Adv Ther

https://doi.org/10.1007/s12325-019-01024-2

ORIGINAL RESEARCH

Effect of Core Stability Exercises and Treadmill

Training on Balance in Children with Down
Syndrome: Randomized Controlled Trial
Reham Saeed Alsakhawi . Mohamed Ali Elshafey

Received: April 26, 2019

Ó Springer Healthcare Ltd., part of Springer Nature 2019

ABSTRACT Group C received the same intervention strate-

gies as group A in conjunction with a treadmill
Introduction: Core stability exercises and exercise program. The children’s balance was
treadmill training play a crucial role in physical evaluated using the Berg balance scale and the
therapy interventions and have an effect on Biodex Balance System. Treatment sessions were
balance in children with Down Syndrome (DS); for 60 min, thrice a week, for 8 consecutive
however, whether core stability exercises or weeks.
treadmill training has more effect on improving Results: There were significance improvements
balance has not been investigated yet. The aim in the three groups in functional balance and
of the study was to investigate the effect of core over all stability indices in favor of groups B and
stability training versus treadmill exercises on C.
balance in children with Down Syndrome. Conclusions: Core stability and treadmill
Methods: Forty-five children aged 4–6 years training improved balance in children with
with Down Syndrome were included in the Down Syndrome and should be applied in
study. The children were equally divided ran- conjunction with physical therapy programs.
domly into three groups. Group A received tra-
ditional physical therapy intervention strategies Keywords: Balance; Berg balance scale; Biodex
to facilitate the balance of participating chil- balance system; Core stability; Down
dren. Group B received the same as group A and Syndrome; Treadmill
additional core stability exercise training.

Enhanced digital features To view enhanced digital

INTRODUCTION
features for this article go to https://doi.org/10.6084/
m9.figshare.8325431. Down Syndrome (DS) is the most common type
of genetic disorder [1, 2]. Children with DS have
R. S. Alsakhawi
M. A. Elshafey a small sized brainstem and delayed cerebellar
The Department of Physical Therapy for Pediatrics, maturation. Lack of training programs and
Faculty of Physical Therapy, Cairo University, Giza,
limited motor experience result in motor dis-
Egypt
turbances and decreased balance capacity of
R. S. Alsakhawi (&) these children when compared to their typically
Rehabilitation Sciences Department, College of developing peers [2, 3]. Children with DS have a
Health and Rehabilitation Sciences, Princess Nourah
Bint Abdulrahman University, Riyadh, Saudi Arabia significant delay in the development of motor
e-mail: [email protected] skills with qualitative differences in movement
 Adv Ther

