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Effectiveness of Different Therapeutic Interventions on the Gait of Children with Down Syndrome Boetz, Lucia; Graetz, Stephanie; McDonald, Colleen; Notooulos, Maria; Harris, Susan; Virji-Babul, Naznin 2007

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The Effects of Therapy on the Gait of Children with Down Syndrome: A Systematic ReviewBy Lucia Botez, StephGraetz, Colleen McDonald and Maria NotopoulosOutline?Background ?Methods ?Results ?Article reviews ?Conclusions ?Limitationswww.foietlumiere.org/site/english/001.htmlBackground?Down syndrome (DS) is common1?1/700 births?Due to trisomyof chromosome 21?15 and 22 less common1?Common characteristics1,2:?muscle hypotoniaand weakness?ligamentouslaxity ?gross motor delay http://medicalimages.allrefer.com/large/hypotonia.jpgBackground?Walking achieved ~1year later than typically developing children3,4,5?Ambulationhaspsychosocial consequences6,7?Parentsof children with DS identify walking as most valued milestone8www.cbdsa.com/images/Warrick_xmas06_008.jpgCourtesy of Naznin-Virji Babul and the Down Syndrome Research FoundationBackground?Common therapy received9?PT:strength, motor control, function  ?OT:visual motor and manipulative skills, community participation ?SLP:oral motor skills, speech?Therapy usually starts in infancy9Can physical therapy effect the gait of these children?http://farm1.static.flickr.com/58/221312636_293942d007.jpgWhat?s in the literature??Scarce overall?Many reviews on early intervention and DS ?Gibson and Harris 198810?Nilholm199611?Review on motor development and DS?Lautteslager2006 (Dutch)www.childrensaustin.org/ama/icache/w300h400/orig/Lily.jpgWhy do thisreview??No systematic review on gait and DS ?Literature in this area is unfocused ?Evidence-based practice ?Gait most important gross motor skill9Objective?To systematically review and rate the levels of  evidence and methodological quality of studies that  examined the effects of various therapeutic  interventions on the gait of children with DS?www.ndss.org/index.php?option=com_content&task=view&id=1812&Itemid=95METHODOLOGYGabriel House of MexicoSearch Strategy1. General search in:?CINAHL ?EMBASE ?ERIC ?MEDLINE ?PsychINFO?PubMed ?SPORTDiscus ?Cochrane ?CENTRALAutoalerts: OVID, EBSCO1. Translocation 15.mp.  2. Translocation 21.mp.  3. Translocation 22.mp.  4. down$ syndrome.mp.  5. mongol$.mp.  6. trisomy.mp.  7. mental retard$.mp.  8. mental$ handicap$.mp.  9. activity.mp.  10. gait.mp.  11. walk$.mp.  12. train$.mp.  13. physical therapy.mp.  14. physiotherapy.mp.  15. exercis$.mp. 16. fitness.mp.  17. treatment.mp.  18. intervention.mp.  19. recreation.mp. 20. stair walking.mp. 21. physical medicine.mp.  22. exercise therapy.mp.  23. therapeutic exercise.mp.  24. movement.mp.  25. motor intervention.mp.  26. swim$.mp.  27. resistance.mp. heading word] 28. climb$.mp.  29. active therapy.mp. 30. locomot$.mp. 31. ambulat$.mp.  32. run$.mp.  33. step$.mp.  34. hydrotherapy.mp.  35. hippotherapy.mp.  36. equinotherapy.mp.  37. pool exercise.mp.  38. aqua therapy.mp.  39. development.mp.  40. participation.mp.  41. impairment.mp.  42. function.mp.  43. functional outcome.mp.  44. motor performance.mp.  45. movement patterns.mp. 46. speed.mp.  47. distance.mp.  48. balance.mp.  49. coordination.mp.  50. gross motor.mp.  51. transfers.mp.  52. stand$.mp.  53. sit$.mp.  54. supine.mp.  55. prone.mp.  56. outcome.mp.  57. rate.mp.  58. physical activit$.mp.  59. rehabil$.mp.  60. strength$.mp. 61. flexib$.mp.  62. manual therapy.mp.  63. electrotherapy.mp.  64. recreation therapy.mp.  65. occupational