01 July 2015: Clinical Research
Delays in Motor Development in Children with Down Syndrome
Roksana Malak ABDEF , Anna Kostiukow F , Agnieszka Krawczyk-Wasielewska AC , Ewa Mojs ACD , Włodzimierz Samborski ADEF
DOI: 10.12659/MSM.893377
Med Sci Monit 2015; 21:1904-1910
Abstract
BACKGROUND: Children with Down syndrome (DS) present with delays in motor development. The reduced size of the cerebrum, brain maturation disorders, and pathophysiological processes lead to motor development delay. The aim of this study was to examine the gross motor function and estimate what motor abilities are significantly delayed in children with Down syndrome even if they attend physical therapy sessions. Another purpose of the study was to assess the functional balance.
MATERIAL AND METHODS: The study group consisted of 79 children with DS (42 boys, 37 girls), average age 6 years and 3 months ±4 years and 6 months. Participants were divided into 3 groups according to (i) age: <3 years old, 3–6 years old, and >6 years old; and (ii) motor impairment scale: mild (SNR 1), moderate (SNR 2), and severe (SNR 3). Children were assessed using the Gross Motor Function Measure-88 (GMFM-88) and Pediatric Balance Scale (PBS).
RESULTS: None of the assessed children developed all the functions included in GMFM-88. The standing position was achieved at the specified age by 10% of children in the first age group (<3 years old) and 95% of children aged 3–6 years. Similarly, the walking ability was performed by 10% of children under 3 years old and by 95% of children aged 3–6 years. The median score of PBS was 50 points (min. 34 p. – max. 56 p.). There was a statistically significant correlation between PBS scores and GMFM-88 scores, r=0.7; p<0.0001, and between balance scores and GMFM – 88 E (walking, running, jumping) (r=0.64; p<0.0001).
CONCLUSIONS: Motor development, especially standing position and walking ability, is delayed in children with Down syndrome. Balance and motor functions are correlated with each other, so both aspects of development should be consider together in physical therapy of children with Down syndrome.
Keywords: Developmental Disabilities - physiopathology, Child, Down Syndrome - physiopathology
Background
AIM:
The aim of this study was to examine motor abilities and determine which are significantly delayed in DS children, even if they receive physical therapy. Another purpose of the study was to assess the functional balance as a feature of quality of movement.
Material and Methods
ETHICS STATEMENT:
The study was approved by the Bioethics Committee of the Poznan University of Medical Sciences in 2009 (consent ref. no. 23/10, dated 7 January 2010). Written consents were obtained from the parents of the children enrolled in the study and the consents were signed on behalf of the children enrolled.
The study was conducted during 2009–2011. The study group consisted of 79 children with DS (42 boys, 37 girls), mean age: 6 years and 3 months ±4 years and 6 months. Participants were divided into 3 groups according to (i) age: <3 years old, 3–6 years old, >6 years old, and (ii) motor impairment rating scale: mild (SNR1), moderate (SNR2) and severe (SNR3). All children attended physical therapy sessions 1 time per week for 2 years. The therapy was conducted by NDT Bobath therapists and sensory integration therapists. The therapy was individually tailored for each child because children with DS have a wide variety of symptoms, although that all of them had laxity, low muscle tone, and psychomotor development deficits. The therapy for each child included developing psychomotor abilities according to individual motor skills assessed in each child. Therapy also focussed on developing good quality of motor function and normalization of muscle tone. Training balance reaction and postural maintenance and change were also addressed in each child’s therapy based on the knowledge of cerebellar hypoplasia, which presents in children with DS. Even children who were younger than 12 months were trained by NDT Bobath therapists, trying to normalize the muscle tone by influencing tone patterns, training protection reaction, and balance reaction appropriate to the age of the child and individual level of motor development. The aim of the therapy of the youngest research group was to facilitate standing position with good postural reactions.
The study took place in the greater Poland region, and involved patients with DS coming from towns and villages of the greater Poland region. Even if a child come from rural areas, she or he had the same therapists, and the same frequency of therapeutic meetings as a child who come from urban areas because each person in research group attended to Poznan Rehabilitation and Orthopedic Center, “YES” Association or to Leszno to Polish Association for Persons with Mental Disability “Kolo”. The economic status and education of parents and the influence of these factors on therapy were not considered. The study was approved by the Bioethics Committee of the Poznan University of Medical Sciences.