patterns compared to children without DS in daily activities and the functional capabilities
[4–6]. Children with DS have difficulty main- of individuals with DS [20].
taining body posture, and coupled with an Previous research has demonstrated
abnormal gait pattern, there are an increased improvement in balance in children with Down
number of falls [2, 7]. Syndrome by using core stability training [7].
Little research supports the use of core sta- Other research indicates that balance and lower
bility to improve balance and postural stability extremity strength in children with DS can be
in children with DS. Ghaeeni et al. [2] reported improved by using treadmill exercise. This led
that the improvement of the static balance of to an improved gait pattern sooner than in
children with DS is one of the benefits of core children with no treadmill exercise programs
stability exercises. It does so by increasing the [6, 20–24]. The purpose of this study is to
power and endurance of all the muscles of the compare the effectiveness of core stability
core stabilization area (deep and superficial). training versus treadmill training on dynamic
Aly and Abonour [7] mention that the therapist balance in children with DS.
can use the core stability training as physical
therapy modality for children with DS that have
balance problems, and can therefore be used to METHODS
reduce the risk of falling and related injuries.
The terms ‘‘core’’ and ‘‘core exercise’’ have been Study Design
the most commonly used in recent years [8–10].
Studies in the field of enhancing the balance The current research is a randomized controlled
functions in children with disabilities were trial to differentiate between the effect of core
interested in core stability exercises [2, 11]. The stability exercises versus treadmill training on
term ‘‘core’’ or ‘‘core stability’’ includes anterior dynamic balance in children with DS.
aspect muscles like the abdominals, the gluteal
and paraspinal muscles posteriorly, and the Subjects
pelvic floor with hip girdle musculature inferi-
orly [2, 12, 13]. The aim of core stability training Forty-five children with DS of both sexes par-
is to achieve the optimal physical ability to ticipated in this research, and their age ranged
maintain the normal state of the spine in daily from 4 to 6 years (mean 4.59 ± 0.53). The
activities, in addition to developing the endur- children were recruited from an outpatient
ance and coordination of these core stability clinic, the Faculty of Physical Therapy, Cairo
muscles [2, 14–16]. University, Egypt. The children in this study
Different studies investigated the impact of were selected according to the following crite-
treadmill training on dynamic balance in chil- ria: able to recognize commands given to them,
dren with DS. Treadmill training of infants with understand our verbal command and encour-
DS is a scheduled and typically prescribed agement, and stand and walk independently
physical therapy intervention aiming to reduce without repeated falling. Children with any
the delay in the onset of walking [6]. Treadmill neurological (signs of epilepsy and instability of
exercises stimulate the kinetic, kinematic, and atlantoaxial joint), musculoskeletal, or mobility
temporal features of walking. These exercises disorders, cardiac anomalies, vision or hearing
improve the strength of the muscles of the loss were excluded.
lower extremities, enhance motor learning, This study was approved by the Ethical
improve functional abilities, and activate the Committee of the Faculty of Physical Therapy,
locomotor control system [17–19]. Using the Cairo University, Egypt (No: P.T.REC/013/
treadmill program regularly has similar benefits 001928) and it is in accordance with the Dec-
for elderly adults with DS and improves the laration of Helsinki of 1964 and its later
strength of lower limbs, balance, and walking amendments. A consent form given to parents
skills. This improvement leads to improvement of potential participants described the
Adv Ther

procedures and purpose of the study in detail. and C). This study was conducted from January
Researchers administered a brief structured to April to 2019.
interview to screen children according to the The 15 children with DS in group A (control
research criteria and gather their demographic group) received a traditional exercise program
information. After rapport-building, instru- with instructions given to the children
ments were administered to children, and par- [7, 24, 31] for 60 min aiming to improve posture
ents of participants were assured of the control and balance (Table 1).
confidentiality of the information about their The 15 children with DS in group B received
children. the same program as group A (for 30 min) in

Measures Table 1 A traditional exercise program used in group A to

improve postural control and balance
Berg Balance Scale
Exercise Description
The Berg balance scale is a clinical assessment of
functional balance. It consists of 14 functional The child stood with feet The therapist sat behind the
tasks of increasing difficulty, and each is scored closed together child and locked the
on a scale ranging from 0 to 4 (task is performed child’s knees manually,
independently = 4; unable to complete the
then slowly tilted the
task = 0). The maximum possible score is 56
child forward, backward,
which indicates no identifiable balance diffi-
culties [25, 26]. The inter-rater reliability of Berg and sideways
balance scale is 0.97 (95% CI 0.96–0.98) and the The child stood with one The therapist stood behind
intra-rater reliability is 0.98 (95% CI 0.97–0.99) foot step forward (step- the and child guided the
[27]. standing) child to shift their weight
alternating in forward
Biodex Balance System (Biodex Medical and backward directions
Systems, Version 3.1)
The Biodex Balance System (BBS) is used to The child stood with one The child tried to keep the
adjust the stability of a suspended circular force foot on a block (high balance of the body
plate. The force platform has a maximum of 20° step-standing)
tilt in any direction when completely unstabi-
Standing child The therapist locked the
lized and determines the stability of the partic-
ipant based on the variance of the platform child’s knees manually
from the center [28]. The BBS is an objective and and the child tried to
reliable assessment for measuring the dynamic stoop and recovery
balance (the reliability indices of medial–lateral actively
stability, anterior–posterior stability, and over-
Child applied postural
all stability are 0.43, 0.80, and 0.82, respec-
reactions training
tively) [29, 30]. It was designed to assess
neuromuscular control and stimulate joint (righting, tilting
mechanoreceptors through the ability to equilibrium, and
maintain dynamic postural stability [30]. protective reactions)
Walking exercises (one of Walking across obstacles
Procedure the most important parts (blocks, books, wedges,
of dynamic balance) and rolls of different
Names of children that met the inclusion cri- sizes) in three directions:
teria of the study were collected and uploaded
backwards, forwards, and
to an electronic program (SPSS) that divided the
sideways
sample randomly into three equal groups (A, B,
 Adv Ther

