Clinical Rehabilitation

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Effect of strength and balance training in children with Down's syndrome: a randomized
controlled trial
Sukriti Gupta, Bhamini krishna Rao and Kumaran SD
Clin Rehabil 2011 25: 425 originally published online 8 November 2010
DOI: 10.1177/0269215510382929

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Clinical Rehabilitation 2011; 25: 425–432

Effect of strength and balance training in children with

Down’s syndrome: a randomized controlled trial
Sukriti Gupta Sardar Bhagwan Singh Post Graduate Institute of Biomedical Sciences, Balawala, Dehradun,
Bhamini krishna Rao and Kumaran SD Manipal College of Allied Health Sciences, Manipal, India

Received 1st May 2010; returned for revisions 27th June 2010; revised manuscript accepted 7th August 2010.

Objective: The aim of the study was to determine the effect of exercise training
on strength and balance in children with Down’s syndrome.
Design: Randomized controlled trial.
Setting: Rehabilitation school for special children.
Subjects and intervention: Twenty-three children were randomized to intervention
and control group. The intervention group (n ¼ 12) underwent progressive resistive
exercises for lower limbs and balance training for six weeks. The control group
continued their regular activities followed at school.
Outcome measure: A handheld dynamometer was used to measure the lower
limb muscle strength. Balance was assessed by the balance subscale of Bruininks
Oseretsky Test of Motor Proficiency (BOTMP).
Results: Following the training, the children in the intervention group showed a sta-
tistically significant improvement (P50.05) in the lower limb strength of all the
muscle groups assessed. The strength of knee extensors was 12.12 lbs in the con-
trol group versus 18.4 lbs in the experimental group; in hip flexors it was 12.34 lbs
in the control group versus 16.66 lbs in the experimental group post-intervention.
The balance of the children also improved significantly with an improvement in
scores of the balance subscale of BOTMP (19.50 in the experimental group versus
9.00 in the control group, P ¼ 0.001).
Conclusion: This study suggests that a specific exercise training programme may
improve the strength and balance in children with Down’s syndrome

Introduction symptoms which include orthopaedic, cardiovas-

Down’s syndrome is a genetic disorder attributed
to chromosomal abnormality (Trisomy 21).
Global estimation of the incidence of the condition
is 1 in 1,000 to 1 in 1,200 live births.1 Down’s
syndrome is characterized by several clinical
Address for correspondence: Sukriti Gupta, Sardar Bhagwan
Singh Post Graduate Institute of Biomedical Sciences,
Balawala, Dehradun, India.
e-mail: sukritigupta22@gmail.com
ß The Author(s), 2010.
Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav
cular, neuromuscular, visual, cognitive and
perceptual impairments. It is the most common
genetic cause of developmental disability and
affects both the gross motor and fine motor
skills of children. Several studies have demon-
strated that individuals with Down’s syndrome
have deficits in eye–hand coordination, laterality,
visual motor control, reaction time, strength and
balance.2–9
Children with Down’s syndrome have been
noted to have reduced strength of the hip abductor
10.1177/0269215510382929

