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Objective: The aim of the study was to determine the effect of exercise training
on strength and balance in children with Downs syndrome.
Design: Randomized controlled trial.
Setting: Rehabilitation school for special children.
Subjects and intervention: Twenty-three children were randomized to intervention
and control group. The intervention group (n 12) underwent progressive resistive
exercises for lower limbs and balance training for six weeks. The control group
continued their regular activities followed at school.
Outcome measure: A handheld dynamometer was used to measure the lower
limb muscle strength. Balance was assessed by the balance subscale of Bruininks
Oseretsky Test of Motor Proficiency (BOTMP).
Results: Following the training, the children in the intervention group showed a statistically significant improvement (P50.05) in the lower limb strength of all the
muscle groups assessed. The strength of knee extensors was 12.12 lbs in the control group versus 18.4 lbs in the experimental group; in hip flexors it was 12.34 lbs
in the control group versus 16.66 lbs in the experimental group post-intervention.
The balance of the children also improved significantly with an improvement in
scores of the balance subscale of BOTMP (19.50 in the experimental group versus
9.00 in the control group, P 0.001).
Conclusion: This study suggests that a specific exercise training programme may
improve the strength and balance in children with Downs syndrome
Introduction
Downs syndrome is a genetic disorder attributed
to chromosomal abnormality (Trisomy 21).
Global estimation of the incidence of the condition
is 1 in 1,000 to 1 in 1,200 live births.1 Downs
syndrome is characterized by several clinical
Address for correspondence: Sukriti Gupta, Sardar Bhagwan
Singh Post Graduate Institute of Biomedical Sciences,
Balawala, Dehradun, India.
e-mail: sukritigupta22@gmail.com
10.1177/0269215510382929
426
S Gupta et al.
that children with Downs syndrome scored significantly lower in the balance subset than the
comparison group.
Balance training in children with Downs
syndrome has been studied by Wang et al.17 who
implemented a programme of vertical and
horizontal jump training for 14 children with
Downs syndrome and children with mental
retardation without Downs syndrome for six
weeks and noted significant improvement in the
balance scores as measured by balance sub-test
in the BOTMP. However, this study was not
done exclusively on children with Downs
syndrome so the results cannot be generalized
since other studies show that children with
Downs syndrome score lower than children with
mental retardation without Downs syndrome
in the balance subset of BOTMP.9 There is no
conclusive evidence on the effect of strength and
balance training in children with Downs
syndrome. So, the aim of this study was to determine the effect of a strength and balance training
programme in these children
Methods
Children (n 28) with a medical diagnosis of
Downs syndrome were recruited from two
schools. The inclusion criteria were: children
between the age of 7 to 15 years, ability to understand simple instructions and ability to stand and
walk independently. The exclusion criteria were:
associated cardiovascular condition and loss
of functional vision and hearing. Out of the
28 children, 23 met the study criteria. The study
was approved by the ethical committee. Informed
consent was taken from all parents/guardians.
The anthropometric details (height and weight)
were recorded. Height was measured with the
shoes removed using a metal tape measure.
Weighing scale was used to measure the weight.
The IQ level was determined using the Binet
kamat test18 administered by a clinical psychologist. This test is the Indian adaptation of the 1934
version of the StanfordBinet Scale test and has
been used in Downs syndrome.19
Handheld dynamometer (HHD) was used to
measure the strength of hip flexors, hip abductors,
427
Results
A total of 28 children were screened, of which
23 met the inclusion criteria and were included in
the study. The anthropometric details of the
children are described in Table 1. Twelve children
were randomly allocated to the experimental
group and 11 were in the control group. Figure 1
demonstrates the progress through trial. All the
participants in the intervention group completed
the exercise protocol successfully.
Strength
Table 2 demonstrates the strength values of the
muscles in the experimental and control groups at
baseline (pre) and following the six week intervention (post) and also the change in the values
following the intervention. Analysis between the
groups revealed that following the intervention,
the experimental and the control group were
statistically different (P50.05) in terms of the
strength in all the muscle groups.
428
S Gupta et al.
Table 1
Baseline characteristics
Characteristics
Gender
Age (yrs)*
IQ
Weight (kg)*
Height (cms)*
M 6, F 5
13.00 (10.0014.00)
3849
23.94 (1134)
137.34 (106152)
M 8, F 4
13.50 (11.2514.00)
3652
28.47 (1340)
132.18 (112143)
*mean (range).
Experimental group
(n =12)
Flow diagram.
