Attention to the child with Down Syndrome from a multimodal

approach to Physical Rehabilitation

MSc. Jorge Alberto Quijije Vélez¹, Dr. Daniela Milagros Palacio González², Dr. Digna Marga-

rita Quijije Zambrano³, Ismaray Gómez Peralta⁴.

¹Lay University “Eloy Alfaro de Manabí”. Ecuador: Email: aquije@gmail.com , jalqui-

vel@hotmail.com : ORCID: https://0009-0008-8305-2063

²Doctor of Science in Physical Culture and MSc. in Didactics of Contemporary Physical Education.

Central University “Marta Abreu” of Las Villas, Faculty of Physical Culture. Email: dpala-

cio@uclv.cu ; ORCID: https://0000-0002-3708-2578

³Lay University “Eloy Alfaro de Manabí”. Ecuador: PT. Doctor of Pedagogical Sciences: Email:

digna.quijije@uleam.edu.ec ; ORCID: https://0009-0000-5053-1035

⁴Methodologist, Inder SC: Email: ismaraygomezperalta@gmail.com ; ORCID: https://0009-0004-

5748-4277

Abstract

Physical rehabilitation in children with Down syndrome should be multidisciplinary, early, and

personalized, addressing physical conditions and promoting autonomy. Recent studies support its

effectiveness in optimizing motor function, preventing sequelae, and improving social participation.

Objective: To analyze the diversity of therapeutic modalities used as a means of physical

rehabilitation in schoolchildren with Down syndrome. Methodology: This is a descriptive-

retrospective bibliometric study that conducts a bibliographic review using four international

databases to compile various studies on the variety of therapeutic modalities used as a means of

physical rehabilitation in schoolchildren with Down syndrome, and thus assess their effectiveness in

addressing the physical conditions associated with the syndrome. Results: The results obtained

indicate that the findings in the articles reviewed in the last five years emphasize various

rehabilitation modalities for the care of children with Down syndrome. Conclusions: The

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effectiveness of applying various modalities such as aquatic therapy, equine therapy, occupational

therapy, and others was demonstrated in the reviewed research.

Keywords: Physical Rehabilitation, Down Syndrome, Multimodal Approach

Introduction

Among the diverse group of children with intellectual disabilities who are integrated into the current

educational system are those diagnosed with Down Syndrome (DS), who require multidisciplinary

attention due to the variety of comorbidities and disorders associated with it.

Down syndrome is a genetic condition caused by the presence of an extra copy of chromosome 21

(trisomy 21), which leads to distinctive phenotypic characteristics, varying degrees of intellectual

disability, and an increased risk of medical comorbidities. It is also associated with alterations in

growth and cognitive, motor, and social development (Bull et al., 2022). These authors also attribute

various clinical manifestations to it, such as cardiac anomalies, respiratory and musculoskeletal

complications, psychomotor delay, hypotonia, and ligamentous laxity, among others.

Among respiratory complications, some authors, such as Bull et al. (2022), mention obstructive sleep

apnea (OSA), which, according to them, affects more than 60% of children with Down syndrome.

Anatomical obstructions of the upper airways also appear, requiring interventions.

The most frequent musculoskeletal abnormality is atlantoaxial instability (AAI), a common

orthopedic complication in children with Down syndrome (DS), characterized by excessive mobility

between the first (atlas) and second (axis) cervical vertebrae. Atlantoaxial instability occurs in 10–

30% of these children, requiring periodic radiological evaluation. Computed tomography (CT) and

dynamic radiography are key to preventing neurological complications.

Physical rehabilitation plays a crucial role in the diagnosis, monitoring, and therapeutic management

of the aforementioned complications. The benefits of reducing these complications are evident,

employing various rehabilitation methods to improve quality of life and prevent further

consequences.

Authors such as Pacheco (2024) and Reynoso & Adarmí (2025), Among the benefits of physical

rehabilitation in school children with Down syndrome, the following stand out: improvement of

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gross and fine motor development (coordination, balance, gait); muscle strength and tone (hypotonia

characteristic of Down syndrome); sensory and cognitive integration (exercises improve attention

and learning); prevention of obesity, heart disease, postural problems, and it contributes to autonomy

and socialization in group activities that promote inclusion.

The main physical-therapeutic alternatives point to neuromotor physiotherapy through balance

exercises (walking on lines), strengthening of core and lower limbs Reynoso & Adarmí, (2025);

hydrotherapy and adapted swimming to improve resistance and muscle relaxation, Madrid, (2024);

and sports activities with adjustments to promote strength and coordination, (Murga, 2025).