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426 S Gupta et al.
and knee extensors as compared to children
without Down’s syndrome.3 Cioni et al. concluded
that children and adolescents with the condition
have reduced quadriceps strength when compared
to children without mental retardation and with
mental retardation without Down’s syndrome.
They also reported that adolescents did not
demonstrate the physiological increase in muscle
strength that typically occurs by 14 years of age.4
Muscle strength, especially the lower-extremity
strength of individuals with mental retardation,
including Down’s syndrome, is of fundamental
importance to their overall health and their ability
to perform daily activities.5 Thus the preservation
of muscle strength at a satisfactory level is neces-
sary for the activities of daily living.
Studies done to determine the effect of strength
training in Down’s syndrome are few and have
been done in the adult population (24–26
years).10,11 The study done by Tsimaras and
Fotiadou10 documented a significant improvement
in leg strength following a 12-week intervention as
measured using a isokinetic dynamomter.
However, in a recent study performed by Taylor
et al.11 the intervention group showed an improve-
ment in the upper limb endurance but no differ-
ence in the lower limb muscle performance as
measured using 1RM. A case study has been
carried out to determine the combined effects of
strength and aerobic conditioning in a 10.5-year-
old child with Down’s syndrome, showing
improvements in strength after a six-week exercise
protocol.12 Strength training has shown positive
results in children with cerebral palsy without
any documented adverse effects.13–16 However,
literature for the same in children with Down’s
syndrome is lacking.
Additionally, postural deficits have been identi-
fied in children with Down’s syndrome. Shumway-
Cook and Woollacott7 found that postural
responses to loss of balance were slow in young
children with Down’s syndrome, and they
concluded that these responses were inefficient
for maintaining stability.They also suggested that
balance problems in these children occur not due
to hypotonia but from defects within higher level
postural mechanisms. Conolly et al.9 compared
the motor skills of children with and without
Down’s syndrome using Bruininks Osteresky
Test of Motor Proficiency (BOTMP), and found
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that children with Down’s syndrome scored signif-
icantly lower in the balance subset than the
comparison group.
Balance training in children with Down’s
syndrome has been studied by Wang et al.17 who
implemented a programme of vertical and
horizontal jump training for 14 children with
Down’s syndrome and children with mental
retardation without Down’s syndrome for six
weeks and noted significant improvement in the
balance scores as measured by balance sub-test
in the BOTMP. However, this study was not
done exclusively on children with Down’s
syndrome so the results cannot be generalized
since other studies show that children with
Down’s syndrome score lower than children with
mental retardation without Down’s syndrome
in the balance subset of BOTMP.9 There is no
conclusive evidence on the effect of strength and
balance training in children with Down’s
syndrome. So, the aim of this study was to deter-
mine the effect of a strength and balance training
programme in these children
Methods
Children (n ¼ 28) with a medical diagnosis of
Down’s syndrome were recruited from two
schools. The inclusion criteria were: children
between the age of 7 to 15 years, ability to under-
stand simple instructions and ability to stand and
walk independently. The exclusion criteria were:
associated cardiovascular condition and loss
of functional vision and hearing. Out of the
28 children, 23 met the study criteria. The study
was approved by the ethical committee. Informed
consent was taken from all parents/guardians.
The anthropometric details (height and weight)
were recorded. Height was measured with the
shoes removed using a metal tape measure.
Weighing scale was used to measure the weight.
The IQ level was determined using the Binet
kamat test18 administered by a clinical psycholo-
gist. This test is the Indian adaptation of the 1934
version of the Stanford–Binet Scale test and has
been used in Down’s syndrome.19
Handheld dynamometer (HHD) was used to
measure the strength of hip flexors, hip abductors,
 Effect of strength and balance training in children with Down’s syndrome
hip extensors, knee flexors, knee extensors and
ankle plantarflexors as per the instruction
manual of the instrument. The intra-rater reliabil-
ity of the instrument was tested prior to collecting
baseline data. The reliability ranged between
0.73–0.90 (ICC values). The procedure was
explained and demonstrated to the children.
Three test trials were performed for each muscle
group for both lower limbs. The best performance
of the right lower limb was used in the data
analysis. The children were allowed a minimum
rest period of 30 seconds between the trials.
Balance was measured using the balance subscale
of the BOTMP, a standardized test which was
administered as per the guidelines in the manual.
After collecting the baseline measurements, the
children were randomly divided into the experi-
mental and control group using stratified
random sampling. Stratification was done based
on the average lower limb extension strength
(average of hip extensor, knee extensor and ankle
plantarflexor strength).This was done to ensure
homogeneity in both the groups. Within each
strata, random sampling was done using chit
method. Experimental or control group was
written on a sheet of paper, placed inside an enve-
lope and sealed. The children within each strata
were asked to pick a envelope to randomize
them into two groups.
Participants in the intervention group under-
went a specific exercise training programme
which included progressive resistance exercises
for the lower limb and exercises for balance train-
ing over a period of six weeks, three times a week.
Strength training was started at 50% of 1RM.
Resistance exercises using sandbags were given
for hip flexors, abductors, extensors, knee flexors
and extensors and ankle plantarflexors. For each
muscle group two sets of 10 repetitions were given,
the resistance was increased by half a kilogramme
(1.1 lbs) when the child was able to complete
the sets with ease and without undue stress.
The following activities were selected for balance
training: horizontal jumps, vertical jumps, one leg
stance with eye open, tandem stance, walking on
line, walking on balance beam and jumping on a
trampoline. Each activity was given initially for
10 repetitions; it was increased by five repetitions
when the child was able to do it with ease.
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427
Instructional procedures were based on demon-
stration and a total communication approach.
Each exercise was demonstrated before its execu-
tion to familiarize each subject. Instructions were
repeated until the subject knew what was expected.
Subjects were positively reinforced during the
entire training programme to ensure their
maximum effort during each training session.
The control group received no special interven-
tion, but continued their activities that were
being followed in the school which included
classroom studying and play activities. Following
the six-week intervention, strength and balance
were measured. Strength was measured using the
HHD and the balance subset of BOTMP was used
to measure balance.
Data analysis was done using the SPSS software
version 11.5. Mann–Whitney U test was used to
analyze between group variables. Non-parametric
tests were used since the sample size was small and
the data was skewed. P-values of 50.05 were
considered significant.
Results
A total of 28 children were screened, of which
23 met the inclusion criteria and were included in
the study. The anthropometric details of the
children are described in Table 1. Twelve children
were randomly allocated to the experimental
group and 11 were in the control group. Figure 1
demonstrates the progress through trial. All the
participants in the intervention group completed
the exercise protocol successfully.
Strength
Table 2 demonstrates the strength values of the
muscles in the experimental and control groups at
baseline (pre) and following the six week interven-
tion (post) and also the change in the values
following the intervention. Analysis between the
groups revealed that following the intervention,
the experimental and the control group were
statistically different (P50.05) in terms of the
strength in all the muscle groups.
428 S Gupta et al.