therapy.mp.  66. active therap$.mp.  67.neurodevelopmentaltherapy.mp.  68. stair climbing.mp.  69. sport$.mp.  70. mobili$.mp.  71. play$.mp.  72. athelet$.mp.  73. taping.mp.  74. splint$.mp.  75. brac$.mp. 76. orthotic$.mp.  77. social$.mp.  78. measure$.mp.  79. velocity.mp.  80. assessment.mp.  81. roll$.mp.  82. posture.mp.  83. anti-gravity movement.mp.  84. independ$.mp.  85. grasp$.mp.  86. reach$.mp.  87. step$.mp.  88. jump$.mp.  89. agility.mp. Selection Protocol -Stage 1Screening Criteria:Yes?No?Title identifies Down syndrome population: ??Title identifies intervention of physical therapy12(or related interventions):??Title identifies outcome or effect on gross motor development:??Title is ambiguous and may have content related to the above:???2 reviewers independently screened TITLES?If 2 of below criteria, or ambiguous, article was screened furtherSelection Protocol -Stage 2?2 reviewers independently screened ABSTRACTS ?If all of below criteria, or ambiguous, article was screened furtherSelection Criteria:Yes?No?Population of Down syndrome??Population of children (0-17yrs)??Physical therapy related intervention??Outcome of gross motor function ??Selection Protocol -Stage 3?FULL TEXT articles divided among reviewers ?Each reviewer extracted population, intervention and outcome data  ?A ?PICO chart?was createdwPICO ChartRef IDPopulationInterventionOutcomesSpecial Notes50 (1)Not able to retrieve full text article346(2)*14 children w/DS; Age Range: 3-8 years old; independent Ambulation for 30 yardsFlexibleSMO?s; 3 testing sessions over 10 weeksStanding, Walking, Running and Jumping Dimensions of GMFM; ROM SMO?sshown to have +veinfluence on postural stability and less complex skills412 (3)10ds(5 experienced sitters 5 non-experienced)Moving room oscillated .2 and .5 Hz. Sitting position. 7 days.OPTOTRAKVEP acuity testFull text not in English585 (4)10 DS infants (gr. 1 12.2 mo and gr.2 17 mo) Visual cues, oscillatory roomTrunk swayThere is a coupling that can be improved with practiceSelection Protocol -Stage 3?Common trends emerged?Early intervention ?Vestibular training ?Gait(reciprocal bipedal locomotion)www.sharethedream.co.nz/images/paris.jpgFinal Inclusion Criteria?Studies?Peer -reviewed journal, English?Population?Clinical diagnosis of DS ?0 -17 years of age?Intervention?Any physical therapy related intervention?Outcome?A variable of gaitExcluded: books, abstracts from conferencesExcluded: intervention for parentsSearch Strategy2.Gait specific search:a. Down syndrome b. gait OR locomotion OR walking OR walk c. a AND b3.Hand-search:?PediatricPhysical Therapy ?Gait and Posture  ?Ambulatory Pediatrics ?Journal of PediatricHealthcare  ?PediatricRehabilitation  ?PediatricGait: A New Milleniumin Clinical Care and Motion Analysis TechnologySearch Strategy4.Forward citation searches on authors 5.Screened reference lists of included articles and background articles 6.Key authors and clinical experts  contacted via e-mail Search Strategy?Articles saved in RefWorks?duplicates removed?Ceased all search methodsin June2007Gabriel House of MexicoMethodological Quality?2 reviewers independently  scored articles using PEDro?Well known in PT community and validhttp://campos-davis.com/infoweek/infoweek/angelmaria.jpgPEDro Scale (last modified March, 1999): 1. eligibility criteria were specified. 2. subjects were randomly allocatedto groups 3. allocation was concealed.4. the groups were similar at baseline 5. there was blinding of all subjects. 6. there was blindingof all therapists 7. there was blindingof all outcome assessors. 