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review Indexing Metadata/Description Title/condition: Down Syndrome Synonyms: Trisomy 21, Downs syndrome Anatomical location/body part affected: Down syndrome (DS) is a genetic disorder that affects multiple organ systems Description 1/733 infants are born with DS; more than 350,000 people in the U.S. have DS ICD-9 codes 758.0 Downs syndrome ICD-10 codes Q90.9 Downs syndrome Q90.0 trisomy 21, meiotic nondisjunction Q90.1 trisomy 21, mosaicism (mitotic nondisjunction) Q90.2 trisomy 21, translocation Q90.9 Downs syndrome, unspecifed Reimbursement: No specifc issues or information regarding reimbursement have been identifed Presentation/signs and symptoms: DS can be diagnosed during pregnancy or shortly after birth; children with DS may present with the following s/sx Musculoskeletal Flat nasal bridge (1) Protruding large tongue (1) Small head (2) Small nose and mouth (1) Excess skin on posterior neck (1) Short hands and fngers (3) Hypotonia (1) Marked joint laxity Atlantoaxial joint instability (4) Increased space between frst and second toe (1) Separated sutures in skull (3) Hip dislocation (3) Pes planus (1) Metatarsus primus varus (1) Patellar instability (1) Cognition/neurologic Mild to moderate mental retardation (1) In some cases retardation is severe (1) Alzheimers disease (4) Seizures (5) Cardiac Atrioventricular septal defect (4) Persistent ductus arteriosus (4) Tetralogy of Fallot (4) Vision/hearing Vision concerns including esotropia (crossed eyes) (5) Cataracts (5) Near or farsightedness (5) Oblique eye fssures (1) Brushfeld spots on the iris (white spots) (1) Hearing problems from fuid or nerve impairment (5) GI/metabolic Gastrointestinal blockages (3) October 10, 2008 Author Amy Lombara, RPT Reviewers Joanne Minichillo, PT Cinahl Information Systems Glendale, California Rehabilitation Operations Council Glendale Adventist Medical Center Glendale, California Editor Sharon Richman, MSPT Cinahl Information Systems Down Syndrome Hypothyroidism (3) Hirchsprungs disease (1) (megacolon) Other Frequent infections (5) Increased risk for developing leukemia (3, 5) Depression (1) Obstructive sleep apnea (3) Causes & Risk Factors Causes Causes of trisomy 21 (more than 90% of DS cases (2) ) An additional, complete 21 st chromosome is present in all of the bodys cells. (2, 4) As a result the embryo will have 47 chromosomes instead of the typical 46 (4) The cell division error occurs before fertilization (5) The genetic error is known as meiotic nondisjunction; usually maternal (1) Causes of mosaic DS (12% of cases (4) ) An additional, complete 21 st chromosome is present in some of the bodys cells (2) In mosaic DS the cell division error occurs after fertilization, in the embryo (1, 5) Causes of translocation DS (34% of cases (5) ) A portion of chromosome 21 attaches or translocates to another chromosome. The child has two typical copies of chromosome number 21 in addition to the translocated chromosome with material from chromosome 21 adhered to it (2) The translocation occurs before fertilization (5) There are 46 total chromosomes (1) Pathogenesis (6) In an individual with DS, the combined cerebellum and brainstem weighs only 66% of normal Evidence of neurological immaturity is noted by decreased myelination and smaller convolutions when compared to typically developing infants at a similar age Also seen are structural abnormalities in dendrites of the motor cortex Risk factors (4) Increased maternal age is associated with increased risk of having a baby with DS A 35-year-old womans risk is 1/350 A 45-year-old womans risk is 1/30 Increased maternal age is not associated with an increased risk of DS caused by translocation A woman who has given birth to a child with DS has a 1/100 chance of having a second child with DS (age may be a component as well) In DS caused by translocation, the occurrence appears to be random; however, one third of DS cases are caused by translocation due to a parent with a translocated chromosome. This increases the risk of DS in the next pregnancy Overall Contraindications/Precautions Atlantoaxial dislocation (4) The hypotonia seen in children with DS causes ligamentous laxity; this is especially true in the frst two cervical vertebrae Increased laxity at this joint increases the risk of spinal cord injury Instability at the atlantoaxial joint occurs in 1020% of DS cases Spinal compression caused by this laxity is rare but can occur X-rays are recommended for all children with DS over the age of 2 years due the risk of dislocation at this joint Avoid high-risk activities that can overtax the cervical joints (diving, gymnastics, high jumping, trampoline, etc.) Pain (1) Individuals with DS may take longer to respond to pain stimuli and in a less precise manner Early weight-bearing (6) Static postures that allow for increased stress on joints, which are inadequately supported (secondary to decreased tone and lax ligaments), such as the knee may be contraindicated in the very young DS population See