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Effectiveness of Different Therapeutic Interventions on the Gait of Children with Down Syndrome Boetz, Lucia 2007

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The Effects of Therapy on the Gait of Children with Down Syndrome: A Systematic Review By Lucia Botez, Steph Graetz, Colleen McDonald and Maria Notopoulos Outline • Background • Methods • Results • Article reviews • Conclusions • Limitations www.foietlumiere.org/site/english/001.html Background • Down syndrome (DS) is common1 – 1/700 births • Due to trisomy of chromosome 21 – 15 and 22 less common1 • Common characteristics1,2: – muscle hypotonia and weakness – ligamentous laxity – gross motor delay http://medicalimages.allrefer.com/large/hypotonia.jpg Background • Walking achieved ~1year later than typically developing children3,4,5 • Ambulation has psychosocial consequences6,7 • Parents of children with DS identify walking as most valued milestone8 www.cbdsa.com/images/Warrick_xmas06_008.jpg Courtesy of Naznin-Virji Babul and the Down Syndrome Research Foundation Background • 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 infancy9 Can physical therapy effect the gait of these children? http://farm1.static.flickr.com/58/221312636_293942d007.jpg What’s in the literature? • Scarce overall • Many reviews on early intervention and DS – Gibson and Harris 198810 – Nilholm 199611 • Review on motor development and DS – Lautteslager 2006 (Dutch) www.childrensaustin.org/ama/icache/w300h400/orig/Lily.jpg Why do this review? • No systematic review on gait and DS • Literature in this area is unfocused • Evidence-based practice • Gait most important gross motor skill9 Objective “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=95 METHODOLOGY Gabriel House of Mexico Search Strategy 1. General search in: – CINAHL – EMBASE – ERIC – MEDLINE – PsychINFO – PubMed – SPORTDiscus – Cochrane – CENTRAL Æ Autoalerts: OVID, EBSCO 1. 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$.mp. 67.neurodevelopmental therapy.mp. 68. stair climbing.mp. 69. sport$.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 1 Screening 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 further Selection Protocol - Stage 2 • 2 reviewers independently screened ABSTRACTS • If all of below criteria, or ambiguous, article was screened further Selection 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 created w w w . d s a l a . o r g / g r a p h i c s / p h o t o s / b a b y _ a n g e l s - 4 . j p g PICO Chart Ref ID Population Intervention Outcomes Special Notes 50 (1) Not able to retrieve full text article 346 (2)* 14 children w/DS; Age Range: 3-8 years old; independent Ambulation for 30 yards Flexible SMO’s; 3 testing sessions over 10 weeks Standing, Walking, Running and Jumping Dimensions of GMFM; ROM SMO’s shown to have +ve influence on postural stability and less complex skills 412 (3) 10 ds (5 experienced sitters 5 non- experienced) Moving room oscillated .2 and .5 Hz. Sitting position. 7 days. OPTOTRAK VEP acuity test Full text not in English 585 (4) 10 DS infants (gr. 1 12.2 mo and gr.2 17 mo) Visual cues, oscillatory room Trunk sway There is a coupling that can be improved with practice Selection Protocol - Stage 3 • Common trends emerged – Early intervention – Vestibular training – Gait (reciprocal bipedal locomotion) www.sharethedream.co.nz/images/paris.jpg Final 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 gait Excluded: books, abstracts from conferences Excluded: intervention for parents Search Strategy 2. Gait specific search: a. Down syndrome b. gait OR locomotion OR walking OR walk c. a AND b 3. Hand-search: • Pediatric Physical Therapy • Gait and Posture • Ambulatory Pediatrics • Journal of Pediatric Healthcare • Pediatric Rehabilitation • Pediatric Gait: A New Millenium in Clinical Care and Motion Analysis Technology Search Strategy 4. 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 methods in June 2007 Gabriel House of Mexico Methodological Quality • 2 reviewers independently scored articles using PEDro • Well known in PT community and valid http://campos-davis.com/infoweek/infoweek/angelmaria.jpg PEDro Scale (last modified March, 1999): 1. eligibility criteria were specified. 