Table 1 Baseline characteristics

Characteristics Control group (n ¼ 11) Experimental group (n ¼ 12)

Gender M ¼ 6, F ¼ 5 M ¼ 8, F ¼ 4
Age (yrs)* 13.00 (10.00–14.00) 13.50 (11.25–14.00)
IQ 38–49 36–52
Weight (kg)* 23.94 (11–34) 28.47 (13–40)
Height (cms)* 137.34 (106–152) 132.18 (112–143)

*mean (range).

Total children screened (n = 28)

Excluded (n = 5 )
Not able to understand simple
commands (n= 2 )

Not aged under 15 yrs (n = 3 )

Included for study (n = 2 3)

Informed consent taken

Baseline strength and balance

measured

Stratification done based on

strength

Experimental group
Control group (n= 11)
(n=12)

Regular school activities Specific exercise training programme:

strength training for lower limb
muscles and balance training for six
weeks

Strength and balance measurement

Figure 1 Flow diagram.

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 Effect of strength and balance training in children with Down’s syndrome 429

Table 2 Pre-post values and change in the strength of lower limb muscles in the experimental and control group

Muscle group Groups (strength in lbs)

Experimental Control
#
Median (range) Change Median (range) Change# p*

Hip flexors Pre 15.31 (12.24–18.72) Pre 12.30 (10.35–18.73) 0.001

Post 16.66 (14.17–20.20) 1.74 (0.95–3.5) Post 12.34 (10.54–17.19) 0.01 (0.48–0.25)
Hip extensors Pre 10.57 (9.24–14.26) Pre 10.70 (8.59–13.66) 0.002
Post 13.66 (10.27–16.30) 2.37 (0.26–3.24) Post 10.34 (7.71–12.85) 0.50 (0.66–0.44)
Hip abductors Pre 11.09 (7.91–15.31) Pre 9.91 (6.61–11.60) 0.001
Post 14.39 (9.14–16.73) 0.95 (0.53–3.9) Post 9.76 (6.17–11.78) 0.22 (0.44–0.13)
Knee flexors Pre 13.44 (10.70–15.20) Pre 11.24 (9.10–15.20) 0.03
Post 15.74 (12.06–18.79) 1.39 (0.19–3.98) Post 12.34 (9.45–15.65) 0.24 (0.80–0.87)
Knee extensors Pre 13.77 (9.86–17.95) Pre 10.80 (8.80–15.64) 0.01
Post 18.41 (15.21–19.61) 2.54 (0.44–5.15) Post 12.12 (9.92–13.00) 0.54 (0.22–1.09)
Ankle plantarflexor Pre 11.13 (9.21–18.62) Pre 10.57 (6.17–13.66) 0.02
Post 13.94 (12.78–19.07) 0.38 (0.17–1.54) Post 12.32 (6.39–13.88) 0.22 (0.22–0.88)