specifc Contraindications/precautions under Assessment/Plan of Care Examination History and tests/measures may be age and setting specifc; recommendations are a guide and should be used as appropriate for each individual patient. History History of present illness/injury Mechanism of injury or etiology of illness What is nature of current reason for eval/treatment? What type of DS has the patient been diagnosed with? What types of physicians is the patient followed by? Course of treatment Medications for current illness/injury Determine what medications clinician has prescribed, if any; are they being taken? Piracetam was shown to be ineffective and potentially harmful in a small randomized controlled trial (7) No drugs or dietary supplements have been shown to improve cognitive function in individuals with DS (1) Diagnostic tests completed Brain imaging may show third ventricle enlargement and reduced brain weight (8) Cervical spine X-rays are critical in detecting atlantoaxial instability Previous therapy: Document whether patient has had occupational or physical therapy for this or other conditions and what specifc treatments were helpful or not helpful Aggravating/easing factors: Any situations or circumstances that appear to exacerbate or ease certain symptoms? Body chart: Use body chart to document location and nature of symptoms Nature of symptoms: Document nature of symptoms (constant vs. intermittent, sharp, dull, aching, burning, numbness, tingling) as able Rating of symptoms: Use a visual analog scale or 010 scale to assess symptoms at their best, at their worst, and at the moment (specifcally address if pain is present now and how much) Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (AM, mid-day, PM, night); also document changes in symptoms due to weather or other external variables Sleep disturbance: Document number of wakings/night, if any Other symptoms: Document other symptoms patient may be experiencing that could be indicative of a need to refer to physician Respiratory status: Note any respiratory complications Barriers to learning Are there any barriers to learning? Yes
No
If Yes, describe _______________________
Medical history Past medical history General inquiry What surgical procedures has the patient undergone, if any? Has the patient had X-rays of cervical spine recently to assess for atlantoaxial dislocation? Any recent hospital admissions? Comorbid diagnoses: Ask patient/caregiver about other problems, including diabetes, cancer, heart disease, pregnancy, psychiatric disorders, orthopedic disorders, etc. Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken (including over-the- counter drugs) Other symptoms: Ask patient/caregiver about other symptoms he/she may be experiencing Social/occupational history Patients goals Document what the patient/caregiver hopes to accomplish with therapy and in general Do the family and patient feel they have necessary support in place? Vocation/avocation and associated repetitive behaviors, if any How is the child able to negotiate the school/home environment? Is the child involved in any activities? Is the older patient involved in any leisure activities? Functional limitations/assistance with ADLs/adaptive equipment Any adaptive or assistive devices used at home? What ADLs can the child perform? Age at which developmental milestones were reached? Living environment Inquire about home: stairs, number of foors in home, with whom does patient live, caregivers, etc. Identify if there are barriers to independence in the home; any modifcations necessary? Any siblings? Is the older patient living at home, group home, and with whom? Is the individual able to tolerate his/her workday? Is the type of work compounding the existing problem? Is the individual able to safely navigate all environments? Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be appropriate to patient medical condition, functional status, and setting) Anthropometric characteristics Is there a leg length discrepancy present? Arousal, attention, cognition (including memory, problem solving) Does the child orient to name? Can the patient follow commands? How many steps? Researchers in a study of 88 adults with DS and 56 adults with mental retardation (conditions other than DS caused the mental retardation) assessed the impact of aging on cognitive domains in these individuals (9) Individuals with DS younger than 45 years of age demonstrated higher scores in the performance (non-verbal abilities) domains than in the verbal domains Individuals with DS who were at least age 45 demonstrated a decline in the performance sections, however, verbal scores remained fairly constant Therefore, it was concluded that aging appeared to have the greatest impact on performance domains in individuals with DS. As non-verbal abilities are often a cognitive strong point in these individuals the impact of aging may have greater ramifcations (compared to a typically aging person) as they are not able to fall back on their verbal communication skills Research reports