Children were also assessed using the Gross Motor Function Measure-88 (GMFM-88). The scale was first validated for children with cerebral palsy and is now also validated for children with DS [22–25]. There was no control group because the original validation sample of GMFM-88 included children aged from 5 months to 16 years, so the score of GMFM-88 is the percentage of the score of the original validation group [22–25]. A 5-year-old child without any motor disabilities should present all functions included on the GMFM-88 scale [22–25].
GROSS MOTOR FUNCTION MEASURE-88 (GMFM-88):
GMFM-88 consists of motor functions grouped into 5 dimensions: 1) GMFM – 88 A: lying and rolling (17 items), 2) GMFM – 88 B: sitting (20 items), 3) GMFM – 88 C: crawling and kneeling (14 items), 4) GMFM – 88 D: standing (13), 5) GMFM – 88 E: walking, running, and jumping (24 items) [22]. According to the GMFM-88 guidelines formulated for the assessment of DS children, the environment should be as familiar for the children as possible to encourage the performance of activities [22]. Sometimes, several meetings were needed to assess a child because of the tendency of DS children to get distracted. Assessment of each child was completed within 1 week to avoid changes in motor functions which otherwise might have appeared due to child development. Each item was measured by observation and scored on a 4-point ordinal scale. The 0 value indicated that a child did not initiate the task, 1 point – the child performed less than 10% of a task, 2 points – the child partially completed an item (10% to <100%), 3 points – the child completed an activity (100%) [22–27].
Body balance was estimated by Pediatric Balance Scale (PBS) among children who were able to stand unsupported and who were older than 4 years old [28]. The scale has been created and validated by Franjoine. We assessed all 14 items of PBS on the criterion, based on a 0–4 scale [28]. For instance, retrieving an object from the floor or changing from a standing position to sitting with each test session lasting 10–20 minutes. A child who successfully completed all the tasks could gain a maximum of 56 points. The nearer to maximum the sore is, the better the functional balance in the context of everyday life.
STATISTICAL ANALYSIS:
Data were analyzed using STATISTICA 8.1 (StatSoft). Nonparametric tests were used to analyze differences between medians in ordinal scales. Mann-Whitney U test was used for comparing two independent samples. A few unrelated samples were tested using Kruskal-Wallis test with Dunn’s multiple comparison post-test. The correlation between samples was measured using Spearman’s rank correlation. P value 0.05 was considered statistically significant.
Results
The median GMFM-88 score for girls was 89.66% (5.1% –100%) and for boys: 91.11% (12.43% – 100%). There was no significant difference in either group divided by sex (p=0.73).
There was no significant difference between motor functions in DS children in different groups divided according to motor impairment rating scale, p=0.56 (Table 1). However, when both age and motor impairment scale were taken into account, a significant difference between groups was observed (Table 2). Two groups with moderate (SNR 2) and severe (SNR3) motor impairment were combined because of the small number of children with severe motor impairment.
Many functions included in GMFM-88 were considered with respect to the typical age when they should be achieved. The standing position was achieved by 10% of children in the first age group (<3 years old) and 95% of children aged 3 to 6 years. Similarly, the walking ability was performed by 10% of children under 3 years old and by 95% of children aged 3 to 6 years.
Functional balance was assessed in 44 children older than 4 years in the research group (26 girls and 18 boys) by Pediatric Balance Scale (PBS). The median score of PBS was 50 points (min. 34 p. – max. 56 p.). There was not any significant correlation between balance score and gender (p=0.7).
There was a statistically significant correlation between PBS scores and GMFM-88 scores, r=0.7; p<0.0001, especially between balance scores and GMFM – 88 E (walking, running, jumping) (r=0.64; p<0,0001 (Figure 1).
Discussion
STUDY LIMITATIONS:
The limitations of the study are associated with the expensive MR examination, 1H-MRS; therefore, information about brain disorders was derived from research literature available in PubMed.
Conclusions
Psychomotor development, especially standing and walking ability, is delayed in DS children even if they attend physical therapy sessions. Functional balance should be considered in therapy of children with DS because balance may influence development of motor abilities, especially those that are developed in childhood.
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