Scenario: A 6-month-old is referred to physical therapy from an early intervention program with a diagnosis of Down syndrome. The parents report the infant was diagnosed in utero and was born at full term; otherwise, the pregnancy and delivery were uneventful. Parents were both over the age of forty. Upon examination, the infant is hypotonic and not yet rolling. In prone, the infant can achieve prone on elbows but not yet prone on extended arms. In supine, the infant exhibits decreased activity when reaching against gravity or kicking the legs. There is a mild head lag when pulled into sitting and mild trunk flexion when supported in sitting. The infant does not take weight on the legs when held in supported standing. As a result, direct physical therapy services are recommended.

Question: What is generally the highest priority for physical therapy goals with this population?

Potential answers:

1. Stability & Balance
2. Mobility
3. Flexibility
4. Strength

Answer with rationale: Strength. Building the strength of the back extensors will help with prone skills and postural deficiencies. Working on the strength if the neck flexors will assist with decreasing head lag during pull to sit, and with activities in supine. Facilitating leg strength will assist with creeping, crawling, cruising, and bearing weight through the legs.

Children with down syndrome will present with ligamentous laxity, therefore they will not need to work on increasing mobility or flexibility. Building strength will also assist in creating stability to counteract ligamentous laxity.

Balance and stability will also be key parts of rehabilitation for this child, but will increase more steadily once strength has been improved.

For more information see Chapter 238 Down Syndrome in the Color Atlas of Physical Therapy.