2. subjects were randomly allocated to groups 3. allocation was concealed. 4. the groups were similar at baseline 5. there was blinding of all subjects. 6. there was blinding of all therapists 7. there was blinding of all outcome assessors. 8. measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups. 9. all subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by "intention to treat". 10. the results of between-group statistical comparisons are reported for at least one key outcome. 11. the study provides both point measures and measures of variability for at least one key outcome. > 6 good to excellent < 5 fair to poor Levels of Evidence Levels of Evidence Sackett (2000)13 Level Description 1a Meta- analysis or systematic review of randomized clinical trials 1b Randomized control trial with narrow confidence interval 2a Systematic review cohort studies 2b Single randomized clinical trial 3a Systematic review of case-control studies 3b Individual case-control study 4 Case series, poor cohort case controlled, including pre-post test 5 Descriptive studies 6 Expert opinion and anecdotal evidence Data Extraction • Data extraction form made for review • 2 reviewers independently extracted data onto form Gabriel House of Mexico Disagreement between reviewers at any of the above stages was resolved by 3rd party arbitration Data Analysis • Data extracted into summary tables – Study characteristics – Outcomes and results • Calculated Kappa – Stage 1, 2, 3 – PEDro – Levels of Evidence www.cdadc.com/jacobage6learningtoread.jpg RESULTS www.babble.com/CS/photos/may2007/images/19911/original.aspx Search Total studies retrieved from search method #2-6 N= 0 Total studies retrieved from search method #1 N= 5197 Excluded by screening titles N= 4817 Abstracts retrieved for further screening N= 380 Excluded by screening abstracts N=316 Studies retrieved for full text analysis N=64 Excluded by evaluating full text N= 54 Studies retrieved for PEDro and data extraction N=10 Final number of included articles N=10 K = 0.79 K = 0.86 K= 1 Articles • 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 results Methodological Quality Year of Publication/ First Author Article Title PEDro Score (/10) Kappa Score (/1) 2004 Martin Effects of supramalleolar orthoses on postural stability in children with Down syndrome 4 1 2001 Selby- Silverstein The effect of foot orthoses on standing foot posture and gait of young children with Down syndrome 5 0.8 2005 Pitetti Dynamic foot orthosis and motor skills of delayed children 5 0.8 2005 Lafferty A Stair Walking Intervention Strategy for Children with Down’s Syndrome 5 1 2001 Ulrich Treadmill training of infants with Down syndrome: evidence-based developmental outcomes 6 1 Methodological Quality Year of Publication/ First Author Article Title PEDro Score (/10) Kappa Score (/1) 2002 Winchester The effect of therapeutic horseback riding on gross motor function and gait speed in children who are developmentally delayed 5 0.8 2003 Uyanik Comparison of Different Therapy approaches in Children with Down Syndrome 5 0.8 1996 Sayers Qualitative Analysis of a Pediatric Strength Intervention on the Developmental Stepping Movements of Infants with Down Syndrome 3 1 1984 Esenther Developmental coaching of the Down syndrome infant 1 0.8 2002 Wang Promoting balance and jumping skills in children with down syndrome 5 1 Levels of Evidence Year / First Author Group DesignEvidence Level 2004 Martin Repeated measures Level 4 2001 Selby-Silverstein Repeated measures Level 4 2005 Pitetti Pre – post Level 4 2005 Lafferty Pre - post Level 4 2001 Ulrich Randomized control trial Level 2b Levels of Evidence Year / First Author Group DesignEvidence Level 2002 Winchester Repeated measures Level 4 2003 Uyanik 3 way comparison pre-post Level 4 1996 Sayers Exploratory multiple case study Level 5 1984 Esenther Retrospective study Level 4 2002 Wang Pre-post study Level 4 K = 1 ARTICLE REVIEWS www.beaumonthospitals.com/images/center/f3c_flowerdoll.jpg Orthoses