p* Level of significance between groups post-intervention change# Week 6 – Baseline.

Balance strength training was started at 50% of 1RM and

Similarly, for the scores of BOTMP, the total
score of the balance subset increased from 10.50
(8.00–15.50) to 19.50 (16.25–24.00) in the experi-
mental group as documented in Table 3. When
analyzing the scores of the control and the exper-
imental group following the intervention period,
they were statistically different except in three
components: walking on a line, standing on a bal-
ance beam with eyes closed and stepping over a
response stick on the balance beam. Overall, there
was a statistically significant difference (P ¼ 0.007)
in the overall scores between the two groups.
Discussion
The main finding of this study is that following six
weeks of an exercise training programme the
children with Down’s syndrome were able to
improve the strength of the lower limb muscles
and overall balance when compared to the control
group. Following the intervention, the strength of
all the muscle groups measured improved. This
indicates that a six week protocol was sufficient
to produce a statistically significant difference.
However, clinically the improvement in strength
was 1.74 (0.53–3.61) lbs. This low difference can
be due to a number of reasons. Firstly, that the
progressed gradually. It has been documented that
resistance should be started at 70–80% of 1RM to
obtain the effects of strength training.20,21
However, we started at a lower resistance because
children with Down’s syndrome have skeletal
muscle hypotonia and ligamentous laxity, hence
high loads can increase the risk of musculoskeletal
injury.20 Secondly, the training programme was
given for six weeks as compared to the 10/12
week programme given in the previous studies.10,11
Since the programme was shorter, the changes in
muscle strength can be attributed to enhanced
neural recruitment rather than changes in
increased muscle fibre size which requires a
minimum of 12 weeks’ training.22 It has also
been documented that prepubescent children do
not demonstrate changes in muscle fibre size,
and increased strength results from enhanced
neural recruitment and timing.23
Strength training in children with cerebral palsy
has been a recent subject of interest among
researchers. A number of studies have reported
that training benefits these children. Strength
training programmes have been documented to
improve the lower limb strength,14 gross motor
function scores14 and gait16 and that they also
have psychological benefits, such as feeling of
increased well-being and improved participation

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430 S Gupta et al.

Table 3 Pre-post values and change in the balance subset of BOTMP in the experimental and control group

Balance subscale Groups (balance subscale of BOTMP)

