods this position was recorded with a stopwatch. The quality of
response was graded, with the following responses each
Participants receiving one point using the following parameters:
(Children aged 6 years and older who were able to maintain
This study was carried out at the Occupational Therapy the position for 30 s would obtain a quality score of 6)
Unit, School of Physical Therapy and Rehabilitation of • Position assumed smoothly, quickly, and nonsegmentally
Hacettepe University. Forty-five children with Down syndrome • Head position held steadily and within 45º of vertical
diagnosed by the Departments of Paediatric Neurology and • Upper trunk (shoulders, chest and arms) raised off floor,
Medical Genetics were included in the study. They were arms abducted and externally rotated approximately 90º,
assigned into three groups according to the date of admit- elbows flexed approximately 90º
tance to our clinic. Pre-school children were not included in • Distal one third of thigh raised far enough off floor to
the study because it may be difficult for these children to allow examiner to place fingers between distal thigh and
cooperate with the sensory integration and other tests. To floor, knees can be flexed
provide homogeneity between groups and to ensure co- • Knees flexed 30º or less, thighs do not have to be off
operation of the children with these tests, an age range floor, but feet cannot touch floor
between 7 and 10 years was selected. • Able to talk in this position
Children with complications were examined. None of the
children had a history of epilepsy. There were two children
Hypotonia of extensor muscles
with congenital heart disease in the first group, two in the
second group and three in the third group. All children with
Hyperextensibility of distal joints, hypotonic posture in
congenital heart disease had been previously operated on.
standing, including lordosis and hyperextended and/or locked
The children’s complications were not severe, so their
knees and muscle tone by palpation were tested.
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 Joint stability (co-contraction test)
spinal cord compression in his computerized tomography
and developmental milestones of skills were not influenced. Quadripedal position was used for this test. Head neutral,
Sensory integrative therapy was applied to the first group, hip, shoulder and knees 90º flexion, fingers extension,
vestibular stimulation and sensory integrative therapy were elbows semiflexion and straight back were accepted as the
applied to the second group and neurodevelopmental therapy normal position. While the children were in this position, the
was applied to the third group. We did not establish a control presence of lordosis, hyperextension, rising medial side and
group in this study because withholding treatment from inferior angulus of scapula and excessive scapular adduction
these children would not be ethical. were assessed.
70 M Uyangk et al.

Gravitational insecurity Table 1 The demographic characteristics of all subjects

Gravitational insecurity was assessed according to the Groups No. subjects Age (years)
Total Female Male (mean~SD)
emotional reactions to vestibular stimuli on the tilt board.
Group 1 15 7 8 9.60~0.51
Automatic movement reactions Group 2 15 6 9 8.67~0.45
Group 3 15 7 8 8.53~0.50
Protective extension and equilibrium reactions were scored
as negative or positive in standing and kneeling position.
3. Reducing gravitational insecurity: Self-initiated linear
Locomotor skill tests
vestibular stimulation in non-threatening positions with
speeds and durations tolerable to the children.18
The time of ten step forward walking (LS-f) and ten step
sideways walking (LS-s) on a straight line were recorded. Group 3: Neurodevelopmental therapy

Pegboard test
Included following activities:
1. Tonic postural extensor muscle strengthening: Push-pull
The time of placing 20 pegs was recorded for both hands.
scooter board games against resistive tubing strips, move
While the treatment program was applied, a sequence of different ways using dowels, and basketball drop games.
normal motor development was followed. The therapy 2. Developmental movement patterns training: Obstacle
progression was done step by step, from simple to complex, crawl, hold swing’s ropes in kneeling and half kneeling
and until the skills at one stage were achieved, there was no position, throw balls to targets in kneeling and standing
progression to the next stage. position.
3. Walking activities: Forward, backward and sideways walk,
Groups animal walks (like crab and cat), line walks and stepping-
stones.
Group 1: Sensory integrative therapy 4. Fine motor activities: Cutting with scissors, copying
designs, chalkboard activities, working different cubes and
The following activities were completed by group 1: pegboard designs.22,23
1. Visual perception activities: Block design, finding shapes Treatment programs were applied for 1.5 hours a day, 3
in pictures, puzzles, matching geometric shapes and letters, days per week for 3 months. The home program was given
numbers, and classification. to all groups. All subjects were assessed at the beginning of
2. Body awareness: Pointing to the body parts, life-size the therapy and after 3 months.
drawing, turning left and right side and awareness of the
body parts through touch. Statistical analysis
3. Tactile perception: Feeling various textures, touching
boards and feeling shapes. Descriptive statistics, ANOVA and McNemar Test were applied
4. Visual-motor co-ordination training: Ocular-pursuit training, to gained scores in order to compare the three groups. The
moving ball and pegboard activities.14,20,21 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 Table 1 summarizes the demographic characteristics of the
group. These included: subjects. The children’s age range was between 7 and 10
1. Linear swinging: With platform swing in standing and years. The mean~SD age of the children was 9.60~0.51
kneeling position, with T-swing and platform swing in years in the first group; 8.67~0.45 years in the second
sitting position, with platform swing quadruped position and group; and 8.53~0.50 years in the third group.
with platform swing in prone and supine positions. In order to investigate whether there was a difference
2. Developing equilibrium reactions: Push-pull and move- among groups pre-treatment, ANOVA was performed. When
ment of the support surface on tilt board on sitting and compared to pre-treatment test values, there was no
standing position, activities on therapy ball in prone significant difference between the three groups in all tests
position, active maintenance of balance on stairs and ramps. (Table 2).
 Down syndrome 71

