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
www.foietlumiere.org/site/english/001.html

Limitations
 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
 Whats 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
www.ndss.org/index.php?option=com_content&ta

children with DS sk=view&id=1812&Itemid=95

 METHODOLOGY

Gabriel House of Mexico

 Search Strategy
1. General search in:

CINAHL PubMed
EMBASE SPORTDiscus
ERIC Cochrane
MEDLINE CENTRAL
PsychINFO

Autoalerts: OVID, EBSCO

1. Translocation 15.mp. 16. fitness.mp. 31. ambulat$.mp.
2. Translocation 21.mp. 17. treatment.mp. 32. run$.mp.
3. Translocation 22.mp. 18. intervention.mp. 33. step$.mp.
4. down$ syndrome.mp. 19. recreation.mp. 34. hydrotherapy.mp.
5. mongol$.mp. 20. stair walking.mp. 35. hippotherapy.mp.
6. trisomy.mp. 21. physical 36. equinotherapy.mp.
medicine.mp.
7. mental retard$.mp. 37. pool exercise.mp.
22. exercise
8. mental$ therapy.mp. 38. aqua therapy.mp.
handicap$.mp.
23. therapeutic 39. development.mp.
9. activity.mp. exercise.mp.
40. participation.mp.
10. gait.mp. 24. movement.mp.
41. impairment.mp.
11. walk$.mp. 25. motor
intervention.mp. 42. function.mp.
12. train$.mp.
26. swim$.mp. 43. functional
13. physical outcome.mp.
therapy.mp. 27. resistance.mp.
heading word] 44. motor
14. physiotherapy.mp. performance.mp.
15. exercis$.mp. 28. climb$.mp.
45. movement
29. active therapy.mp. patterns.mp.
30. locomot$.mp.
46. speed.mp. 61. flexib$.mp. 76. orthotic$.mp.
47. distance.mp. 62. manual therapy.mp. 77. social$.mp.
48. balance.mp. 63. electrotherapy.mp. 78. measure$.mp.
49. coordination.mp. 64. recreation 79. velocity.mp.
therapy.mp.
50. gross motor.mp. 80. assessment.mp.
65. occupational
51. transfers.mp. therapy.mp. 81. roll$.mp.
52. stand$.mp. 66. active therap$.mp. 82. posture.mp.
53. sit$.mp. 67.neurodevelopmental 83. anti-gravity
54. supine.mp. therapy.mp. movement.mp.
55. prone.mp. 68. stair climbing.mp. 84. independ$.mp.
56. outcome.mp. 69. sport$.mp. 85. grasp$.mp.
57. rate.mp. 70. mobili$.mp. 86. reach$.mp.
58. physical activit$.mp. 71. play$.mp. 87. step$.mp.
59. rehabil$.mp. 72. athelet$.mp. 88. jump$.mp.
60. strength$.mp. 73. taping.mp. 89. agility.mp.
74. splint$.mp.
75. brac$.mp.
Selection Protocol - Stage 1
2 reviewers independently screened TITLES

If 2 of below criteria, or ambiguous, article

was screened further

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:
 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

www.dsala.org/graphics/photos/baby_angels-4.jpg
 PICO Chart
Ref Population Intervention Outcomes Special Notes
ID

50 Not able to retrieve full text article

(1)

346 14 children Flexible SMOs; 3 Standing, SMOs shown to

(2)* w/DS; Age testing sessions Walking, have +ve
Range: 3-8 years over 10 weeks Running and influence on
old; independent Jumping postural stability
Ambulation for Dimensions of and less complex
30 yards GMFM; ROM skills
412 10 ds (5 Moving room OPTOTRAK Full text not in
(3) experienced oscillated .2 and VEP acuity test English
sitters 5 non- .5 Hz. Sitting
experienced) position. 7 days.

585 10 DS infants (gr. Visual cues, Trunk sway There is a

(4) 1 12.2 mo and oscillatory room coupling that can
gr.2 17 mo) 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 Excluded:
books,
abstracts
Peer - reviewed journal, English from
conferences

Population
Clinical diagnosis of DS
0 - 17 years of age Excluded:
intervention
for parents
Intervention
Any physical therapy related intervention

Outcome
A variable of gait
 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. > 6 good to

2. subjects were randomly allocated to groups
excellent
3. allocation was concealed. < 5 fair to poor
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.
 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 www.cdadc.com/jacobage6learningtoread.jpg

Levels of Evidence
 RESULTS

www.babble.com/CS/photos/may2007/images/19911/original.aspx
 Search
Total studies retrieved from search method #1 N= 5197 K = 0.79

Excluded by screening titles N= 4817

Abstracts retrieved for further screening N= 380

K = 0.86
Excluded by screening abstracts N=316

Studies retrieved for full text analysis N=64

Excluded by evaluating full text N= 54

K= 1

Studies retrieved for PEDro and data extraction N=10

Total studies retrieved from search

method #2-6 N= 0

Final number of included articles N=10

 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 PEDro Kappa
Publication/ Article Title Score Score
First Author (/10) (/1)

2004 Effects of supramalleolar orthoses 1

Martin on postural stability in children with 4
Down syndrome
2001 The effect of foot orthoses on standing 0.8
Selby- foot posture and gait of young children 5
Silverstein with Down syndrome
2005 Dynamic foot orthosis and motor 0.8
Pitetti skills of delayed children 5
2005 A Stair Walking Intervention Strategy for 1
Lafferty Children with Downs Syndrome 5
2001 Treadmill training of infants with Down 1
Ulrich syndrome: evidence-based 6
developmental outcomes
 Methodological Quality
Year of PEDro Kappa
Publication/ Article Title Score Score
First Author (/10) (/1)

