INFLUENCE OF PHYSICAL THERAPY ON POSTURAL CONTROL IN CHILDREN WITH DOWN SYNDROME: A SYSTEMATIC REVIEW

INFLUENCE OF PHYSICAL THERAPY ON POSTURAL CONTROL IN CHILDREN WITH DOWN SYNDROME: A SYSTEMATIC REVIEW | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 21 October 2025 V1 Latest version Share on INFLUENCE OF PHYSICAL THERAPY ON POSTURAL CONTROL IN CHILDREN WITH DOWN SYNDROME: A SYSTEMATIC REVIEW Authors : Lana Paula Cardoso Moreira 0000-0001-7949-4995 [email protected] , Daniela Lima Silva , Alinnie Pinto Vianna Afonso , Luciane Gisele Olimpio de Souza , Katiane da Costa Cunha , Rodrigo Santiago Barbosa Rocha , Biatriz Araújo Cardoso Dias , and Lucieny da Silva Pontes Authors Info & Affiliations https://doi.org/10.22541/au.176106972.23766342/v1 268 views 133 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract ABSTRACT Purpose: To analyze the effectiveness of physical therapy interventions in improving postural control performance in children with Down syndrome. Methods: This systematic review was conducted according to PRISMA guidelines and registered in PROSPERO (CRD42024599420). Randomized controlled trials were included and assessed for risk of bias using the RoB 2.0 tool. Results: Fourteen studies met the inclusion criteria, exploring interventions such as virtual reality, treadmill training, hippotherapy, vestibular stimulation, and balance or strength exercises. These interventions were associated with improvements in balance, muscle strength, motor coordination, and functional performance. Despite methodological variations, the findings consistently support the positive influence of multimodal physical therapy approaches on postural control. Conclusion: Physical therapy interventions have a positive impact on postural control in children with Down syndrome, promoting improvements in balance, muscle strength, and motor coordination. INFLUENCE OF PHYSICAL THERAPY ON POSTURAL CONTROL IN CHILDREN WITH DOWN SYNDROME: A SYSTEMATIC REVIEW ABSTRACT Purpose: To analyze the effectiveness of physical therapy interventions in improving postural control performance in children with Down syndrome. Methods: This systematic review was conducted according to PRISMA guidelines and registered in PROSPERO (CRD42024599420). Randomized controlled trials were included and assessed for risk of bias using the RoB 2.0 tool. Results: Fourteen studies met the inclusion criteria, exploring interventions such as virtual reality, treadmill training, hippotherapy, vestibular stimulation, and balance or strength exercises. These interventions were associated with improvements in balance, muscle strength, motor coordination, and functional performance. Despite methodological variations, the findings consistently support the positive influence of multimodal physical therapy approaches on postural control. Conclusion: Physical therapy interventions have a positive impact on postural control in children with Down syndrome, promoting improvements in balance, muscle strength, and motor coordination. HIGHLIGHTS • Investigates how physical therapy improves postural control in children with Down syndrome. • Reviews fourteen randomized controlled trials analyzing diverse rehabilitation interventions. • Highlights the benefits of multimodal, evidence-based therapy for motor development and quality of life. Keywords: Child; Down Syndrome; Rehabilitation; Postural Control; Motor Skills. INTRODUCTION Down syndrome (DS) is a genetic condition caused by the presence of an extra copy of chromosome 21, with a global prevalence of approximately 1 in every 700–1,000 live births. This disorder results in a disruption of the regulatory function that genes exert on protein synthesis, including proteins such as DYRK1A, APP, or COL6A1/COL6A2. The abnormal expression of these proteins affects cell development and function, leading to phenotypic changes and delays in motor development (Zago, Tacchini, Deriu, & Lencioni, 2020; Silva, Rocha, & Rezende, 2021; Leite, 2024). In this pathophysiological condition, the central nervous system is impaired due to reduced total cerebellar volume, cellular alterations in the hippocampal region, and decreased synaptic density in the temporal cortex. As a result, this population experiences delays in neuropsychomotor development, such as impaired balance, hypotonia, spatial awareness deficits, poor motor coordination, and postural control difficulties, given that cerebellar impairment disrupts the synergistic activation of muscles (Leite, 2024). Furthermore, when balance is disturbed, the body may recover through the movement of one or more body segments to reposition the center of mass or adjust the base of support width. This process requires sensory integration from the proprioceptive, vestibular, and visual systems. When any of these systems are compromised, functional performance is affected—common in children with DS—resulting in increased risk of falls and limitations in activity and participation (Maïano et al., 2019; Nahla et al., 2022; Leite, 2024). Therefore, physical therapy strategies are developed to address deficits in muscle synergies by improving postural alignment, promoting adequate muscle tone distribution, and enhancing motor repertoire skills (Maïano et al., 2019; Nahla et al., 2022). Recent studies suggest that physical therapy rehabilitation can provide valuable improvements in balance, strength, gait, and functional independence in children with Down syndrome through interventions such as virtual reality, treadmill