www.footdoc.ca/www.FootDoc.ca/Orthotics.JPEG Orthoses Year/ First Author Group Design/ Evidence Level/ PEDro Intervention Control Interventio n Population/ N Ages 2004 Martin14 Repeated Measures Level 4 PEDro 4 Children wore flexible SMO’s 8hrs/day; 6 weeks Shoes only DS N= 14 3yr6 mo – 8 yrs 2001 Selby- Silverstei n15 Repeated Measures Level 4 PEDro 5 Children wore FO’s 5hrs/day; 4 consecutive days DS: Shoes only Non-DS: No FO’s DS (n=16) Non-DS (n=10) N=26 36 – 84 mo 2005 Pitetti16 Pre – post Level 4 PEDro 5 Children wore Pattibob DFO’s Frequency unclear; 2 mo and 1 week No DAFO’s CP (n=3) DS (n=2) DD (n=20) N=17 46.6 ±10.6 mo DS: 28.0± 1.4 mo Orthoses Year/ First Author Out- come Measure Results 2004 Martin14 Gait GMFM Dimension E: Walking, Running, Jumping Dimension Significant p = 0.0001 2001 Selby- Silverstein1 5 Gait speed Tachometer Non-significant p = 0.09 2005 Pitetti16 Gait PDMS-2 Locomotion Section Non-significant Orthoses • Only intervention where multiple studies were conducted • Intervention and population varied • Outcome measures varied • Small sample sizes • Only one control group Orthoses Clinical recommendation: Clinicians should evaluate orthoses suitability and effectiveness on a case by case basis Active Therapy / Stair Walking www.faqs.org/health/images/uchr_04_img0399.jpg Active Therapy / Stair Walking Children participated in a hierarchical active therapy program progressed on ability 3hrs biweekly; 12 weeks No Control DS N=7 Age= ± 3.4 yrs Kinematic joint angle data for ascent and decent phases Observational analysis Significant in R. ankle, L. hip and trunk Qualitative and quantitative showed improvements in stair walking Lafferty 200517 Pre – post, Level 4, PEDro 5 Intervention and Population Outcome, Measures and Results Active Therapy / Stair Walking • Whole and part task stair walking practice Æ improvements • Exercises could easily be used in therapy • Study design and methodology assessed as: – Sackett Levels of Evidence: 4 – PEDro score: 5 • Most significant critique – Small sample size of only 7 Clinical recommendation: whole and part task stair walking may be useful to facilitate stair walking in children with DS Treadmill Training www.kines.umich.edu Treadmill Training Stepping on a treadmill + traditional PT From 1 – 8 mins, 5 days/week, until independently walking Control: traditional PT, 2x/week, until independently walking DS, 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 independent Significant p=0.02 Experiment: 300 days ± Control: 401 days ± Ulrich et al. 20018 Randomized control trial, Level 2b, PEDro 6 Intervention and Population Outcome, Measures and Results Clinical recommendation: treadmill training should be considered as a treatment option for infants with DS • Treadmill training is unique and innovative • Of the reviewed studies it is the highest quality – Sackett Levels of Evidence: 2b – PEDro score: 6 • Outcomes showed statistically significant improvements • ? practicality of implementation for clinicians Treadmill Training Horseback Riding www.downsyndromefoundation.org/images/PICT0035.JPG Horseback Riding Winchester et al. 200218 Repeated Measures, Level 4, PEDro 5 Intervention and Population Horseback riding focusing on      No Control   DS (n=2); Ages stretching, strength, postural CP (n=2);  57.8- Control DS and autism (n=1);     86.5 mo SB (n=1); 1 hr, once/wk, 7 wks TBI (n=1) Outcomes, Measures and Results Gait GMFM Dimension E Significant at 1 wk and 7 wks post Gait speed          Time to walk 10 m Non-significant Horseback Riding • Previously shown to improve strength and balance in developmentally delayed children19,20 • Sustained improvements at 7 week follow- up • Study design quality and methodology assessed as: – Sackett Levels of Evidence: 4 – PEDro score: 5 • Most significant critique – Small sample size of 7, only 3 had DS Clinical recommendation: therapeutic horseback riding may be considered for use when treating the gait of children with DS in combination with other therapies Sensory Integration Therapy, Vestibular Therapy, or Neurodevelopmental Therapy www.whiterose4jon.net/sitebuilder/images/Jon-in-Swing-597x451.jpg