Experimental group Control group

#
Median (range) Change Median (range) Change# p*
Median (range) Median (range)

One leg stance Pre 2.0 (1.0–3.0) Pre 2.0 (1.0–3.0) 0.007
Post 4.0 (2.25–4.0) 1.0 (1.00–2.00) Post 2.0 (1.0–3.0) 0 (0–1)
One leg stance on a balance beam Pre 1.0 (1.0–2.0) Pre 2.0 (1.0–2.0) 0.001
Post 3.5 (2.0–4.75) 2.0 (1.00–3.00) Post 2.0 (1.0–2.0) 0 (0–0)
One leg stance on a balance Pre 0.0 (0.0–1.0) Pre 0.0 (0.0–1.0) 0.19
beam eye closed
Post 1.0 (0.0–1.0) 0 (0–1.00) Post 0.0 (0.0–1.0) 0 (0–0)
Walking forward on a line Pre 3.0 (3.0–3.0) Pre 2.0 (2.0–3.0) 0.49
Post 3.0 (3.0–3.0) 0 (0–0) Post 3.0 (2.0–3.0) 0 (0–1)
Walking forward on a balance beam Pre 1.0 (1.0–2.75) Pre 1.0 (1.0–1.0) 0.001
Post 3.5 (2.0–4.0) 1.0 (0.25–2.75) Post 1.0 (0.2–1.0) 0 (0–0)
Walking heel toe Pre 2.0 (1.0–2.75) Pre 1.0 (1.0–2.0) 0.003
Post 3.0 (3.0–3.0) 1.0 (0.25–2.00) Post 1.0 (1.0–2.0) 0 (0–1)
Walking heel toe on a balance beam Pre 1.0 (1.0–1.0) Pre 1.0 (0.0–1.0) 0.016
Post 2.0 (1.0–4.0) 1.5 (0–2.75) Post 1.0 (0.0–1.0) 0 (0–0)
Stepping stick on a balance beam Pre 0.0 (0.0–0.75) Pre 0.0 (0.0–1.0) 0.09
Post 1.0 (0.0–1.0) 0 (0–1) Post 0.0 (0.0–1.0) 0 (0–0)
Total score Pre 10.5 (8.0–15.5) Pre 8.0 (7.0–12.0) 0.007
Post 19.5 (16.25–24) 9.5 (5.00–10.0) Post 9.0 (8.0–13.0) 1 (0–1)

p* Level of significance between groups post intervention change# Week 6 – Baseline.

in school.13 Thus, the need is to apply similar
strength training protocols in children with other
disabilities.
Among children with Down’s syndrome, a case
study was done on a 10.5-year-old girl, which
included lower limb strengthening in the protocol.
This study showed that the subject improved her
10RM significantly following the six week inter-
vention and no adverse effects were reported.
More studies on this population are required so
that the benefits can be documented and training
programmes can be incorporated for all children
with Down’s syndrome. The results of our study
add evidence to effects of strength training.
The children also benefited from the balance
training and the scores on the balance subscale
of BOTMP improved from 10.50 to 19.50 in the
experimental group which was statistically signifi-
cant. However, some individual components did
not show any difference as compared to the
control group post-intervention. Ceiling effect
was seen in the component of walking on a
straight line. In this component the child is
supposed to walk forward six steps on a line to
achieve the maximum score of 3. The median
score at baseline itself was 3, hence there was no
difference seen post-intervention (P ¼ 0.49).
The other component that did not show
improvement was standing on a balance beam
with eyes closed. This is the only test in the scale
that checked balance with vision occluded. None
of the exercises in the balance training included
activities with eyes closed, this could be the
reason why there was no difference in the scores
of this component.
The last component was stepping over a
response stick on a balance beam. In this compo-
nent the child is given a score of 0 if they are
unable to perform the activity and a score of 1 if
they are able to do it. Although, the children in
our study found it difficult to perform this task,
the score improved from 0.00 (0.00–1.00) to 1.00
(0.00–1.00) in the intervention group. However, it
was not statistically significant.
Overall, majority of participants in this trial had
a moderate level IQ, yet they were all capable of

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 Effect of strength and balance training in children with Down’s syndrome
taking part in the programme and experienced
benefits from doing so despite their intellectual
disability. Adequate demonstration was given for
each exercise. This was done to make sure that the
children were able to understand and perform the
exercises in the correct manner. Compliance to
the intervention was excellent with no drop-outs.
Hence we can safely say that the training
programme implemented in this study was feasible
for children with Down’s syndrome.
One of the limitations of the study was that
blinding was not done as the assessor knew
which group the patient was in. Also, the control
group was not given any intervention; hence no
attention was given to them. The improvement in
the experimental group could have arisen from
attention. Lastly, the sample size was small.
Future studies can be done with a larger sample
size to enhance the applicability of the results.
Also, studies can be done using a more objective
measure of balance like force platform and the
balance exercises which include components that
occlude vision can be added. The long-term effect
of such training programmes can be documented
by doing follow-up studies. It would also be inter-
esting to see the effect of such interventions on
activity levels and physical function.
Clinical messages
 Strength and balance improves in children
with Down’s syndrome following a six
week intervention.
 Such programmes are feasible.
Acknowledgement
The authors wish to thank the children who par-
ticipated in the study.
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