From a medical-preventive point of view, periodic evaluations of the spine (scoliosis), hips

(instability) and feet (flat feet) are suggested; cardiac monitoring (due to the high prevalence of

congenital heart disease); weight control to avoid obesity and its musculoskeletal complications;

early detection of hypothyroidism and visual/auditory problems that affect motor development.

(Murga,2025).

The multidisciplinary approach emphasizes the collaborative work of physiotherapists, occupational

therapists, psychologists, and family involvement, and supports evidence for Multimodal

Interdisciplinary Rehabilitation Programs (MIRMPs), which include physical exercise combined

with structured psychosocial interventions. These programs are superior to unimodal treatments in

reducing pain intensity, improving physical function, and decreasing work disability in patients with

chronic low back pain and generalized musculoskeletal pain. Watson, et al. (2022).

Incorporating pain neuroscience education strategies alongside cognitive-behavioral therapy within a

multimodal framework produces significant improvements in pain reduction and self-efficacy,

surpassing the effects obtained solely with manual therapy or isolated exercise. This approach

facilitates the patient's reconceptualization of pain, decreasing the perceived threat and promoting

adaptive behaviors. (Kamper, et al., 2021).

Multimodal treatment models that combine specific therapeutic exercise, manual therapy techniques

for modulation of the autonomic nervous system, and gradual exposure strategies to feared

movements have proven to be more effective than isolated interventions in patients with subacromial

pain syndrome and upper extremity tendinopathies, particularly when considering long-term

prognosis and symptom recurrence. (Pieters et al., 2023).

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Many studies indicate that the variety of therapeutic modalities, including physical rehabilitation,

aquatic therapy, and equine therapy, among others, have clearly demonstrated their effectiveness in

some systems affected by Down syndrome. Objective: To analyze the diversity of therapeutic

modalities used as a means of physical rehabilitation in school-aged children with Down syndrome,

with emphasis on the resource or method used and the objective of the treatment.

Methodology

This is a descriptive literature review, analyzed according to the recommendations for qualitative

studies through the synthesis and discussion of the main findings. The following steps were followed

to carry out the study: a review of national journals in the field of physical rehabilitation; a search for

articles in the international literature; data collection; analysis of the studies; and discussion of the

results. The Boolean operator AND was used for study selection. The keywords "physical

rehabilitation," "rehabilitation modality," and "Down syndrome" were used in four international

databases: Google Scholar, SciELO, and Redalic, as well as international repositories.

The inclusion criteria were studies published in the last 5 years in international sources and written in

Spanish. Duplicate articles, studies outside the established timeframe, and those that did not include a

rehabilitation method other than physical exercise were excluded. For initial eligibility, the titles of

each record were considered to verify their relevance to the topic. Then, the abstracts were analyzed,

followed by the full text to extract information relevant to the discussion. Data such as the author,

objective, type of research, and main results were used for data analysis and synthesis.

Results and discussion

The first three pages of the Google Scholar search engine were consulted until the sources for the

period 2020 to 2025 were exhausted. 55 studies were identified, of which, after applying the

eligibility selection with inclusion and exclusion criteria, 22 studies were selected, and to compose

the final version of the research, only 8 studies were selected with the inclusion and exclusion

criteria, as shown in the flow diagram.

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Studies identified in

databases (n =55)

Studies eliminated due

to duplicates (n = 18)

Identified

Studies reviewed

(n = 37)

Screenings

Included

Excluded studies

(n = 15)

Studies evaluated for

eligibility(n = 22)

Excluded studies:

Criterion 1 (n = 7) Criterion

(n = 8)

Included studies

(n = 8)

Figure 1. Flowchart of the study identification process

Findings resulting from the analysis of the selected studies Diversity of

Resources or Means in Physical Rehabilitation for Down Syndrome

Physical rehabilitation for people with Down syndrome employs a wide range of innovative and

traditional methods, adapted to the specific needs of this population. The eight studies reviewed

highlight objectives aimed at addressing motor, cognitive, and sensory areas through multifaceted

interventions.

Among the most relevant methods or resources used in the eight reviewed studies are aquatic thera-

py; multisensory stimulation; eccentric exercise; the Bobath Method; equine therapy; respiratory

physiotherapy; virtual reality; and comprehensive early intervention.

The multisensory stimulation used in the study by Ruiz et al. (2022) is a therapeutic and educational

technique that aims to activate the senses (sight, hearing, touch, smell, taste, and proprioception) to

improve cognitive, emotional, and physical development, especially in people with disabilities, neu-

rodevelopmental disorders, or older adults.