addition to treadmill training. The child walked Phase 1 consisted of a fixed position with iso-
on the treadmill (motorized treadmill, EN- metric contractions, and a slow movement in
TRED, Enraf–Nonius) at 75% of over-ground an unstable setting for difficulty progression.
speed and individually prescribed low-en- Phase 2 began in an unbalanced position to a
durance walking at 0% incline [20] for 20 min, more balanced one with isometric contractions
three times a week for 8 successive weeks with the aim to increase the endurance of the
[24, 32]. The walking area of the treadmill is movements in an unbalanced position. Phase 3
made from heavy steel with a minimum 8-inch was done by using the child’s weight, and
thickness and is available with cushioning in dynamic movements with Swiss and Madison
case of accidental impacts. Before the walking balls were done.
session, each child underwent 5 min of active
stretching exercises that include prolonged and Statistical analysis
progressive stretching of the hamstrings,
quadriceps muscles, and Achilles tendon [20]. The statistical analyses were calculated using
Children were in an upright position when Statistical Package for the Social Sciences (SPSS)
standing on the treadmill, and the therapist version 20. All data in the current study were
adjusted the elevation of the handrails accord- presented as means and standard deviations.
ing to each child. As much as possible, the child The differences between the pre- and post-
was kept looking forwards to stimulate the set- treatment measurements were evaluated using a
ting of independent walking. The child com- paired t test. The differences between the three
pleted treadmill training under three conditions groups were analyzed using one-way analysis of
in 1-min training cycles. For 15 s of each minute variance (ANOVA) followed by least-square dif-
the child could hold on to the railings with ference (LSD) post hoc test. The level of signif-
both hands, for the next 15 s with one hand, icance for all tests in this study was set at 0.05.
and finally with no hands on the handrails for
30 s. Each child repeated this procedure 20
times [24, 33]. At the end of the procedure, RESULTS
there was a 5-min cooldown. Each child wore
street clothes and sports shoes during the pro- Demographic Characteristics
cedure. There was conversation between the
therapist and the child during where their There were no statistically significant differ-
interests were discussed, and motivation was ences between three groups (A, B, and –C) in age
continually provided. (p = 0.69), weight (p = 0.52), height (p = 0.97),
The 15 children with DS in group C received and gender (p = 0.59).
the same traditional physical therapy exercises
as group A (for 30 min) in addition to core sta-
Comparing Between the Three Groups
bility training. Jeffrey’s core stability exercises
Before Treatment
(Table 2) were performed for 8 weeks, with three
30-min sessions per week [2, 7, 34, 35]. Jeffrey’s
protocol included lumbar-pelvic proprioception There were no statistically significant differ-
retraining, specific spinal stabilization exercises, ences in functional balance and overall stability
different muscle contractions, and abdominal index pre-treatment between the three groups
maneuvers. After completion of those exercises, (p [ 0.05) (Table 3).
using dynamic stability was exercised, and the
children needed to maintain stabilization in Comparing Between Pre and Post
various positions such as squatting, supine, and Treatment Among Three Groups
prone. The dynamic components made use of
Swiss ball and limb (upper or lower limb) There was a statistically significant improve-
movement in advanced stages. The previous ment in functional balance and overall stability
exercises [7, 34, 36] included three phases:
Adv Ther

Table 2 Jeffrey’s core stability exercises [37, 38]