age-associated declines in cognitive functioning in the DS population at a much earlier age than in the general population. Specifcally, changes in new learning, memory, and attention span were documented (9) Research recommends short and straightforward instruction and increasing the amount of time necessary for successful completion of a task (10) Also recommended were a gradual integration of new information, structure, consistency, and allowing for the feeling of success (4) Assistive and adaptive devices As the child grows, it may be necessary to provide assistive devices to promote independence during mobility and gait. Orthotic consults may also be indicated In the older DS population assistive devices may be indicated to assist with independent mobility as motor skills may deteriorate over time Balance Delayed and atypical balance development is frequently seen (11) Decreased pelvic control, hypotonia, and pes planus can impact balance reactions (12) At age-appropriate stages balance should be assessed statically and dynamically in sit and stance: The Timed Up and Go (TUG) test is an objective measure of a patients ability to rise into stance. Increased risk of falls, quick fatigue, and decreased safety outdoors are associated with a score of more than 30 seconds (13) The Berg Balance assessment may be used for children aged 5 years and older Cardiorespiratory function and endurance Document vital signs during, pre-, and post-exertion Patients with DS typically present with decreased work capacity and decreased peak oxygen consumption (14) Decreased maximal heart rates (derived from typical formula of 220 minus age) are common; possibly as much as 30 beats/min lower (14) A nonrandomized controlled study found that individuals with DS have a reduced heart rate response during exercise that could be diagnosed as chronotropic incompetence. In this study chronotropic incompetence was defned as inappropriate heart rate response to maximal exertion or failure to reach 85% of age-predicted maximal heart rate (14) Circulation Clinician may assess radial and pedal pulses Note capillary refll time in fngers and toes Ergonomics/body mechanics Observe posture/body mechanics during various activities; document substitute motions Functional mobility Observe a childs ability to transition in out of positions and how he or she accomplishes the task Developmental tests with gross motor and fne motor components include (partial list) The Battelle Developmental Inventory; birth to age 11 years; with cognitive component Bruininks-Oseretsky Test of Motor Profciency (BOTMP), 2nd edition; ages 4-21 The PEDI (Pediatric Evaluation of Disability Inventory); 6 months to 7 years; ADL component Peabody Developmental Motor Scales; birth to 5 years Gait/locomotion Children with DS begin to walk ~ 1 year later than typical children (15) Perform gait assessment. Subjective reports of gait deviations include (11) Decreased and early hip extension Increased hip abduction with swing Increased hip/knee fexion Increased plantar fexion Decreased ankle rotations in the sagittal plane Increased double support time Wider step width (16) Longer stance time Shorter step lengths Limitations in ascending and descending stairs have been seen in the DS population, with actions such as forward lean, decreased balance, marking time patterns, and incorrect foot placement. (Marking time pattern was defned as favoring the dominant leg and reducing the balance requirements of the task) (17) Joint integrity and mobility: Lax joints and hypermobility are common in individuals with DS. A general assessment of joints is indicated; however, the clinician must use caution not to further tax joints during evaluation process Motor function (motor control/tone/learning) Patients with DS have hypotonia Research has also proposed that individuals with DS may compensate for their perceived instability by increasing stiffness. It is surmised that their sense of instability comes from their decreased muscle tone and resulting joint laxity (16) It has been noted that individuals with DS, when compared to typically developing peers, tend to have more variable movement patterns (16) Children with DS often use substitute motions and will develop compensatory movement patterns that are ultimately detrimental to the musculoskeletal system (4) Muscle strength MMT as able Assessing strength in children with DS can be achieved through observation of functional/developmental skills. An example would be an assessment in the quadruped position. The clinician should observe the childs ability to maintain a neutral head position, shoulders/ hips/knees at 90, and holding of a neutral spine. Also observe position of scapulas (12) In cases of longstanding mental retardation, the individuals muscle strength is often below normal (10) In DS often there is a reduced quality and amount of muscle tissue (10) Neuromotor development Patients with DS may have the following associated conditions Hypotonia (11) Diffculty sustaining muscle contractions (11) Muscle