Table 2 Comparison of pretreatment evaluations Table 3 Comparison of differences between groups

Score ANOVA Score ANOVA

Tests mean SD F P Tests mean SD F P

Balance eyes closed (right) Balance eyes closed (right)

Group 1 2.00 3.74 Group 1 1.33 2.64
Group 2 2.47 2.44 0.12 >0.05 Group 2 2.40 1.80 1.02 >0.05
Group 3 2.46 2.72 Group 3 1.80 1.57
Balance eyes closed (left) Balance eyes closed (left)
Group 1 1.27 1.38 Group 1 1.53 2.13
Group 2 1.35 1.24 0.62 >0.05 Group 2 2.20 1.52 0.52 >0.05
Group 3 1.40 1.41 Group 3 2.00 1.81
Balance eyes open (right) Balance eyes open (right)
Group 1 6.93 4.28 Group 1 2.60 2.75
Group 2 7.20 5.44 0.52 >0.05 Group 2 10.33 10.76 4.40 <0.05*
Group 3 8.00 6.24 Group 3 6.13 5.46
Balance eyes open (left) Balance eyes open (left)
Group 1 5.80 4.85 Group 1 3.47 7.76
Group 2 6.13 4.77 0.34 >0.05 Group 2 8.93 11.13 1.80 >0.05
Group 3 6.40 4.65 Group 3 4.87 4.17
Pivot prone position (time) Pivot prone position (time)
Group 1 21.06 12.08 Group 1 5.87 12.96
Group 2 20.86 15.43 0.06 >0.05 Group 2 14.13 13.21 2.61 >0.05
Group 3 22.73 18.79 Group 3 6.00 6.70
Pivot prone position (score) Pivot prone position (score)
Group 1 4.20 0.77 Group 1 0.33 0.62
Group 2 4.00 1.19 0.84 >0.05 Group 2 0.80 0.77 3.26 <0.05*
Group 3 3.60 1.25 Group 3 1.07 0.96
Design copying Design copying
Group 1 4.00 3.54 Group 1 1.93 3.37
Group 2 3.40 2.66 0.59 >0.05 Group 2 1.67 1.68 0.52 >0.05
Group 3 3.26 3.36 Group 3 2.53 1.73
Imitation of posture Imitation of posture
Group 1 10.27 5.90 Group 1 1.87 1.30
Group 2 13.20 6.49 1.15 >0.05 Group 2 3.27 2.63 2.50 >0.05
Group 3 10.67 4.62 Group 3 1.80 1.93
Locomotor skills (front) Locomotor skills (front)
Group 1 6.93 1.87 Group 1 0.60 0.83
Group 2 6.27 2.15 0.86 >0.05 Group 2 1.13 0.74 6.69 <0.05*
Group 3 7.13 1.64 Group 3 1.73 0.96
Locomotor skills (side) Locomotor skills (side)
Group 1 8.67 2.47 Group 1 0.93 1.75
Group 2 8.45 1.72 0.12 >0.05 Group 2 1.33 1.40 0.30 >0.05
Group 3 8.73 1.62 Group 3 .20 1.08
Peg right hand Peg right hand
Group 1 302.80 9.61 Group 1 28.40 35.23
Group 2 345.06 7.56 0.96 >0.05 Group 2 30.67 40.02 0.12 >0.05
Group 3 298.13 8.66 Group 3 24.87 17.98
Peg left hand Peg left hand
Group 1 313.80 7.78 Group 1 17.53 18.57
Group 2 329.06 8.94 0.39 >0.05 Group 2 41.20 54.18 1.72 >0.05
Group 3 342.86 9.18 Group 3 27.40 20.23

*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. In the second group (sensory integrative therapy and
When pre and post-test values of the first group (sensory vestibular stimulation), significant improvements were
integrative therapy) were compared, results indicated a observed in sensory integrative subtests, vestibular system,
statistically significant improvement only in sensory fine hand skills, reflex development and gravitational
integration subtests and fine motor skills (P<0.05). insecurity (P<0.05).
72 M Uyangk et al.