2002 The effect of therapeutic horseback riding 0.8

Winchester on gross motor function and gait speed in 5
children who are developmentally delayed

2003 Comparison of Different Therapy 0.8

Uyanik approaches in Children with Down 5
Syndrome
1996 Qualitative Analysis of a Pediatric Strength 1
Sayers Intervention on the Developmental Stepping 3
Movements of Infants with Down Syndrome

1984 Developmental coaching of the Down 0.8

Esenther syndrome infant 1
2002 Promoting balance and jumping skills in 1
Wang children with down syndrome 5
 Levels of Evidence
Group Design
Year / First Author
Evidence 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
Group Design
Year / First Author
Evidence 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

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 Orthoses

www.footdoc.ca/www.FootDoc.ca/Orthotics.JPEG
 Orthoses
Group
Year/ Design/ Control
Population/
First Evidence Intervention Interventio Ages
N
Author Level/ n
PEDro
2004 Repeated Children wore flexible Shoes only DS 3yr6 mo 8 yrs
Martin14 Measures SMOs N= 14
Level 4
8hrs/day; 6 weeks
PEDro 4

2001 Repeated Children wore FOs DS: Shoes DS (n=16) 36 84 mo

Selby- Measures only Non-DS
Silverstei 5hrs/day; 4 (n=10)
n15 Level 4
consecutive days Non-DS:
PEDro 5 No FOs N=26

2005 Pre post Children wore No DAFOs CP (n=3) 46.6 10.6 mo

Pitetti16 Pattibob DFOs DS (n=2)
Level 4 DD (n=20) DS: 28.0 1.4 mo
Frequency unclear; 2
PEDro 5 mo and 1 week N=17
 Orthoses
Year/
Out- Measure Results
First
come
Author
2004 Gait GMFM Dimension E: Significant
Martin14 Walking, Running, p = 0.0001
Jumping Dimension
2001 Gait Tachometer Non-significant
Selby- speed p = 0.09
Silverstein1
5
2005 Gait PDMS-2 Locomotion Non-significant
Pitetti16 Section
 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
Lafferty 200517
Pre post, Level 4, PEDro 5

Intervention and Population

Children participated in a hierarchical active No Control DS Age=
therapy program progressed on ability N=7 3.4
yrs
3hrs biweekly; 12 weeks

Outcome, Measures and Results

Kinematic joint angle data for ascent Significant in R. ankle, L. hip and trunk
and decent phases

Observational analysis Qualitative and quantitative showed

improvements in stair walking
 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
Ulrich et al. 20018
Randomized control trial, Level 2b, PEDro 6

Intervention and Population

Stepping on a treadmill + Control: traditional DS, N=30 Ages:
traditional PT PT, 2x/week, until
Control Control (312.1
independently
(N=15) days)
From 1 8 mins, 5 walking
Experiment Experiment
days/week, until
(N=15) (302.6 days)
independently walking

Outcome, Measures and Results

Independent walking: # of days from Significant p=0.02

onset of study until independent Experiment: 300 days
Control: 401 days
 Treadmill Training
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

Clinical recommendation: treadmill training should be

considered as a treatment option for infants with DS
 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
Uyanik et al. 200321
3 way comparison pre-post, Level 4, PEDro 5

Intervention and Population

Group 1: SIT No Control DS: N=45 Ages:
Group 2: SIT+Vest
SIT (n=15) SIT: 9.6
Group 3: NDT
SIT+Vest (n=15) SIT+ Vest:
1.5 hrs/day, tri-weekly, 3 NDT (n=15) 8.67
months NDT: 8.53

Outcome, Measures and Results

Time of 10 steps forward walking SIT and SIT+vest: non-significant
NDT: significant
Time of 10 step sideways walking SIT and SIT+vest: non-significant
NDT: significant
 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
Sayers et al. 199622
Exploratory multiple case study, Level 5, PEDro 3

Intervention and Population

Individualized strength No Control DS: N= 5 Ages:
intervention using ankle 22-38 mo
weights
1/wk teacher, 3-5/wk with
parent; 8 wks
Outcome, Measures and Results
HELP strands (Walk/ Run) Improved
PMISM (n=3) Improved
BDI (Locomotion) No change (n=2), improved (n=2)
Height of step (n=3) Improved (n=1), improve L. foot (n=1), decline (n=1
Improved (n=1), improve R. foot (n=1), decline R.
Stride Length (n=3) foot (n=1)
 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 childs 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
 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

Clinical recommendations: we are unable to draw any

clinical conclusions from this research
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 childs specific
needs and preferences

We strongly encourage all pediatric

therapists to continuously re-evaluate each
childs 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
Special thank you to:
Susan Harris
Naznin Virji-Babul
Charlotte Beck
Angela Busch
For their support and
contributions

www.goldcoastdownsyndrome.org
 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 Downssyndrome persons: patterning
and longevity of benefits. J Mental Def Research. 1988;32:117.
11. Nilholm C. Early intervention with children with Down syndromepast and future issues. Down
Syndrome: Res Pract. 1996;4:5158
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.
www.plan.ca/belong/uploaded_images/beautiful_baby_cdss-756468.bmp
Questions???