8. measures of at least one key outcomewere obtained from more than 85% of the subjects initially allocated to groups. 9. all subjects for whom outcome measures were available receivedthe treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysedby "intention to treat". 10. the results of between-group statistical comparisons are reportedfor at least one key outcome. 11. the study provides both point measures and measures of variabilityfor at least one key outcome.>6 good to excellent<5 fair to poorLevels of EvidenceLevels of Evidence Sackett(2000)13LevelDescription1aMeta-analysis or systematic review of randomized clinical trials1bRandomized control trial with narrow confidence interval2aSystematic review cohort studies 2bSingle randomized clinical trial3aSystematic review of case-control studies3bIndividual case-control study4Case series, poor cohort case controlled, including pre-post test 5Descriptive studies6Expert opinion and anecdotal evidenceData Extraction?Data extraction form made for review ?2 reviewers independently   extracted data onto  formGabriel House of MexicoDisagreement between reviewers at any of the above stages wasresolved by 3rdparty arbitrationData Analysis?Data extracted into summary tables?Study characteristics ?Outcomes and results?CalculatedKappa?Stage 1, 2, 3 ?PEDro ?Levels of Evidencewww.cdadc.com/jacobage6learningtoread.jpgRESULTSwww.babble.com/CS/photos/may2007/images/19911/original.aspxSearchTotal studies retrieved from search method #2-6 N= 0Total studies retrieved from search method #1 N= 5197Excluded by screening titles N= 4817Abstracts retrieved for further screeningN= 380Excluded by screening abstracts N=316Studies retrieved for full text analysis N=64Excluded by evaluating full text N= 54Studies retrieved for PEDro and data extraction N=10Final number of included articles N=10K = 0.79K = 0.86K= 1Articles?3 articles on orthoses and 7 on other interventions ?Total of 181 children with DS were studied ?8 of 10 studies showed significant or positive resultsMethodological QualityYear ofPublication/First AuthorArticle TitlePEDroScore(/10)KappaScore(/1)2004 MartinEffects of supramalleolarorthoseson postural stability in children withDown syndrome412001 Selby-SilversteinThe effect of foot orthoseson standing foot posture and gait of young children with Down syndrome50.82005 PitettiDynamic foot orthosisand motorskills of delayed children50.82005LaffertyA Stair Walking Intervention Strategy for Children with Down?s Syndrome512001 UlrichTreadmill training of infants withDown syndrome: evidence-based developmental outcomes61Methodological QualityYear ofPublication/First AuthorArticle TitlePEDroScore(/10)KappaScore(/1)2002 WinchesterThe effect of therapeutic horseback riding on gross motor function and gait speed in children who are developmentally delayed50.82003 UyanikComparison of Different Therapyapproaches in Children with DownSyndrome50.81996 SayersQualitative Analysis of a PediatricStrength Intervention on the Developmental Stepping Movements of Infants with Down Syndrome311984 EsentherDevelopmental coaching of the Down syndrome infant 10.82002 WangPromoting balance and jumping skills in children with down syndrome51Levels of EvidenceYear/ First AuthorGroup DesignEvidence Level2004 MartinRepeated measuresLevel 42001 Selby-SilversteinRepeated measuresLevel 42005 PitettiPre ?post Level 42005 LaffertyPre -postLevel 42001 UlrichRandomized control trialLevel 2bLevels of EvidenceYear/ First AuthorGroup DesignEvidence Level2002 WinchesterRepeated measuresLevel 42003 Uyanik3 way comparison pre-postLevel 41996 SayersExploratory multiple case studyLevel 51984 EsentherRetrospective studyLevel 