oscillations at fnal joint positions (11) Impaired timing of muscle contractions (11) Signifcant developmental delays (6) Observation/inspection/palpation (including skin assessment) Document any skin breakdown, bruising, rashes, etc. Palpation may assist in detecting any subluxations Pain Watch for facial grimacing or body tensing as indicators of pain Posture Assess posture Delayed postural response patterns are typical in the DS population (11) An example of the delayed development of postural tone is marked head lag and decreased antigravity extension seen when eliciting the Landau response (6) While striving to maintain anti-gravity stability during sit, the child may assume a W-sitting posture; (18) this posture is extremely taxing on the childs hips The initial or early standing posture of an infant with DS typically consists of decreased trunk control, hip instability, and knee hyperextension (6) Adult patients with DS often posture themselves in standing position without lateral weight loading on feet, center of pressure is displaced forward, and ankle eversion. Pes planus and hallux valgus are very common in individuals with DS as well (11) As the child grows, scoliosis screenings should be completed (18) Range of motion General assessment as indicated May be observed through functional movement unless defcit is suspected Typically hypermobility is present Refex testing Assess childs protective reactions to front, sides, and rear Assess for atypical deep tendon refexes Primitive refexes such as the Moro, stepping, and palmar were seen in infants with DS long after they would have normally been expected to integrate (6) Self-care/activities of daily living (objective testing) Evaluate as indicated Sensory testing Evaluate proprioception, kinesthesia, and response to touch as able Hypotonia has been linked as a contributor to decreased stereognosis and kinesthetic feedback (6) A study of 35 school-aged children with DS found a signifcant reduction in postrotary nystagmus response compared to Ayres sample of typically developing children. The impact of this fnding cannot be fully evaluated as a link between vestibular dysfunction and low post-rotary nystagmus has not been fully developed (19) Overall, children with DS have reduced sensory experiences as a result of delayed and decreased motor skills (12) Assessment/Plan of Care Contraindications/precautions Modalities Use modalities in this population cautiously as sensation may be impaired, and a delay in pain reporting may occur Therapeutic strategies (18) The clinician should be cautious when participating with the child in activities which may increase the risk of a fall with resultant injury to the head/neck Avoid extremes in ROM; particularly in the neck Joint compression/approximation (in the cervical region) is contraindicated when atlantoaxial instability is known to be present Patients with this diagnosis are at risk for falls; follow facility protocols for fall prevention and post fall prevention instructions at bedside, if inpatient. Ensure that patient and family/caregivers are aware of the potential for falls and educated about fall prevention strategies. Discharge criteria should include independence with fall prevention strategies Diagnosis/need for treatment The ability to walk fosters cognitive and social growth as the child can interact with the environment from a different perspective (15) A childs depth perception, object permanence awareness, and sense of self/objects in space increases as he/she becomes mobile (15) Individuals with mental impairment are believed to have increased morbidity; impacted by decreased motivation, limited opportunities to participate in therapeutic programs, and physical development that has been impaired (20) The medical community generally believes that poor cardiovascular ftness places individuals with DS at increased risk for developing obesity, osteoporosis, type II diabetes, and cardiovascular diseases (21) Overall the research reviewed supports positive reinforcement to bolster motivation and actually found that without such praise in this population participants would often cease activity all together One article suggests that interventions should be geared around trying to increase a childs muscle tone during therapy as hypotonia in this population has been shown to have such a negative, global impact (6) Rule out: N/A Prognosis: Based on fndings from a study completed in Atlanta, Georgia (1979-1998), approximately 93% of infants with DS survived their frst year and approximately 90% of infants survived their frst 10 years of life (22) African Americans with DS, at age 20, are seven times more likely to die than White individuals with DS at age 20 (22) Infants with DS who are White and have congenital heart defects are eight times more likely to die than those infants without congenital heart defects (22) Referral to other disciplines An orthotic consult may be indicated to address marked pronation commonly seen in this population A speech consult for support with