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Physical Therapy for Children with Down Syndrome: Post Walking Skills Patricia C.

Winders, PT

What is the goal of physical therapy for children with Down syndrome?

Refined walking pattern


Narrow base Knees and feet point straight ahead Rotation of pelvis Long step length Mild knee bending Optimal foot alignment Heel-toe pattern Hip hyperextension Speed and endurance

Physical Therapy Services Should:


Focus on gait, posture, and exercise Be concerned with the childs long-term functional outcome Seek to minimize the development of abnormal compensatory movement patterns Be based on a thorough understanding of the compensatory movement patterns that children with Down Syndrome are prone to develop Be strategically designed to proactively build strength in the appropriate muscle groups so the child develops optimal movement patterns

The Critical Periods for Physical Therapy


Birth to walking Acquisition of post-walking skills

Home Program
Daily practice and repetitions build strength and motor plan Practice when child is at his/her best Prioritized activities Customized to family and built into daily routines

Post Walking Period


The goal is: To refine the walking pattern

Initial Walking Pattern


Wide base Toeing-out Weight bearing on the medial borders of the feet No pelvic rotation Short step length Stiff knees Inactive ankles Arms in high guard

Refined walking pattern


Narrow base Knees and feet point straight ahead Rotation of pelvis Long step length Mild knee bending Optimal foot alignment Heel-toe pattern Hip hyperextension Speed and endurance

Optimizing the walking pattern is accomplished by:


Foot Management
Using a shoe with a flexible sole Providing adequate support in the shoe

Practicing post walking skills to improve specific movement patterns

Post Walking Skills


Walking on uneven surfaces Kicking a ball Fast walking and running Balance beam skills Walking up and down inclined surfaces Walking up and down curbs Walking up and down stairs Rise up high on tiptoes & jumping Pedaling and steering a tricycle

Non-sequential Nature of Post Walking Skills


Provide an environment with a variety of activities
Try all skills and see what child is interested in doing Alternate hard and easy

Walking on Uneven Surfaces


The goal is: To walk on all types of surfaces and from one surface to another

Steps
Walk on squishy surfaces Walk on grass Walk on sand Walk on sidewalk with cracked, uneven pavement Walk on wood chips Walk on gravel

Guidelines
Practice within childs tolerance Give hand support, then let go Choose flat surfaces Check protective reactions Footwear

Kicking a ball
The goal is: To kick a ball 10-20 feet

Steps
Kick a ball with two hand support Kick a ball with one hand support Kick a ball without support Kick a ball with hip flexion and knee extension

Guidelines
Choose ball of appropriate size/weight Kick with the leg child chooses Provide verbal, visual, tactile cues Surface and space Footwear

Running
The goal is: To run 100 feet in 15 seconds

Steps
Fast walking with two hand support on level surfaces Fast walking down an incline Fast walking swinging one/both arms for momentum Fast walking 100 feet in 25 seconds Run with two-hand support, leaning trunk forward Run 100 feet in 15 seconds

Guidelines
Moving fast Use even surfaces and wide open spaces Hand support; let go Hand/arm support Verbal cues Build distance, speed and endurance Use running for breaks Footwear

Walking across a Balance Beam


The goal is: To walk across a 4 inch wide balance beam without support

Steps
Walk across 10 inch wide balance beam Walk across 7 inch wide balance beam Walk across 5.5 inch wide balance beam Walk across 4 inch wide balance beam

Guidelines
Make sure balance beam is stable Hand support; let go Verbal and visual cues Barefoot Readiness Leave out balance beam for self exploration Use balance beams in the community

Walking Up and Down Inclines


The goal is: To walk up and down all types of inclined surfaces

Steps
Walk up/down small incline Walk up/down medium incline Walk up/down large incline

Guidelines
Vary angle and length Walking up is easier Walking down is harder Surface Verbal and visual cues Encourage walking vs. climbing Footwear

Walking up/down Curbs


The goal is: To walk up/down an 8 inch curb without support

Guidelines
Lead with the foot the child chooses Identify whether up/down is easier Provide verbal and visual cues Surfaces Size of surface Encourage walking vs. climbing Height of curb vs. childs leg length Practice a variety of heights