Week Form of exercise The volume and intensity of exercise
1 and Contracting abdominal muscles while lying in a supine position Three sets and 20 repetitions in each
2 set
Contracting abdominal muscles while lying in a prone position Three sets and 20 repetitions in each
set
Contracting abdominal muscles while in a squat position Three sets and 20 repetitions in each
set
3 Contracting abdominal muscles while lying in a supine position with one Three sets and 20 repetitions in each
leg stretched and the other bent at the knee and pressed against the set
abdomen
Contracting abdominal muscles while lying in a prone position with one Three sets and 20 repetitions in each
leg stretched and the body weight on the other leg which is bent at the set
knee
Side lying bridge for each side of the body Six repetitions, a 10-s pause
4 Contracting abdominal muscles while lying in a supine position and Three sets and 20 repetitions in each
pulling the limbs upward with arms and legs kept close set
In squat position, one leg is raised and pulled outward and backward Three sets for each leg and 20
repetitions in each set
Trunk rotation while holding weights in each hand Three sets each part of the body and
20 repetitions in each set
5 Sitting on a Swiss ball and holding the abdomen in Three sets, 10 s
Squatting while the Swiss ball is on the shoulder Three sets and 15 repetitions for each
set
Bringing up the arms and legs simultaneously in the prone position Three sets and 15 repetitions for each
set
6 Bending 45° to the left or right Three sets for each side, 12 repetitions
in each set
Bridging while shoulders and hands are on the floor and one leg is raised Three sets for each leg, 15 repetitions
in each set
Contracting abdominal muscles while lying in a supine position on the Three sets, 12 repetitions in each set
Swiss ball
7 Lying supine on the Swiss ball and rotating the trunk to the sides Three sets and 15 repetitions for each
set
Doing the above exercise with holding weights in the hands Three sets and 15 repetitions for each
set
Side lying bridge with bringing up the leg Six repetitions for each side of the
body and a 10-s pause
 Adv Ther

Table 2 continued
Week Form of exercise The volume and intensity of exercise

8 Lying supine on the Swiss ball and holding the abdomen in and bringing Three sets, 12 repetitions in each set
one leg up
Raising the opposite arm and leg while squatting Three sets, 12 repetitions in each set
Bridge so that the feet are placed on the Swiss ball and raise one leg Three sets and a 15-s pause for each
set

Table 3 Pretreatment statistics for the three groups

Variable  – SD)
Group A (X  – SD)
Group B (X  – SD)
Group C (X p value
Functional balance 32.5 ± 3.8 31.7 ± 3.3 33.2 ± 2.5 0.61
Overall Stability Index 4.20 ± 0.406 4.6 ± 0.289 5.1 ± 0.15 0.42
 ± SD mean ± standard deviation, p level of significance
X

Table 4 Pre- and post-treatment statistics for three groups

Variable Group Functional balance p value Overall stability index p value
Pre Post Pre Post
 ± SD)
Group A (X 32.5 ± 3.8 38 ± 2.58 0.001* 4.20 ± 0.40 5.40 ± 0.70 0.001*
 ± SD)
Group B (X 31.7 ± 3.3 43.8 ± 2.91 0.001* 4.6 ± 0.289 6.9 ± 0.33 0.001*
 ± SD)
Group C (X 33.2 ± 2.5 45 ± 2.12 0.001* 5.1 ± 0.15 7.4 ± 0.54 0.001*
p value 0.61 0.15 0.42 0.27
 ± SD mean ± standard deviation, p level of significance
X
*Significant

index for the three groups after treatment DISCUSSION

(p \ 0.05) (Table 4).
The purpose of this study was to determine if
Comparing Between Three Groups After core stability exercises were more effective than
Treatment treadmill training exercises on balance in chil-
dren with DS or vice versa. The outcomes in the
Post hoc test statistics demonstrated that there current study demonstrated that there was not a
was statistically significant improvement in significant difference of balance improvement
group B and group C in functional balance and between treadmill exercises and core stability
overall stability index compared to group A exercises after treatment in children in groups B
(p \ 0.05), but there was no statistically signifi- and C, while there was improvement in the
cant difference between group B and group C in three groups in functional balance and overall
functional balance and overall stability index stability indices in favor of groups B and C.
(p [ 0.05). Previous research studied the effect of treadmill
Adv Ther