SIT, Vestibular, NDT Group 1: SIT Group 2: SIT+Vest Group 3: NDT 1.5 hrs/day, tri-weekly, 3 months No Control DS: N=45 SIT (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: significant SIT and SIT+vest: non-significant NDT: significant Uyanik et al. 200321 3 way comparison pre-post, Level 4, PEDro 5 Intervention and Population Outcome, Measures and Results SIT, Vestibular, NDT • Study design quality and methodology assessed as: – Sackett Levels of Evidence: 4 – PEDro score: 5 • One of the largest sample sizes of articles analyzed • Most significant critique – No control group Clinical recommendation: Since NDT was found to be effective at improving walking skills of children with DS it may be considered a treatment option Strength Intervention www.uoregon.edu/~vaintrob/katya/climb_up.jpg Strength Intervention Individualized strength intervention using ankle weights 1/wk teacher, 3-5/wk with parent; 8 wks No Control DS: N= 5 Ages: 22-38 mo HELP strands (Walk/ Run) PMISM (n=3) BDI (Locomotion) Height of step (n=3) Stride Length (n=3) Improved Improved No change (n=2), improved (n=2) Improved (n=1), improve L. foot (n=1), decline (n=1 Improved (n=1), improve R. foot (n=1), decline R. foot (n=1) Sayers et al. 199622 Exploratory multiple case study, Level 5,  PEDro 3 Intervention and Population Outcome, Measures and Results Strength Intervention • Study design quality and methodology assessed as: – Sackett Levels of Evidence: 5 – PEDro score: 3 • Results are difficult to interpret – Qualitative study design – Lack statistical analyses – Small sample size: 1 withdrawal, 1 child incomplete data • Acknowledging each child’s health needs and individualization of therapy is commended Clinical recommendations: we are unable to draw any clinical conclusions from this research Developmental Coaching http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=12259 Developmental Coaching Esenther 198423 Retrospective Study, Level 3, PEDro 1 Intervention and Population Developmental coaching with       Control: Normative          DS Ages not 3 hand skills, 3 mobility skills            values from literature       N=40 reported targeted of typical children Duration and frequency of intervention not specified Outcomes, Measures and Results Independent walking : Bonaparte 40% achieved free walking by 18 Infant Parent Service (BIPS) months of age free walking category Clinical recommendations: we are unable to draw any clinical conclusions from this research Developmental Coaching • Of the reviewed studies it is the lowest quality – Sackett Levels of Evidence: 4 – PEDro score: 1 • Most significant critique – Retrospective study design without true experimental manipulation – No integrated control group • Uncertainty of intervention Jump Training www.theulloms.com/hopscotch2.jpg Jump Training Wang et al. 200224 Pre-Post, Level 4, PEDro 5 Intervention and Population Horizontal and vertical Control: Typically DS Ages: jump practice    developing children N=20 3-6 years 30 min practice sessions 3 x/week, 6 weeks Outcomes, Measures and Results Gait: # of steps walking on a Significantly greater pre-post forward line and balance beam scores compared to typically developing children Jump Training • Study design quality and methodology assessed as: – Sackett Levels of Evidence: 4 – PEDro score: 5 • Improvements of only 1-2 additional steps is statistically significant but is it functionally significant ? Clinical recommendations: balance and jumping had positive (although small) effects, thus, it could be considered as part of a program to improve the gait of children with DS Conclusions • Current research is a heterogeneous mix of interventions and outcomes • Low quality designs overall • We recommend combinations of different therapies that accommodate child’s specific needs and preferences • We strongly encourage all pediatric therapists to continuously re-evaluate each child’s progress in order to ensure best evidence practice Future Research • More research must be done • Higher quality research • Optimal treatment parameters • Emerging research25-30 www.goldcoastdownsyndrome.org Limitations • 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 DS Acknowledgements Thank you to clinicians and researchers Anne Chin, Bonnie Forrester, Julia Looper, Kenneth Pitetti, Charmayne Ross and Dale Ulrich www.goldcoastdownsyndrome.org Special thank you to: Susan Harris Naznin Virji-Babul Charlotte Beck Angela Busch For their support and contributions ☺ References 1. Goodman CC, Fuller KS, Boissonnault WG. 