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 child’s 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 child’s 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. child’s 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 Avg St D NormRngWalk up 4 inch curb 36 12 24-48Walk down 4 inch curb 35 12 23-47Walk up stairs marking time 39 9 30-48Walk down stairs marking time 40 10 30-50Walk across 7 inch balance beam 38 9 29-47Fast walk 100 feet in 25 seconds 37 12 25-49Walk up 8 inch curb 49 13 36-62Walk down 8 inch curb 47 12 35-59Run 100 feet in 15 seconds 52 11 41-63Jump 47 12 35-59Walk up stairs alternating feet 56 10 46-66Ride tricycle 15 feet 61 11 50-72Walk across 4 inch balance beam 64 25 39-89Walk down stairs alternating feet 81 21 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: •  Leg and foot posture •  Walking pattern •  Trunk posture •  Shoulder girdle

posture

•  Post walking skills •  Gross motor skills at

3-4 year level

•  Once established, then practice what the child likes to do to further develop: •  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: Passé & 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