training exercises on balance and others studied stability exercises have been demonstrated to be
the improvement of balance by using core sta- effective compared with group A (control
bility exercises in children with DS. All the group). Utilization of various treadmill inter-
research results showed a statistically significant ventions improved the development of joint
improvement in the balance. There are not kinematics in infants with DS. Previous study
enough available studies reporting a compar- found the treadmill interventions to be benefi-
ison between the effect of treadmill training cial on neuromuscular coordination develop-
and core stability exercise on balance in chil- ment [23]. In terms of core stability, Aly and
dren with DS. Abonour [7], Norris [40], and Gribble and Hertel
Previous research approves and supports the [41] found improvements in acceleration and
outcomes of this study and that there are no deceleration, optimal lumbar–pelvic–hip chain
statistically significant differences between the mobility, appropriate proximal stability, proper
effectiveness of the core stability exercises and function, and muscular balance. Improved
treadmill training exercises on balance in chil- lower extremity muscle strength was more able
dren with DS. Both training exercises improved to control the movement.
muscle strength in different ways resulting in On the other hand, the non-significant dif-
improvement of balance. Ghaeeni et al. [2] ference in balance between groups B and C after
investigated the improvement of static balance treatment in this study could mean that both
by using the core stability exercise training in training programs have a similar effect on gait
children with DS. The outcomes of their study patterns through an improvement of static and
indicated that the experimental group had sig- dynamic balance. Changes in walking velocity
nificant improvement of static balance com- and gait parameters by using trunk coordina-
pared to the control group. Their results showed tion have been investigated [12, 42]. In cadence,
that progressive resistance training improves the core stabilization exercise group showed
balance capacity in children with DS. The pro- more improvement than the control group, but
gressive resistance training elements that were there was no statistically significant difference
present in the training program of their study between these groups. The core stability train-
were in the form of weight-bearing exercises. ing exercises might improve the postural sta-
This led to improved balance by increasing bility of the pelvis, and lower trunk. This results
muscle strength [39]. in an increased ability in static and dynamic
Moreover, Carmeli et al. [19] investigated the balance when the weight is supported by the
efficacy of treadmill training on the muscle lower limbs and may ultimately contribute to
strength and balance in elderly people with DS. more stability during gait.
They found significant improvements in the Moreover, Ulrich et al. [5] suggested that
strength of lower extremity muscles, dynamic treadmill training of infants with DS is a critical
balance, and walking function. Their study supplement to regular physical therapy treat-
indicated that measurements of mean peak tor- ment strategies to decrease the delay in begin-
que, the power of hamstrings and quadriceps ning to walk. Increasing the intensity of
muscles, in addition to the parameters of the treadmill training increases the step rate. It is
dynamic balance of elderly people with DS were recommended that research should study the
improved after 6 successive months of treadmill long-term effects of the treadmill training on
exercises. They suggested that the improved the ability of the child to cross obstacles in its
balance was due to improved knee muscle per- pathway and maintain balance during the
formance. These results are supported by several movement. This is because children with DS are
studies also reporting the positive effects of more likely to lose their balance when coming
walking training programs on endurance, muscle across obstacles in their surroundings
strength, and balance in elderly people [2, 40]. [20, 24, 42].
While there was no significant difference The small sample size is a limitation in this
when comparing between groups B and C after study and may impact the generalization of the
treatment, both treadmill exercises and core results. The other limitation is that the effect of
 Adv Ther

interventions was measured immediately after Data Availability. The datasets generated
the period of treatment which was 3 months, so during and/or analyzed during the current
it is not certain if the effect is sustained for the study are not publicly available (this paper is
long term. our work and it is part of our project that is not
finished yet) but are available from the corre-
sponding author on reasonable request.
CONCLUSION
Core stability exercises and treadmill training
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