training, hippotherapy, vestibular stimulation, and strength and balance training (Silva et al., 2021; Pino-Ramos et al., 2021; Nahla et al., 2022; Kaya, Saka, & Tuncer, 2023). Thus, this study aims to analyze the effectiveness of physical therapy interventions in improving postural control performance in children with Down syndrome. METHODS This systematic review followed the research protocol based on the guidelines and recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Handbook . The protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the identifier CRD42024599420. Search Strategy A high-sensitivity search was conducted in the following databases: US National Library of Medicine (PubMed), Web of Science, Scopus, Virtual Health Library (BVS), and Cochrane Library. The search was not restricted by publication period or language. Keywords were selected from the Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH), including: “child,” “Down syndrome,” “rehabilitation,” and “postural balance.” The descriptors were combined using the Boolean operators “AND” and/or “OR.” The specific search strategies used for each database are presented in Appendix 1. Each study was independently evaluated by two reviewers (APVA, DLS) using the Rayyan platform. Articles were selected based on title and abstract screening, with duplicates removed. Discrepancies were resolved by a third reviewer (LPCM). Following this step, full-text articles were read and assessed for eligibility. Gray literature and preprints were not included. Eligibility Criteria The eligibility criteria for primary studies were established using the PICO framework ( Population, Intervention, Comparison, and Outcomes ), defined as follows: (P) children with Down syndrome, (I) rehabilitation, (C) placebo, and (O) postural control. Studies included in this review were randomized controlled trials (RCTs) that investigated the effects of physical therapy rehabilitation on postural control in children with Down syndrome. Exclusion criteria included editorials, letters to the editor, opinion articles, case reports, gray literature, and short communications. Narrative reviews, case studies, duplicate publications, and studies focused on adolescents or adults, individuals without a Down syndrome diagnosis, or those not employing physical therapy interventions aimed at improving postural control were also excluded. Data Extraction Data were extracted independently by two authors (LPCM, LGOS) using a standardized form developed by the research team. Extracted information included study characteristics (authors, study design, journal name, country and study setting, year of publication), sample (size and mean age), interventions (type, duration, and frequency), evaluation (instruments and questionnaires used), outcomes, adverse events, and conclusions. After extraction, the data were organized using Microsoft Excel 2016. Quality Assessment of Evidence The risk of bias in the included studies was assessed using tools appropriate for the study designs. For randomized controlled trials, the risk of bias was evaluated using the RoB 2.0 tool ( Revised Cochrane risk-of-bias tool for randomized trials ), which assesses five domains: bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. Study Selection A total of 3,056 potentially relevant articles were initially identified across the selected databases. Of these, 274 articles were excluded due to duplication, leaving 2,782 records. After screening titles and abstracts, 2,752 articles were excluded for not meeting the eligibility criteria, resulting in 17 studies selected for full-text reading and evaluation. Three studies were excluded due to lack of access to the full text. At the end of the selection process, 14 articles were included in this systematic review. The PRISMA flowchart illustrates the study selection process (Figure 1). Characteristics of Included Studies The characteristics of the studies included in this systematic review are summarized in Table 1, which presents information such as the country of origin, applied interventions, and the outcome measures analyzed. Most studies were conducted in Middle Eastern and Asian countries, including Egypt (6), Turkey (2), Pakistan (2), India (1), and Saudi Arabia (3). A wide variety of therapeutic interventions were investigated, including conventional physical therapy, treadmill training, core stability exercises, whole-body vibration, Pilates, resistance and balance training, vestibular stimulation therapies, and hippotherapy. The outcome measures varied depending on the aim of each study and included muscle strength, mobility, balance, motor skills, proprioception, and quality of life. Table 2 describes the characteristics of study participants, including sample size, study duration, total number of patients, number of female participants, and age range. The number of participants per study ranged from 20 to 56, with treatment durations varying from 6 to 24 weeks. Participants’ ages ranged from 2 to 17 years, with most studies focusing on children between 6 and 12 years old. The number of female participants ranged from 9 to 23; however, some studies did not report gender-specific data. These demographic details help provide a clearer understanding of the participant profiles and allow for the identification of gender and age group representation across the studies. Interventions in the Selected Studies Table 3 summarizes the main characteristics of the interventions in the selected