In the third group (neurodevelopmental therapy), there vestibular stimulation, there was a significant difference in
were significant differences in all capabilities (P<0.05). all tests except for locomotor skill-side (P<0.05). In the
In BEOR, PPP-s and LS-f tests, there were significant third group undergoing the neurodevelopmental therapy,
differences among all three groups, while in other tests there there were significant differences in all capabilities (P<0.05).
was not a significant difference. Kantner et al. have shown that effectiveness of the vesti-
The children in the first group had lower scores in all bular stimulation training has a positive effect on motor skills
tests except DC and pegboard tests, than the second and in children with Down syndrome.12 Kelly described the effects
third groups. The children in the second group had higher of rotational vestibular stimulation to increase gross motor
scores in all tests except PPP-s, DC and LS-f than the other co-ordination in children and adults.32 Kelly showed that
groups, but those scores were not statistically significant rotational vestibular stimulation was effective in increasing
(P>0.05). The children in the third group have higher reflex integration, balance, intellectual functions, perception–
scores in PPP-s, DC, and LS-f tests. The differences between motor skills, hearing–language and socioemotional develop-
this group and the other groups was significant (P<0.05). ment.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
Discussion important improvement in arrangement and equilibrium
reactions.33 The results of the present study were similar to
The results of the present study indicated that vestibular the results of the other studies, showing the effectiveness of
stimulation in addition to sensory integrative therapy and vestibular stimulation in children with Down syndrome.
neurodevelopmental therapy was much more effective than Neurodevelopmental therapy, proprioseptive neuromuscular
the sensory integrative therapy alone. facilitation and sensory feedback techniques have been used
Children with Down syndrome have muscular hypotonia, to develop the integration of postural responses.25,31 Harris
joint hypermobility and loss of balance.24–26 Connoly and applied neurodevelopmental therapy according to the
Michael examined the effects of hypotonicity on balance, individual needs of children with Down syndrome. Neuro-
finding that the hypotonus, pelvic stability and pes planus developmental therapy was applied 3 days per week for 9
affect ability to balance.24 In the present study the mean weeks. There was no significant difference between the
times of subjects’ ability to balance on one leg were found neurodevelopmental therapy group and the control group.15
to be low, at 7.73~0.87 s with eyes open, and 2.22~0.34 s Anderson et al. stated that play therapy in addition to
with eyes closed.24 In the present study subjects in all three neurodevelopmental therapy developed cognitive and per-
groups obtained low scores on the posture imitation test ceptual skills and was useful for increasing subjects’
which was used to assess praxis. In accordance with motivation for participating in the therapy.34
previous studies, the results of study showed that children Haley showed the effects of therapeutic and educational
with Down syndrome have motor planning impairment. programs and postural reactions stimulation in decreasing
Children with Down syndrome suffer from loss of visual motor retardation in babies with Down syndrome.35
motor control laterality, loss of balance and slow running In the present study, the neurodevelopmental therapy
speed.3,27,28 In the present study, children in all three groups group (group 3) showed an important improvement in
obtained low scores on the DC test which was used to assess balance, visual motor co-ordination, praxis, fine motor and
visual motor co-ordination and visual perception. The mean locomotor skills after 3 months of therapy. When compared
scores obtained were 3.22~0.60 out of a possible total of with first and second group, the third group had much higher
26 points. The results of the present study support the results scores in PPP, DC and LS. Because neurodevelopmental
of previous studies. therapy includes postural tonus, reflex reactions and move-
Studies in the published literature have shown that ment patterns, the children in the third group showed greater
different therapy programs have been used to facilitate improvement of extensor hypotonus and joint stability. This
mental and motor developments. Sensory integrative therapy, would have affected the PPP scores. The success in
perceptual–motor training, neurodevelopmental therapy, vesti- locomotor skills and DC in the third group is due to the
bular stimulation and play therapy have been used either as inclusion of fine motor co-ordination and walking activities.
sole treatment programs or as combined programs according When all groups were compared, no significant difference
to the necessity of the children with motor problems.4,15,29–31 was found (P<0.05), except in BEOR, PPP and LS tests.
Although there was a significant difference in DC and The tests have shown in that children with Down
posture imitation tests, in the first group who received syndrome have different problems in sensory integration,
sensory integrative therapy alone there was not any vestibular system and motor functions. It was concluded that
difference in locomotor skills and balance (P>0.05). In the each treatment program was effective in development
second group who received sensory integration and training of children with Down syndrome.
 Down syndrome 73

Assessment of physical and cognitive features, improving performance in the developmentally delayed infant. Phys. Ther.
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children with Down syndrome, because they can increase and perceptual–motor training in treating children with
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integration, vestibular stimulation and neurodevelopmental Disabilities, Houghton Miftlin, Boston, 1985: 264–307.
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18 Payton OD. Vestibular stimulation in the treatment of postural
Acknowledgments and related deficits. In: Fisher AG, Bundy AC (eds). Manual of
Physical Therapy, Churchill Livingstone, New York, 1989; 239–58.
19 Trombly CA, Scott AD. Evaluation of motor control. In:
The authors would like to acknowledge the contributions of
Trombly CA (ed). Occupational Therapy for Physical Dys-
Prof. Meral Topçu, MD and Prof. Ergül Tunçbilek, MD, at function, Williams & Wilkins, Baltimore, 1989; 55–71.
Hacettepe University, Turkey. 20 Ayres AJ. Sensory Integration and Learning Disorders,
Western Psychological Services, Los Angeles, 1972.
21 Ayres AJ. Sensory Integration and the Child, Western Psycho-
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