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 Ther Rev. 2004;9:109-115. 3. Carr J. Mental and motor development in young mongol children. J Ment Defic Res. 1970;14:205-220. 4. Hall B. Somatic deviations in newborn and older mongoloid children: Follow up investications. Acta Paediatr Scand. 1970;59:199-204. 5. Share J, Veale AMO. Developmental Landmarks for Children with Down's Syndrome (Mongolism). Dunedin, New Zealand: University of Otago Press; 1974. 6. Harris SR. Physical therapy and infants with down's syndrome: The effects of early intervention. Rehabil Lit. 1981;42:339-343. 7. Bax M. Walking. Dev Med and Child Neur. 1991;33:471-472. 8. Ulrich DA, Ulrich BD, Angulo-Kinzler RM, Yun J. Treadmill training of infants with down syndrome: Evidence-based developmental outcomes. Pediatrics. 2001;108:E84-E84. 9. Jobling A, Virji-Babul N, Nichols D. Children with down syndrome: Discovering the joy of movement. Joperd. 2006;77:34-54. 10. Gibson D, Harris A. Aggregated early intervention effects for Down’ssyndrome persons: patterning and longevity of benefits. J Mental Def Research. 1988;32:1–17. 11. Nilholm C. 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. References 13. Sackett DL, Strauss SE, Richardson WS. Evidence-Based Medicine: How to Practice and Teach EBM. London: Churchill-Livingstone; 2000. 14. Martin K. Effects of supramalleolar orthoses on postural stability in children with Down syndrome. Developmental Medicine & Child Neurology. 2004;46:406-411. 15. Selby-Silverstein L, Hillstrom HJ, Palisano RJ. The effect of foot orthoses on standing foot posture and gait of young children with down syndrome. Neurorehabilitation. 2001;16:183-193. 16. Pitetti K, Wondra V. Dynamic foot orthosis and 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, Winkley T. The effect of therapeutic horseback riding on gross motor function and gait speed in children who are developmentally delayed. Phys Occup Ther Pediatr. 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. Bertoti D. Clinical suggestions: Effect of therapeutic horseback riding on posture in children with cerebral palsy. Phys Ther. 1991;10:1505-1512. 21. Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with down syndrome. Pediatr Int. 2003;45:68-73. 22. Sayers LK, Cowden JE, Newton M, Warren B, Eason B. Qualitative analysis of a pediatric strength intervention on the developmental stepping movements of infants with down syndrome. Adapted Physical Activity Quarterly. 1996;13:247-268. 23. Esenther SE. Developmental coaching of the down syndrome infant. Am J Occup Ther. 1984;38:440- 445. 24. Wang W, Ju Y. Promoting balance and jumping skills in children with down syndrome. Percept Mot Skills. 2002;94:443-448. References Future Research 25. Looper, Julia E. Ulrich, Dale A. The Effects of Foot Orthoses on Gait in New Walkers with Down syndrome. Pediatric Physical 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 D and Angulo Barroso R. Optimizing treadmill training to improve onset and quality of gait in infants with Down syndrome . Current Research. 28. Ulrich D and Angulo Barroso R. Long term outcomes of preambulatory treadmill training in children with Down syndrome. Current Research. 29. Llpyd M, 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. References Photographs 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.jpg 5. 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.bmp 11. 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-Virji Babul. Down Syndrome Research Foundation. Questions??? w w w . p l a n . c a / b e l o n g / u p l o a d e d _ i m a g e s / b e a u t i f u l _ b a b y _ c d s s - 7 5 6 4 6 8 . b m p

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