studies, including the type of intervention, frequency, and assessment tools used. Most interventions were conducted an average of three times per week, with each session lasting between 30 minutes and one hour. The studies generally reported favorable outcomes from applied interventions. Risk of Bias Analysis of Included Studies The included studies were classified as having low risk of bias, high risk of bias, or some concerns using the RoB 2.0 tool, as shown in Figure 2. One study presented some concerns due to insufficient information about the randomization process. Another study raised concerns regarding deviations from intended interventions. A third study reported some concerns related to blinding of the intervention. Additionally, five studies raised concerns due to the absence of prior registration of the study protocol. Overall, five studies were rated as having some concerns, while nine were rated as having low risk of bias. DISCUSSION This systematic review analyzed the influence of physiotherapeutic rehabilitation on postural control in children with Down Syndrome (DS) based on randomized clinical trials. Overall, rehabilitation programs were found to be beneficial, promoting improvements in balance, muscle strength, and proprioception in these children. The included studies evaluated the effects of programs based on conventional physiotherapy and combined therapies. Results indicate that physiotherapy is effective in improving dynamic and static balance, gait, and functional independence in children with DS. Additionally, associated therapies such as hippotherapy (Kaya et al., 2023; Siddiqui et al., 2024) stood out for their playful aspect, which is essential to maintain the attention of the pediatric population. Interventions like vestibular stimulation (Uyanik et al., 2003; Nahla et al., 2022), which promote sensory integration, as well as exercises based on the Pilates method, aerobic training, trampoline, and suspension therapy (Eid et al., 2017; Al-Nemr et al., 2024; Azab et al., 2022; El-Meniawy et al., 2012) also showed significant results in postural control, strength, and motor coordination. When comparing the results, it is observed that integrative methods such as hippotherapy combined with conventional physiotherapy (Kaya et al., 2023), mechanical vestibular stimulation exercises (Nahla et al., 2022), isokinetic training (Eid et al., 2017), Pilates (Al-Nemr et al., 2024), weight-bearing exercises (Rahman et al., 2010), and aerobic training (Eid et al., 2022) presented superior outcomes compared to isolated therapies, reinforcing previous findings in the literature about the benefits of multimodal interventions. From a theoretical perspective, the findings suggest that interventions combining muscle strengthening, balance, and sensory integration have the potential to optimize neural plasticity in children with DS, contributing to more efficient motor organization and possibly directly affecting the development of postural control. This aspect underscores the importance of investing in rehabilitation strategies that address multiple systems, aligned with the specific characteristics of this population. According to Shumway-Cook and Woollacott (2012), postural control is the ability to control the body’s position in space for the purpose of stability and postural orientation, and Horak (2006) describes that the result of the interaction between multiple sensory and motor systems contributes to postural orientation and stability. Therefore, therapies that combine sensory integration, balance strategies, and motor tasks seem to be more effective. On the other hand, there are divergences in the efficacy of specific modalities. For example, while core stability exercises (Zulfiqar et al., 2022) were shown to be more effective than balance training regarding improvement in postural control, other studies, such as those by El-Meniawy et al. (2012) involving suspension therapy and treadmill training, suggest that these approaches can be equally effective, also attributing a positive relationship between improvements seen in study groups to the effect of conventional exercise programs for balance and postural control. Such divergence may be due to significant variation among protocols regarding frequency, session duration, and population characteristics, making direct comparisons between studies and interventions difficult. For example, while Al-Nemr et al. (2024) reported improvements with the inclusion of the Pilates method, other studies such as Gupta et al. (2011) emphasized the role of progressive resistance training, using different tools to assess the proposed variables, pointing out methodological gaps and highlighting differences in measurement instruments, such as the Biodex Balance System and portable dynamometers, which capture different modalities of balance and muscle strength. Clinical and Practical Implications for Research The practical and clinical implications are highly relevant to research, as they contribute to the advancement of evidence-based scientific knowledge, development of assessment and clinical protocols aimed at professional practice, present innovation in rehabilitation treatments, and promote improvements in public health services. The analyzed studies indicate favorable clinical outcomes, highlighting the effectiveness of new therapies and combined approaches to improve postural stability and motor development in children with DS, helping reduce risks and complications in motor repertoire skills, since