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

• Limitationswww.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&ta

sk=view&id=1812&Itemid=95

METHODOLOGY

Gabriel House of Mexico

Search Strategy1. General search in:

– CINAHL– EMBASE– ERIC– MEDLINE– PsychINFO

– PubMed– SPORTDiscus– Cochrane– CENTRAL

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.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 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

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PICO ChartRef 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 +veinfluence 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.

OPTOTRAKVEP 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)

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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 Strategy2. Gait specific search:

a. Down syndromeb. gait OR locomotion OR walking OR walkc. 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 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 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 EvidenceLevels 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 wasresolved 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

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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 QualityYear of

Publication/First Author

Article TitlePEDroScore(/10)

KappaScore

(/1)

2004 Martin

Effects of supramalleolar orthoseson postural stability in children withDown 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 motorskills of delayed children 5 0.8

2005Lafferty

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 QualityYear of

Publication/First Author

Article TitlePEDroScore(/10)

KappaScore

(/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 Therapyapproaches in Children with DownSyndrome

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 EvidenceYear / First Author Group Design

Evidence Level2004 Martin Repeated measures

Level 42001 Selby-Silverstein Repeated measures

Level 42005 Pitetti Pre – post

Level 42005 Lafferty Pre - post

Level 42001 Ulrich Randomized control trial

Level 2b

Levels of EvidenceYear / First Author Group Design

Evidence Level2002 Winchester Repeated measures

Level 42003 Uyanik 3 way comparison pre-post

Level 41996 Sayers Exploratory multiple case study

Level 51984 Esenther Retrospective study

Level 42002 Wang Pre-post study

Level 4K = 1

ARTICLE REVIEWS

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Orthoses

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OrthosesYear/First

Author

Group Design/

Evidence Level/PEDro

InterventionControl

Intervention

Population/N Ages

2004 Martin14

Repeated Measures

Level 4

PEDro 4

Children wore flexibleSMO’s

8hrs/day; 6 weeks

Shoes only DSN= 14

3yr6 mo – 8 yrs

2001 Selby-Silverstein15

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

OrthosesYear/First

Author

Out-come

Measure Results

2004 Martin14

Gait GMFM Dimension E: Walking, Running, Jumping Dimension

Significant p = 0.0001

2001 Selby-Silverstein15

Gait speed

Tachometer Non-significantp = 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 orthosessuitability and effectiveness on a case by case basis

Active Therapy / Stair Walking

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Active Therapy / Stair Walking

Children participated in a hierarchical active therapy program progressed on ability

3hrs biweekly; 12 weeks

No Control DSN=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

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 RidingWinchester et al. 200218

Repeated Measures, Level 4, PEDro 5

Intervention and PopulationHorseback 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 ResultsGait 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

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SIT, Vestibular, NDT

Group 1: SIT Group 2: SIT+VestGroup 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: significantSIT 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 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)

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 CoachingEsenther 198423

Retrospective Study, Level 3, PEDro 1

Intervention and PopulationDevelopmental coaching with Control: Normative DS Ages not3 hand skills, 3 mobility skills values from literature N=40 reportedtargeted 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 agefree 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

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Jump TrainingWang 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 sessions3 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 hadpositive (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 pediatrictherapists 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

AcknowledgementsThank 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 HarrisNaznin Virji-Babul Charlotte Beck Angela Busch For their support and contributions ☺

References1. 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;4:51–5812. 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. 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 TherPediatr. 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.

ReferencesFuture 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.

ReferencesPhotographs1. Gabriel House of Mexico2. http://medicalimages.allrefer.com/large/hypotonia.jpg3. www.cbdsa.com/images/Warrick_xmas06_008.jpg4. http://farm1.static.flickr.com/58/221312636_293942d007.jpg5. www.childrensaustin.org/ama/icache/w300h400/orig/Lily.jpg6. www.ndss.org/index.php?option=com_content&task=view&id=1812&Itemid=957. www.dsala.org/graphics/photos/baby_angels-4.jpg8. http://www.sharethedream.co.nz/images/paris.jpg9. http://campos-davis.com/infoweek/infoweek/angelmaria.jpg10. http://www.plan.ca/belong/uploaded_images/beautiful_baby_cdss-756468.bmp11. http://www.cdadc.com/jacobage6learningtoread.jpg12. www.babble.com/CS/photos/may2007/images/19911/original.aspx13. www.beaumonthospitals.com/images/center/f3c_flowerdoll.jpg14. \www.footdoc.ca/www.FootDoc.ca/Orthotics.JPEG15. www.faqs.org/health/images/uchr_04_img0399.jpg16. www.kines.umich.edu/17. www.downsyndromefoundation.org/images/PICT0035.JPG18. www.whiterose4jon.net/sitebuilder/images/Jon-in-Swing-597x451.jpg19. www.uoregon.edu/~vaintrob/katya/climb_up.jpg20. http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=1225921. http://www.theulloms.com/hopscotch2.jpg22. www.goldcoastdownsyndrome.org23. www.foietlumiere.org/site/english/001.html

Video1. Naznin-Virji Babul. Down Syndrome Research Foundation.

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