language and or feeding concerns may be indicated Treatment summary Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patients physician. The summary listed below is meant to serve as a guide, not to replace orders from a physician or a clinics specifc protocols Therapeutic exercises A study of 14 individuals with DS documented signifcant improvement in strength in those participants who underwent a weight training program. The remaining participants, who were placed in a more typical circuit exercise program (isometrics/calisthenics), had signifcant gains in strength as well. However, the gains in strength seen in the circuit training group were not as substantial as those seen in the weight training group (23) An interventional study with before/after comparison of 31 adolescent males with DS found regular exercise increased erythrocyte glutathione peroxidase (GPX) in the blood. GPX is an antioxidant enzyme that assists in preventing cell damage. More research is needed to conclude whether regular exercise does in fact slow oxidative damage in individuals with DS (24) A clinical investigation comparing different therapeutic approaches found a combination of vestibular stimulation, neurodevelopmental therapy, and sensory integrative therapy was more effective than sensory integrative therapy as the sole intervention. All three interventions were found to be effective in treating children with DS. The study recommended a combination approach to treatment with greater emphasis placed on the specifc needs of that child (12) A small, controlled study of young adults with DS found signifcant improvement in muscle strength and dynamic balance reactions (in the treatment group) following a 12-week training program consisting of various therapeutic activities. Examples of the treatment groups activities included hopping, jumping, single leg stance, and balance beam work (10) In a controlled study of 20 children with DS who underwent jumping lessons 3x/wk for 6 weeks, signifcant improvements in the foor walk, beam walk, and horizontal and vertical jumping tests were recorded. The study concluded that the clinical implication would be the promotion of better motor movement through therapeutic intervention (25) Functional training A Cochrane systematic review evaluated available studies meeting their inclusion criteria to determine if aerobic exercise training programs for adults with DS would improve their overall health. The authors concluded that there was insuffcient evidence to support that aerobic exercise in adults with DS will improve physical or psychosocial outcomes. The review called for more well-conducted research to assess adverse effects, long-term physical outcomes, psychosocial outcomes, and costs in an effort to improve clinical practice decisions (26) In a blinded, controlled study of elderly individuals with DS, leg strength and balance were found to be signifcantly improved after a 25-week submaximal treadmill walking program. Further benefts from these measured gains may include a reduced fall risk and the promotion of social activities (13) A controlled trial of 14 elderly individuals with DS and mild intellectual impairment found a submaximal treadmill walking program 3x/wk for 15 consecutive weeks improved walking speed, duration, and distance. Pain levels were found to be decreased in subjects who also had a diagnosis of intermittent claudication (20) A randomized, controlled trial found that children with DS learned to walk signifcantly faster when participating in a home treadmill training program 5 days a week for 8 minutes a day when compared to control group (1) In a small controlled study of 8 preadolescents with DS and 8 preadolescents with typical development, the children with DS were found to have reduced stiffness and impulse values after massed practice of treadmill walking. This study would suggest that the effect of practice on this novel task was positive and the children were able to acclimate their bodies response demonstrated by more effcient behavior as repetitions went on (16) A study of 7 children with DS evaluated the effects of bi-weekly exercise/12-week duration created to enhance stair climbing ability. The study found signifcant improvements in ascent and descent phases after the programs completion (17) Anecdotal evidence of some of the perceived benefts of a swim program in a small group of individuals with DS included participant enjoyment, increased endurance, weight loss, improved personal hygiene, improved social skills/confdence, and a more balanced gait (27) Prescription, application of devices and equipment A controlled study (with a repeated measures design) found that foot orthoses (FO) decreased heel eversion or decreased the pronation seen during stance in young children with DS. (The study did note the critical nature of a proper ftting FO in patient tolerance and effectiveness.) Also observed in the study was that the childrens transverse plane foot angle became abnormally internally rotated while wearing the FOs. This