such interventions act on postural alignment by promoting adequate muscle tone distribution, as well as enhancing strength, coordination, and balance in this population (Silva et al., 2021; Pino-Ramos et al., 2021; Nahla et al., 2022; Kaya et al., 2023). The applicability of these results favors the planning of specialized interventions and continuous monitoring in daily clinical practice, promoting quality of life for these children. Furthermore, these results are relevant for the development of public policies based on rehabilitation treatment strategies with scientific evidence, as well as investments in education, research, and innovation, thereby reducing social impacts. Limitations Despite careful selection of keywords and search strategies, it is possible that potentially useful literature may have been excluded from this review at some point. The large variability of data observed is due to the wide population assessed, as well as the conditions in which these individuals were evaluated and the instruments used in their respective studies. That is, although some studies evaluate the same parameters, heterogeneity in variables such as age and sex, differences in scales and/or instruments used for assessment, comparators, and types of intervention may hinder direct comparisons. The article selection criteria for this review included randomized clinical trial designs, but many articles had to be excluded due to variability in study design. Another important limitation to highlight is that among the selected articles, three were not available in full in the consulted databases, and of the 14 studies used, five showed some concerns (mostly due to lack of study registration), although the other nine studies presented low risk of bias, thus demonstrating the reliability of this review despite the limitations encountered. All these limitations may directly impact not only the results but also the interpretation of data provided by the articles used, potentially causing significant implications in the development of scientific research through systematic reviews. It becomes evident the need for further investigations on this topic, aiming to fill gaps still existing in specialized literature. The importance of more rigorous and detailed protocol registrations, as well as standardization of variables analyzed—especially in studies with more homogeneous samples—is emphasized. Furthermore, the adoption of more robust methodologies is recommended to allow more consistent comparisons among findings. Such advances are fundamental for strengthening scientific production in this specific field of Physiotherapy, contributing significantly to the construction of solid and applicable clinical evidence. CONCLUSION The physiotherapeutic interventions analyzed in the studies showed a positive impact on postural control in children with Down Syndrome, promoting improvements in balance, muscle strength, and motor coordination. Among the approaches analyzed, combined interventions such as hippotherapy, vestibular stimulation, and Pilates stood out by showing superior results when simultaneously addressing multiple sensory and motor systems. Despite methodological variations among studies, the findings reinforce the importance of multimodal, evidence-based rehabilitation strategies to enhance motor development and quality of life in these children. The results offer valuable subsidies for improving clinical practices and developing public policies aimed at this population. REFERENCES Al-Nemr, A., & Reffat, S. (2024). Effect of Pilates exercises on balance and gross motor coordination in children with Down syndrome. 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Gait and postural control patterns and rehabilitation in Down syndrome: A systematic review. Journal of Physical Therapy Science, 32 (4), 303–314. Zulfiqar, H., et al. (2022). Effect of core stability exercises and balance training on postural control among children with Down syndrome. Pakistan Biomedical Journal , (n.d.), 18–22. Supplementary Material File (figures.docx) Download 155.91 KB File (tables.docx) Download 29.44 KB Information & Authors Information Version history V1 Version 1 21 October 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords child down syndrome motor skills postural control rehabilitation Authors Affiliations Lana Paula Cardoso Moreira 0000-0001-7949-4995 [email protected] Universidade do Estado do Para View all articles by this author Daniela Lima Silva Universidade do Estado do Para View all articles by this author Alinnie Pinto Vianna Afonso Universidade do Estado do Para View all articles by this author Luciane Gisele Olimpio de Souza Universidade do Estado do Para View all articles by this author Katiane da Costa Cunha Universidade do Estado do Para Centro de Ciencias Biologicas e da Saude View all articles by this author Rodrigo Santiago Barbosa Rocha Universidade do Estado do Para Centro de Ciencias Biologicas e da Saude View all articles by this author Biatriz Araújo Cardoso Dias Universidade do Estado do Para Centro de Ciencias Biologicas e da Saude View all articles by this author Lucieny da Silva Pontes Universidade do Estado do Para Centro de Ciencias Biologicas e da Saude View all articles by this author Metrics & Citations Metrics Article Usage 268 views 133 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Lana Paula Cardoso Moreira, Daniela Lima Silva, Alinnie Pinto Vianna Afonso, et al. 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