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Table1. List of studies included in the review

Treatment

Objective

Author and year

Study

Resource used

1 Alban. (2023)

Multisensory module for cognitive

Intelligent

module

Cognitive

stimulation

development

prefrontal lesions

2 Ruiz, EAA, & Digital ecosystem for multisensory

in

children

with

Digital

ecosystem

Multisensory

stimulation

Ruiz,

(2023).

RSA stimulation in children with Down

syndrome.

3 Córdova,

JPA, Playful virtual reality in visual and

Visual and

cognitive

training

Velez, APM, & cognitive training in children with

Guanoluisa,

KAM (2024).

Virtual reality

Equine therapy

Down syndrome.

4 Pacheco

Pozo, Equine

therapy

to

develop

. MPE DOWN IN psychomotor skills in preschool

THE AQUATIC children with Down syndrome.

ENVIRONMEN

Psychomotor

skills

T. (2024).

5 Pasto

Respiratory

with

(Bachelor's

National

physiotherapy

Down syndrome

thesis, Riobamba,

University of

in

Yanchatipan, AI patients

(2024).

Breathing

exercises

Respiratory

system

Chimborazo).

6 Madrid Concha, Methods for training students with

Aquatic

environment

Aquatic

therapy

J. (2024).

Down syndrome in the aquatic

environment

7 Murga

Lemus, Literature review of the therapeutic

benefits of eccentric exercise as a

JR (2025).

The eccentric

exercise

Muscle

strength

treatment

strength in patients with Down

syndrome aged 10 to 15 years

to

improve

muscle

8 Reynoso, M., & Literature review of the therapeutic

Adarmí,

(2025).

G. benefits of the Bobath method in

psychomotor delay in patients with

Down syndrome aged 0-10 years

(Doctoral dissertation).

Bobath

Method

Psychomotor

Development

Ruiz et al. (2022) also employ digital environments and smart modules with lights, sounds, and tex-

tures to enhance sensory integration.

The use of multisensory stimulation is based on principles such as individualization, adapting to each

person's sensory needs; non-directiveness, allowing participants to freely explore stimuli without

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pressure; safety, using safe materials and environments to prevent overstimulation; and the principle

of sensory integration, which aims to organize the nervous system's responses to stimuli.

Among the benefits of this approach for children with Down syndrome, this author states that it re-

duces stereotypies, improves attention, and promotes communication, exploration of the environ-

ment, and motor and cognitive development, addressing the intellectual disability that is often asso-

ciated with them.

Equine therapy, or hippotherapy, is a therapeutic method that uses the horse's movement and the hu-

man-animal bond to improve physical, cognitive, emotional, and social areas in people with disabili-

ties. In this review, Pacheco (2024) discusses its use to strengthen balance, posture, and emotional

connection in young children with Down syndrome.

Among the elements to highlight regarding the use of this method, the author points out how the

transmission of the horse's movement stimulates the pelvis and spine, improving balance and pos-

ture; it also increases confidence and self-esteem through the bond with the horse. Furthermore, it

integrates tactile, visual, and auditory stimuli as multisensory stimulation.

The benefits of the environment for children with Down syndrome are framed in the physical order:

in the improvement of muscle tone, coordination and gait; the cognitive order stimulates attention

and memory, and in the social and emotional order it increases interaction and reduces anxious be-

haviors.

Findings related to new technologies as a means of physical rehabilitation in children with Down

syndrome were found in the studies by Ruiz et al. (2023) and Córdoba et al. (2024). In the digital

ecosystem developed by Ruiz et al. (2023), environments are used to enhance multisensory stimula-

tion. This ecosystem also combines tablets and sensors with traditional techniques to stimulate atten-

tion and learning.

In the case of Córdoba et al. (2024), ludic virtual reality (LVR) is used as a methodology that

combines immersive digital environments with game elements to promote learning and

rehabilitation. It is based on principles such as: sensory immersion for visual, auditory, and

kinesthetic stimulation; interactivity through active user participation in designed tasks; gamification

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with the use of game mechanics (rewards, levels) for motivation; and personalization through

adaptation to individual needs.

Both authors propose interactive games and 3D environments to train visual, cognitive, and

coordination skills, with immediate feedback, in individuals with Down syndrome. Regarding the

benefits of virtual reality and digital ecosystems for individuals with Down syndrome, both studies

mention improved motor coordination; reinforced cognitive learning through repetition in safe

environments; increased motivation by making therapies fun activities; and greater independence in

activities of daily living (Pérez et al., 2022).