42002WangPre-poststudyLevel 4K = 1ARTICLE REVIEWSwww.beaumonthospitals.com/images/center/f3c_flowerdoll.jpgOrthoseswww.footdoc.ca/www.FootDoc.ca/Orthotics.JPEGOrthosesYear/First AuthorGroup Design/Evidence Level/PEDroInterventionControl InterventionPopulation/NAges2004 Martin14Repeated MeasuresLevel 4PEDro4Children wore flexibleSMO?s 8hrs/day; 6 weeksShoes onlyDSN= 143yr6 mo ?8 yrs2001 Selby- Silverstein15Repeated MeasuresLevel 4PEDro5Children wore FO?s 5hrs/day; 4 consecutive days  DS: Shoes onlyNon-DS: No FO?sDS (n=16)Non-DS (n=10)N=2636 ?84 mo2005 Pitetti16Pre ?post Level 4PEDro5Children wore PattibobDFO?sFrequency unclear; 2 mo and 1 weekNo DAFO?sCP (n=3) DS (n=2)DD (n=20)N=1746.6 ?10.6 moDS: 28.0?1.4 moOrthosesYear/First AuthorOut-comeMeasureResults2004 Martin14GaitGMFM Dimension E: Walking, Running, Jumping DimensionSignificant p = 0.00012001 Selby-Silverstein15Gait speedTachometerNon-significantp = 0.092005 Pitetti16GaitPDMS-2 Locomotion SectionNon-significantOrthoses?Only intervention where multiple studies were conducted ?Intervention and populationvaried ?Outcome measures varied ?Small sample sizes ?Only one control groupOrthosesClinical recommendation: Clinicians should evaluate orthoses suitability and effectiveness on a case  by case basisActive Therapy / Stair Walkingwww.faqs.org/health/images/uchr_04_img0399.jpgActive Therapy / Stair WalkingChildren participated in a hierarchical active therapy program progressed on ability 3hrs biweekly; 12 weeksNo ControlDSN=7Age= ?3.4 yrsKinematicjoint angle data for ascent and decent phases  Observational analysisSignificantin R. ankle, L. hip and trunk Qualitative and quantitative showed improvements in stair walkingLafferty 200517Pre ?post, Level 4, PEDro5 Intervention and Population Outcome, Measures and ResultsActive Therapy / Stair Walking?Whole and part taskstair walking practice improvements  ?Exercises could easily be used in therapy ?Studydesign and methodology assessed as: ?SackettLevels of Evidence: 4 ?PEDroscore: 5?Most significant critique?Small sample size of only 7Clinical recommendation: whole and part task stair walking may be useful to facilitate stair walking in children with DSTreadmill Trainingwww.kines.umich.eduTreadmill TrainingStepping on a treadmill + traditional PT From 1 ?8 mins, 5 days/week, until independently walkingControl: traditional PT, 2x/week, until independently walkingDS, N=30 Control  (N=15) Experiment   (N=15)Ages:  Control (312.1 days?) Experiment (302.6 days?)Independent walking: #of days from onset of study until independentSignificant p=0.02  Experiment: 300 days ? Control: 401 days ?Ulrich et al. 20018Randomized control trial, Level 2b, PEDro6 Intervention and Population Outcome, Measures and ResultsClinical recommendation: treadmilltraining shouldbe considered as a treatment option for infants with DS?Treadmill training is unique and innovative ?Of the reviewed studies it is the highest quality?SackettLevels of Evidence: 2b?PEDroscore: 6?Outcomes showed statistically significant improvements?? practicality of implementation for cliniciansTreadmill TrainingHorseback Ridingwww.downsyndromefoundation.org/images/PICT0035.JPGHorseback RidingWinchester et al. 200218Repeated Measures, Level 4, PEDro5 Intervention and Population Horseback riding focusing on      NoControl   DS (n=2); Ages stretching, strength, postural CP (n=2);  57.8-ControlDS and autism (n=1);     86.5 mo SB (n=1);1 hr, once/wk,7 wks TBI (n=1)  Outcomes, Measures and Results GaitGMFM Dimension ESignificantat 1 wk and 7 wks postGait speed          Time to walk 10 mNon-significantHorseback Riding?Previouslyshown toimprove