fnding raised the concern that FOs may cause torsional moments up the leg with an undesirable impact on the knee joint. The study recommends a close look at each individual patient and providing knee supports/strengthening as indicated. The study also recommended the following practices when working with patients with DS and implementing FOs: (11) Strengthening lower extremities with goal of increased muscular support about the knee and improved push off Heel cord stretching with heel in neutral position Dynamic balance activities which promote weight shift during late swing vs. heel contact A crossover study found signifcant improvements in postural stability, immediately and 7 weeks out, in children with DS while wearing fexible supramalleolar orthoses (SMOs) to correct increased pronation (28) Problem Goal Intervention Expected Progression Home Program Developmental delay Decreased endurance Attainment of motor milestones Improved endurance The clinician can foster the acquisition of developmental milestones through various positioning/handling strategies from very early on. Interventions should focus on the ability to withstand the forces of gravity while maintaining proper alignment during the completion of functional tasks (18) Progress each child as appropriate and indicated through the developmental sequence Design a home program that addresses developmental delay and decreased endurance as indicated and appropriate Problem Goal Intervention Expected Progression Home Program Decreased strength Compensatory movement patterns/substitute motions Gait deviations Improved strength Prevention of compensatory movement patterns/ substitute motions Improved gait pattern Therapeutic strategies May increase strength through play early on. Examples include the encouragement of neck extension while in supported prone on a therapy ball or crawling through a tunnel with pillows placed inside to offer resistance Alignment must be monitored during strengthening activities (18) Functional training Gait training as indicated and appropriate Progress as indicated depending on age of child and functional level Strengthening activities may later include ambulating through the sand at the beach or walking up hill, for example Provide a home program that incorporates strengthening activities as indicated Educate the caregivers on proper alignment during mobility and with static activities (Ex: Avoid W-sitting) Ligament laxity/joint hypermobility Hypotonia Poor postural tone/reactions Improved joint stability Strategies to improve muscle tone Improve postural tone/ reactions Application of devices/ equipment Bracing may be indicated to address laxity about major joints Assistive devices to support gait until muscles are strong enough to maintain proper alignment and avoid the need for compensatory strategies Therapeutic strategies Strengthening activities designed to bolster support around joints will help to compensate for joint laxity
Interventions to increase muscle tone prior to the start of treatment sessions (light bouncing on a therapy ball, stimulating lighting/ sound, etc.) Therapeutic strategies NDT has been advocated as a valuable treatment intervention in the DS population due to the generalized hypotonia seen. The basis behind NDT is to promote normal muscle tone to allow for more typical movement patterns, and facilitating protective, righting, and equilibrium responses. The theory is sound, but more research needs to be completed to support its efcacy in this population (6) Progress as indicated Reduce assistive device use as able Provide education/wearing schedule for bracing as indicated Problem Goal Intervention Expected Progression Home Program Decreased proprioception Decreased balance Improved proprioception Improved balance Therapeutic strategies Interventions designed to improve proprioception can range from swimming to light joint compression through a particular joint (see contraindications above) Balance strategies may begin as simply reducing the amount of support provided though the trunk during the beginning stages of sit or placing a child in sidelying and promoting the controlled attainment of supine or prone Progress as indicated For the ambulatory child high-level balance activities can be introduced. Playgrounds often provide a great medium for this type of work Provide home program designed to promote balance reactions and foster proprioception as indicated Joint deformity; pes planus, hallux valgus Joint pain Prevention or appropriate adaptation for joint deformity Reduce/eliminate pain Orthotic consult as indicated N/A Provide instruction on orthotic use and wearing schedule as indicated Decreased coordination Improve coordination Therapeutic strategies Bilateral tasks that foster a midline point of reference (18) Crossing midline Incorporate coordination activities into home program as indicated Desired Outcomes/Outcome Measures Document improvements in strength, balance, functional mobility, endurance, pain, postural alignment, and gait pattern Document orthotic intervention and tolerance Document use of adaptive/assistive equipment and tolerance Maintenance or Prevention See Home Program section of grid