Walking up/down Stairs


The goals are: 1. To walk up/down stairs holding rail, marking time 2. To walk up/down stairs holding rail, alternating feet

Steps
Climb up/down stairs Walk up/down, marking time, with two hand support (forward or sideways) Walk up/down, marking time, with one hand support Walk up alternating with two hand support, then one hand support Walk down alternating with two hand support, then one hand support

Guidelines
Lead with the leg the child chooses Identify whether up/down is easier Give hand support; then let go Give verbal, visual, tactile cues Railing Begin with a few stairs Use carpeted stairs Use stairs 3-6 inches high Height of child vs. stair

Jumping
The goals are: 1. To jump in place 2. To jump forward 3. To jump off a stair

Steps
Bounce on a springy surface with feet flat with hand support Bounce on a springy surface on tiptoes with hand support Bounce on a springy surface and lift feet off surface with hand support Jump on the floor and lift feet off the surface with/ without hand support Jump forward 8 inches with/without hand support Jump off 4-8 inch step with both feet together with/without hand support

Guidelines
Provide verbal, visual and tactile cues Hand support Footwear Practice for short periods AAI Continue jumping activities

Riding a Tricycle
The goal is: To ride a tricycle using pedaling and steering

Steps
Climb on/off Scoot forward on a riding toy and steer Ride a tricycle with support to pedal and steer Steer and pedal a tricycle down an inclined surface Steer and pedal a tricycle on a level surface 15 feet

Guidelines
Choose traditional tricycle, not Big Wheels Size of tricycle Limit the accessories Practice when and as long as child chooses Provide verbal, visual and tactile cues Use smooth surface and open space

Skill Walk up 4 inch curb Walk down 4 inch curb Walk up stairs marking time Walk down stairs marking time Walk across 7 inch balance beam Fast walk 100 feet in 25 seconds Walk up 8 inch curb Walk down 8 inch curb Run 100 feet in 15 seconds Jump Walk up stairs alternating feet Ride tricycle 15 feet Walk across 4 inch balance beam Walk down stairs alternating feet

Avg 36 35 39 40 38 37 49 47 52 47 56 61 64 81

St D 12 12 9 10 9 12 13 12 11 12 10 11 25 21

NormRng 24-48 23-47 30-48 30-50 29-47 25-49 36-62 35-59 41-63 35-59 46-66 50-72 39-89 60-102

Bones of the foot

From the back: heels tilting in

Inside borders of the feet collapsing to the ground

Refined walking pattern

Foot Management Post Walking Period


Using a shoe with a flexible sole Providing adequate support in the shoe

Shoe
Very flexible in toebox area Firm heel counter Broad rounded toe box Firm medial counter Flat bottom Not high top

Sure Step orthoses www.surestep.net

Cascade Dafo Inc www.dafo.com


Hot dogs with very dense foam medial arch fill

Evaluate the walking pattern


From the front:
Feet point straight or toe out?

From the back:


Narrow base
(heels in line with hips?)

Heels tilted or vertical?

From the side:


Is there an arch or collapse?

Foundation needed: Once established, then practice what Leg and foot posture Walking pattern the child likes to do Trunk posture to further develop:
Shoulder girdle posture

Post walking skills


Gross motor skills at 3-4 year level

Strength Speed Coordination Endurance Balance

Beyond Physical Therapy:


Creating Dance and Sports Programs

Be Beautiful Be Yourself Dance Program


Partnered with Colorado Ballet Site visit to the Boston Ballet program

http://www.coloradoballet.org/education/daretodance

Ballet: Pass & Chasse

Alternate fast and slow, small and big

Solos: Individual Expression

Ed McCaffrey Dare to Play Football Camp


Ed McCaffrey and his youth football camp program
Valor Christian High School coaches, athletic trainer, and football players

2010, 2011, and 2012

Ed McCaffrey Dare to Cheer Camp


2010 Led by the Rocky Mountain Rock Starz cheerleaders 2011 and 2012 Led by the Broncos cheerleaders Received training T-shirts and game day cheerleading outfits