Respiratory physiotherapy, a specialty that seeks to prevent, treat and stabilize dysfunctions of the

respiratory system through manual techniques, exercises and patient education, is fundamental in

people with Down syndrome (DS), due to their anatomical characteristics (muscle hypotonia, narrow

airways, higher incidence of respiratory infections)

Pasto (2024) employs techniques such as incentive spirometry and recurrent postural drainage,

common in people with Down syndrome. This approach is based on improving pulmonary

ventilation through thoracic expansion techniques; draining secretions to reduce infections; and

promoting the strengthening of the diaphragm and intercostal muscles. It also aims to stimulate

effective coughing to prevent mucus accumulation.

Specifically in SD the benefits are expressed in the decrease of respiratory infections (pneumonia,

bronchitis); in the improvement of oxygenation and lung capacity Guillén et al., (2020); in the

prevention of atelectasis due to accumulation of secretions; and the strengthening of respiratory

muscles, improving physical resistance.

Aquatic therapy is a rehabilitation method that uses the physical properties of water (buoyancy,

viscosity, hydrodynamic resistance and temperature) to facilitate movement, improve muscle

strength, coordination and relaxation.

Its principles of buoyancy, viscous resistance, hydrostatic pressure, and water temperature are

fundamental because they reduce joint impact, allow for less strenuous movement, promote

progressive muscle strengthening, improve circulation and proprioception, and encourage muscle

relaxation.

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The following benefits of aquatic therapy have been demonstrated in children with Down syndrome:

➢ Improves muscle tone (characteristic hypotonia).

➢ It stimulates gross and fine motor coordination.

➢ It promotes sensory integration.

➢ It promotes socialization and self-esteem.

For their part,Madrid (2024) considers it a therapeutic means to improve coordination, muscle tone

and motor confidence; he includes flotation exercises, resistance and directed games, promoting

relaxation and psychomotor development.

Eccentric exercise refers to the phase of a muscle movement in which the muscle lengthens under

tension, acting as a brake or controller of the movement; it occurs when the external force exceeds

the force generated by the muscle, such as when lowering a weight.

As principles it refers

1. Greater force production: muscles can generate more force in the eccentric phase than in the

concentric phase

2. Lower energy expenditure: although more force is produced, oxygen consumption is lower

compared to concentric actions

3. Controlled muscle damage: induces micro-lesions that stimulate hypertrophy and adaptation

4. Selective fiber recruitment: Primarily activates type II (fast-twitch) muscle fibers

Street band (2025) showed the therapeutic benefits of eccentric exercise as a treatment to improve

muscle strength in children with Down syndrome aged 10 to 15 years using eccentric contractions,

which are less fatiguing and more effective in hypotonia.

Other benefits were also demonstrated (Schoenfeld, 2020), focusing on:

- Muscle hypertrophy, a greater stimulus for growth

- Improved strength and power, the foundation for explosive sports

- Injury prevention strengthens tendons

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-Metabolic efficiency, ideal for populations with cardiovascular limitations

The Bobath Method is a neurodevelopmental rehabilitation approach designed to improve postural

control and movement in individuals with neuromotor impairments. Developed in the 1940s, it is

based on neuroplasticity, promoting more efficient movement patterns by facilitating normal

postures and movements.

According to authors Reynoso & Adormí (2025), the Bobath Method for children aged 0-10 years is

a neurodevelopmental therapy that corrects abnormal postural patterns and improves motor control

through guided movements.

The method's key principles include individualization, postural control, inhibition of abnormal

reflexes, facilitation of normal movements, and sensorimotor integration. Benefits for individuals

with Down syndrome include improved muscle tone, gross and fine motor development,

advancement of milestones such as sitting, crawling, and walking, sensory integration, support for

proprioception and balance, and increased independence by facilitating activities of daily living

(ADLs).

Conclusions

1. The diversity of media reflects the need to personalize interventions from the playful-aquatic to

the technological (virtual reality, digital ecosystems) and the physiological (eccentric exercise).

2. The current trend integrates technological innovation with conventional therapies, highlighting

the role of interdisciplinarity in rehabilitation. These approaches not only improve physical

capabilities but also promote social inclusion.

3. Recent studies highlight its impact on autonomy, physical and emotional health, supported by a

preventative medical approach. In short, physical rehabilitation for school children with Down

syndrome should be comprehensive, personalized, and evidence-based, combining traditional

exercises with technological innovations.

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