References 1. DynaMed Editorial Team. Downs syndrome. DynaMed Web site. http://www.ebscohost.com/dynamed Updated September 22, 2008. Accessed October 7, 2008. (RV) 2. MayoClinic Staff. Down syndrome. MayoClinic Web site. http://www.mayoclinic.com/health/down-syndrome/DS00182 Updated April 6, 2007. Accessed October 7, 2008. (GI) 3. Lewis RA. Down syndrome. MedlinePlus Medical Encyclopedia Web site. http://www.nlm.nih.gov/medlineplus/ency/article/000997. htm Updated May 10, 2007. Accessed October 7, 2008. (GI) 4. National Down Syndrome Society. http://www.ndss.org Accessed October 7, 2008. (GI) 5. Down syndrome. March of Dimes Web site. http://www.marchofdimes.com/printableArticles/4439_1214.asp Updated March 2007. Accessed October 7, 2008. (GI) 6. Harris SR. Physical therapy and infants with Down's syndrome: the effects of early intervention. Rehabil Lit. 1981;42(11-12):339-343. (RV) 7. Lobaugh NJ, Karaskov V, Rombough V, et al. Piracetam therapy does not enhance cognitive functioning in children with Down syndrome. Arch Pediatr Adolesc Med. 2001;155(4):442-448. (RCT) 8. Schimmel MS, Hammerman C, Bromiker R, Berger I. Third ventricle enlargement among newborn infants with trisomy 21. Pediatrics. 2006;117(5):e928-e931. (R) M Published meta-analysis SR Published systematic or integrative literature review RCT Published research (randomized controlled trial) R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PGR Published government report PFR Published funded report PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other such materials CP Conference proceedings, abstracts, presentations Coding Matrix References in this Clinical Review are rated using the following codes, listed in order of strength: 9. Devenny DA, Krinsky-McHale S. Age-associated differences in cognitive abilities in adults with Down syndrome. Topics in Geriatric Rehabilitation. 1998;13(3):65-72. (R) 10. Tsimaras VK, Fotiadou EG. Effect of training on the muscle strength and dynamic balance ability of adults with Down syndrome. J Strength Cond Res. 2004;18(2):343-347. (R) 11. 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(3):183-193. (R) 12. Uyanik M, Bumin G, Kayihan H. Comparison of different therapy approaches in children with Down syndrome. Pediatr Int. 2003;45(1):68-73. (R) 13. Carmeli E, Kessel S, Coleman R, Ayalon M. Effects of a treadmill walking program on muscle strength and balance in elderly people with Down syndrome. J Gerontol A Biol Sci Med Sci. 2002;57(2):M106-M110. (R) 14. Guerra M, Llorens N, Fernhall B. Chronotropic incompetence in persons with Down syndrome. Arch Phys Med Rehabil. 2003;84(11):1604-1608. (R) 15. Ulrich DA, Ulrich BD, Angulo-Kinzler RM, Yun J. Treadmill training of infants with Down syndrome: evidence-based developmental outcomes. Pediatrics. 2001;108(5):E84. (RCT) 16. Smith BA, Kubo M, Black DP, Holt KG, Ulrich BD. Effect of practice on a novel taskWalking on a treadmill: Preadolescents with and without Down Syndrome. Physical Ther. 2007;87(6):766-777. (R) 17. Lafferty ME, Hons BA. A stair-walking intervention strategy for children with Down's syndrome. J Bodywork Movement Ther. 2005; 9 (1): 65-74. (R) 18. Tecklin JS. Pediatric Physical Therapy. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. (GI) 19. Zee-Chen EL, Hardman ML. Postrotary nystagmus response in children with Down's syndrome. Am J Occup Ther. 1983;37(4):260- 265. (R) 20. Carmeli E, Barchad S, Masharawi Y, Coleman R. Impact of a walking program in people with Down syndrome. J Strength Cond Res. 2004;18(1):180-184. (R) 21. Dodd KJ, Shields N. A systematic review of the outcomes of cardiovascular exercise programs for people with Down syndrome. Arch Phys Med Rehabil. 2005;86(10):2051-2058. (SR) 22. Down syndrome survival rate increasing: racial disparities exist in a large metropolitan area. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/od/oc/media/pressrel/r060630.htm Updated June 30, 2006. Accessed October 7, 2008. (PGR) 23. Weber R, French R. Downs syndrome adolescents and strength training. Clin Kinesiol. 1988;42(1):13-21. (R) 24. Francisco Javier O, Manuel R, Manuel RR. Regular physical activity increases glutathione peroxidase activity in adolescents with Down syndrome. Clin J Sport Med. 2006;16(4):355-356. (R) 25. Wang WY, Ju YH. Promoting balance and jumping skills in children with Down syndrome. Percept Mot Skills. 2002;94(2):443-448. (R) 26. Andriolo RB, El Dib RP, Ramos LR. Aerobic exercise training programmes for improving physical and psychosocial health in adults with Down syndrome. Cochrane Database Syst Rev. 2005;(3):CD005176. doi: 10.1002/14651858.CD005176. (SR) 27. Goodwin C. Exploring the effects of a swim program for clients with Down syndrome. OT Pract. 2007;12(2):17-21. (RV) 28. Martin K. Effects of supramalleolar orthoses on postural stability in children with Down syndrome. Dev Med Child Neurol. 2004;46(6):406-411. (R)