429
Pre-post values and change in the strength of lower limb muscles in the experimental and control group
Muscle group
Hip flexors
Pre
Post
Hip extensors
Pre
Post
Hip abductors
Pre
Post
Knee flexors
Pre
Post
Knee extensors
Pre
Post
Ankle plantarflexor Pre
Post
15.31
16.66
10.57
13.66
11.09
14.39
13.44
15.74
13.77
18.41
11.13
13.94
(12.2418.72)
(14.1720.20)
(9.2414.26)
(10.2716.30)
(7.9115.31)
(9.1416.73)
(10.7015.20)
(12.0618.79)
(9.8617.95)
(15.2119.61)
(9.2118.62)
(12.7819.07)
Control
Change
Median (range)
Pre
Post
Pre
(0.263.24)
Post
Pre
(0.533.9)
Post
Pre
(0.193.98)
Post
Pre
(0.445.15)
Post
Pre
(0.171.54) Post
1.74 (0.953.5)
2.37
0.95
1.39
2.54
0.38
12.30 (10.3518.73)
12.34 (10.5417.19)
10.70 (8.5913.66)
10.34 (7.7112.85)
9.91 (6.6111.60)
9.76 (6.1711.78)
11.24 (9.1015.20)
12.34 (9.4515.65)
10.80 (8.8015.64)
12.12 (9.9213.00)
10.57 (6.1713.66)
12.32 (6.3913.88)
Change#
p*
0.001
0.01 (0.480.25)
0.002
0.50 (0.660.44)
0.001
0.22 (0.440.13)
0.03
0.24 (0.800.87)
0.01
0.54 (0.221.09)
0.02
0.22 (0.220.88)
Balance
Similarly, for the scores of BOTMP, the total
score of the balance subset increased from 10.50
(8.0015.50) to 19.50 (16.2524.00) in the experimental group as documented in Table 3. When
analyzing the scores of the control and the experimental group following the intervention period,
they were statistically different except in three
components: walking on a line, standing on a balance beam with eyes closed and stepping over a
response stick on the balance beam. Overall, there
was a statistically significant difference (P 0.007)
in the overall scores between the two groups.
Discussion
The main finding of this study is that following six
weeks of an exercise training programme the
children with Downs syndrome were able to
improve the strength of the lower limb muscles
and overall balance when compared to the control
group. Following the intervention, the strength of
all the muscle groups measured improved. This
indicates that a six week protocol was sufficient
to produce a statistically significant difference.
However, clinically the improvement in strength
was 1.74 (0.533.61) lbs. This low difference can
be due to a number of reasons. Firstly, that the
430
S Gupta et al.
Table 3
Pre-post values and change in the balance subset of BOTMP in the experimental and control group
Balance subscale
Median (range)
Median (range)
Change
Median (range)
Pre
Post
Pre
Post
Pre
Pre
1.0 (1.002.00) Post
Pre
2.0 (1.003.00) Post
Pre
2.0
2.0
2.0
2.0
0.0
(1.03.0)
(1.03.0)
(1.02.0)
(1.02.0)
(0.01.0)
0 (01.00)
0.0
2.0
3.0
1.0
1.0
1.0
1.0
1.0
1.0
0.0
0.0
8.0
9.0
(0.01.0)
(2.03.0)
(2.03.0)
(1.01.0)
(0.21.0)
(1.02.0)
(1.02.0)
(0.01.0)
(0.01.0)
(0.01.0)
(0.01.0)
(7.012.0)
(8.013.0)
Post
Pre
Post
Walking forward on a balance beam Pre
Post
Walking heel toe
Pre
Post
Walking heel toe on a balance beam Pre
Post
Stepping stick on a balance beam
Pre
Post
Total score
Pre
Post
Walking forward on a line
Control group
#
2.0
4.0
1.0
3.5
0.0
(1.03.0)
(2.254.0)
(1.02.0)
(2.04.75)
(0.01.0)
1.0 (0.01.0)
3.0 (3.03.0)
3.0 (3.03.0)
1.0 (1.02.75)
3.5 (2.04.0)
2.0 (1.02.75)
3.0 (3.03.0)
1.0 (1.01.0)
2.0 (1.04.0)
0.0 (0.00.75)
1.0 (0.01.0)
10.5 (8.015.5)
19.5 (16.2524)
Post
Pre
0 (00)
Post
Pre
1.0 (0.252.75) Post
Pre
1.0 (0.252.00) Post
Pre
1.5 (02.75)
Post
Pre
0 (01)
Post
Pre
9.5 (5.0010.0) Post
Change#
p*
Median (range)
0.007
0 (01)
0.001
0 (00)
0.19
0 (00)
0.49
0 (01)
0.001
0 (00)
0.003
0 (01)
0.016
0 (00)
0.09
0 (00)
0.007
1 (01)
Clinical messages
Strength and balance improves in children
with Downs syndrome following a six
week intervention.
Such programmes are feasible.
Acknowledgement
The authors wish to thank the children who participated in the study.
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Pediatric physical therapy. London: Lippincott
Williams & Wilkins, 2008, 283.
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