strength and balance in developmentally delayed children19,20?Sustainedimprovementsat 7 week follow-up?Studydesign quality and methodology assessed as: ?SackettLevels of Evidence: 4 ?PEDroscore: 5?Most significant critique?Small sample size of 7, only 3 had DS Clinical recommendation: therapeutichorseback riding may be considered for usewhen treating the gait of children with DS in combination with other therapiesSensory Integration Therapy, Vestibular Therapy, or NeurodevelopmentalTherapywww.whiterose4jon.net/sitebuilder/images/Jon-in-Swing-597x451.jpgSIT, Vestibular, NDTGroup 1: SIT  Group 2: SIT+Vest Group 3: NDT 1.5 hrs/day, tri-weekly, 3 monthsNo ControlDS: N=45SIT (n=15) SIT+Vest (n=15) NDT (n=15)Ages:  SIT: 9.6? SIT+ Vest: 8.67? NDT: 8.53?Time of 10 steps forward walking Time of 10 step sideways walking SIT and SIT+vest: non-significant NDT: significantSIT and SIT+vest: non-significant  NDT: significant213 way comparison pre-post, Level 4, PEDro5 Intervention and Population Outcome, Measures and ResultsSIT, Vestibular, NDT?Studydesign quality and methodology assessed as: ?SackettLevels of Evidence: 4 ?PEDroscore: 5?One of the largest sample sizes of articles analyzed?Most significant critique?No control groupClinical recommendation: Since NDT was found to be effective at improving walking skills of children with DS it may be considered a treatment optionStrength Interventionwww.uoregon.edu/~vaintrob/katya/climb_up.jpgStrength InterventionIndividualized strength intervention using ankle weights 1/wk teacher, 3-5/wk with parent; 8 wksNo ControlDS: N= 5Ages: 22-38 mo HELP strands (Walk/ Run) PMISM (n=3)BDI (Locomotion) Height of step (n=3)Stride Length (n=3)Improved ImprovedNo change (n=2), improved (n=2) Improved (n=1), improve L. foot (n=1), decline (n=1Improved (n=1), improve R. foot (n=1), decline R. foot (n=1) 22Exploratory multiple case study, Level 5,  PEDro3 Intervention and Population Outcome, Measures and ResultsStrength Intervention?Studydesign quality and methodology assessed as: ?SackettLevels of Evidence: 5 ?PEDroscore: 3?Results are difficult to interpret?Qualitative study design?Lack statistical analyses ?Small sample size: 1 withdrawal, 1 child incomplete data ?Acknowledgingeach child?s health needs and individualization of therapy is commendedClinical recommendations: we are unable to draw any clinical conclusions from this researchDevelopmental Coachinghttp://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=12259Developmental CoachingEsenther198423Retrospective Study, Level 3, PEDro1 Intervention and PopulationDevelopmental coaching with       Control: Normative          DSAges not3 hand skills, 3 mobility skills            values from literature       N=40reportedtargetedof typical childrenDuration and frequency of intervention not specified Outcomes, Measures and Results Independent walking : Bonaparte40% achieved free walking by 18 Infant Parent Service (BIPS)months of agefree walking category Clinical recommendations: we are unable to draw any clinical conclusions from this researchDevelopmental Coaching?Of the reviewed studies it is the lowest quality?SackettLevels of Evidence: 4 ?PEDroscore: 1?Mostsignificant critique?Retrospectivestudy design without true experimental manipulation ?No integrated control group?Uncertainty of interventionJump Trainingwww.theulloms.com/hopscotch2.jpgJump TrainingWang et al. 200224Pre-Post, Level 4, PEDro5 Intervention and Population Horizontal and vertical Control: TypicallyDS Ages:jump practice    developing childrenN=203-6 years30 min practice sessions3 x/week, 6 weeks Outcomes, Measures and Results Gait: # of steps walking on a Significantly greater pre-post forward line and balance beamscores compared to typicallydeveloping childrenJump Training?Studydesign quality and methodology assessed as: ?SackettLevels of Evidence: 4 ?PEDroscore: 5?Improvements of only 1-2 additional steps is statistically significant but is it functionally significant ? Clinical recommendations: balanceand jumping hadpositive (although small) effects, thus, it could be considered as part of a program to improve the gait of children with DSConclusions?Current researchis a heterogeneous mix of interventions and outcomes ?Low quality designsoverall ?We recommend combinations of different therapies that accommodatechild?s specific needs and preferences ?We strongly encourage all pediatrictherapists to continuously re-evaluate each child?s progressin order to ensure best evidence practiceFuture Research?More research must be done?Higher quality research ?Optimal treatment parameters?Emerging research25-30www.goldcoastdownsyndrome.orgLimitations?Some studies could not be evaluated because full text not in English ?Authors lack of expertise in the field of publishing literature ?Limited experience in working with children with DSAcknowledgementsThank you toclinicians and researchers Anne Chin, Bonnie Forrester, JuliaLooper, Kenneth Pitetti, CharmayneRoss and Dale Ulrichwww.goldcoastdownsyndrome.orgSpecial thankyou to:Susan HarrisNazninVirji-Babul Charlotte Beck  Angela Busch For theirsupport and contributions?References1.Goodman CC, Fuller KS, BoissonnaultWG. Pathology: Implications for the Physical Therapist. 2nd ed. Philadelphia: Elsevier; 2003.  2.Shields N, Dodd K. A systematic review on the effects of exercise programmes designed to improve strength for people with Down syndrome. Phys TherRev. 2004;9:109-115. 3.Carr J. Mental and motor development in young mongolchildren. J MentDeficRes. 1970;14:205-220.  4.Hall B. Somatic deviations in newborn and older mongoloid children: Follow up investications. ActaPaediatrScand. 1970;59:199-204.  5.Share J, Veale AMO. Developmental Landmarks for Children with Down's Syndrome (Mongolism). Dunedin, New Zealand: University of OtagoPress; 1974.  6.Harris SR. Physical therapy and infants with down's syndrome: The effects of early intervention. RehabilLit. 1981;42:339-343.  7.BaxM. Walking. Dev Med and Child Neur. 1991;33:471-472. 8.Ulrich DA, Ulrich BD, Angulo-KinzlerRM, YunJ. Treadmill training of infants with down syndrome: Evidence-based developmental outcomes. Pediatrics. 2001;108:E84-E84.  9.JoblingA, Virji-Babul N, Nichols D. Children with down syndrome: Discovering thejoy of movement. Joperd. 2006;77:34-54.  10.Gibson D, Harris A. Aggregated early intervention effects for Down?ssyndromepersons: patterning and longevity of benefits. J Mental Def Research. 1988;32:1?17.11.NilholmC. Early intervention with children with Down syndrome?past and future issues. Down Syndrome: Res Pract. 1996;4:51?58 12.14th General Meeting World Confederation of Physical Therapy. Description of Physical Therapy-What is Physical Therapy? Available at: http://www.wcpt.org/policies/description/whatis.php. Accessed July/22, 2007. References13.SackettDL, Strauss SE, Richardson WS. Evidence-Based Medicine: How to Practice and Teach EBM. London: Churchill-Livingstone; 2000.  14.Martin K. Effects of supramalleolarorthoseson postural stability in children with Down syndrome. Developmental Medicine & Child Neurology. 2004;46:406-411.  15.Selby-Silverstein L, HillstromHJ, PalisanoRJ. The effect of foot orthoseson standing foot posture and gait of young children with down syndrome. Neurorehabilitation. 2001;16:183-193.  16.PitettiK, WondraV. Dynamic foot orthosisand motor skills of delayed children. Journal of Prosthetics & Orthotics(JPO). 2005;17:21-26.  17.Lafferty ME. A stair-walking intervention strategy for children with down's syndrome.Journal of Bodywork & Movement Therapies. 2005;9:65-74.  18.Winchester P, Kendall K, Peters H, Sears N, WinkleyT. The effect of therapeutic horseback riding on gross motor function and gait speed in children who are developmentally delayed. Phys OccupTherPediatr. 2002;22:37-50.  19.Campbell S. Efficacy of therapeutic horseback riding on posture in children with cerebral palsy. Phys Ther. 1990;90:135-140.  20.BertotiD. Clinical suggestions: Effect of therapeutic horseback ridingon posture in children with cerebral palsy. Phys Ther. 1991;10:1505-1512.  21.UyanikM, BuminG, KayihanH. Comparison of different therapy approaches in children with down syndrome. PediatrInt. 2003;45:68-73.  22.Sayers LK, Cowden JE, Newton M, Warren B, Eason B. Qualitative analysis of a pediatricstrength intervention on the developmental stepping movements of infants with down syndrome. Adapted Physical Activity Quarterly. 1996;13:247-268.  23.EsentherSE. Developmental coaching of the down syndrome infant. Am J OccupTher. 1984;38:440-445.  24.Wang W, JuY. Promoting balance and jumping skills in children with down syndrome. Percept Mot Skills. 2002;94:443-448. ReferencesFuture Research 25.Looper, Julia E.Ulrich, Dale A.The Effects of Foot Orthoseson Gait inNew Walkers with Down syndrome. PediatricPhysical Therapy. 2006;18(1):96-97. Not yet published. 26.Wu, Jianhu.The effect of early treadmill training on gait.Gait and Posture. Not yet published. 27.Ulrich Dand AnguloBarrosoR. Optimizing treadmill training to improve onset and quality of gait in infants with Down syndrome. Current Research. 28.Ulrich Dand AnguloBarrosoR. Long term outcomes of preambulatorytreadmill training in children with Down syndrome. Current Research.29.LlpydM, Ulrich D. Relationship between kicking and motor milestones in infants with Down syndrome: An early intervention study. Current Research.30.Ulrich D. The effects of learning to ride a two wheel bicycle in 8-15 year old children with Down syndrome: A randomized trial. Current Research.ReferencesPhotographs 1.Gabriel House of Mexico 2.http://medicalimages.allrefer.com/large/hypotonia.jpg 3.www.cbdsa.com/images/Warrick_xmas06_008.jpg 4.http://farm1.static.flickr.com/58/221312636_293942d007.jpg5.www.childrensaustin.org/ama/icache/w300h400/orig/Lily.jpg 6.www.ndss.org/index.php?option=com_content&task=view&id=1812&Itemid=95 7.www.dsala.org/graphics/photos/baby_angels-4.jpg 8.http://www.sharethedream.co.nz/images/paris.jpg 9.http://campos-davis.com/infoweek/infoweek/angelmaria.jpg 10.http://www.plan.ca/belong/uploaded_images/beautiful_baby_cdss-756468.bmp11.http://www.cdadc.com/jacobage6learningtoread.jpg 12.www.babble.com/CS/photos/may2007/images/19911/original.aspx 13.www.beaumonthospitals.com/images/center/f3c_flowerdoll.jpg 14.\www.footdoc.ca/www.FootDoc.ca/Orthotics.JPEG 15.www.faqs.org/health/images/uchr_04_img0399.jpg 16.www.kines.umich.edu/ 17.www.downsyndromefoundation.org/images/PICT0035.JPG 18.www.whiterose4jon.net/sitebuilder/images/Jon-in-Swing-597x451.jpg 19.www.uoregon.edu/~vaintrob/katya/climb_up.jpg 20.http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=12259 21.http://www.theulloms.com/hopscotch2.jpg 22.www.goldcoastdownsyndrome.org 23.www.foietlumiere.org/site/english/001.html Video 1.Naznin-VirjiBabul. Down Syndrome Research Foundation. Questions???w

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