EVALUATION OF BALANCE IN DOWN PERSONS.

AN EPIDEMIOLOGICAL AND CLINICAL INVESTIGATION ON 383 SUBJECTS.

Renato COCCHI, neurologist and medical psychologist.

 Summary.

Out of 510 Down subjects, 383 of them (219 M and 164 F; normal distribution of the chromosomal anomalies; average age at the first consultation 83.53 +/- 71.23 months with 6-506 months range). had even an evaluation of the balance or during the first examination or 5-7 months after they got the walking. This investigation showed that the troubles are more frequent in the males, the balance improves with the age growing, in part, even creditable to the rehabilitation therapies, but this doesn't happen in all subjects. In this sample 19 subjects (about 5%), seen for the first time after they were 15 years old, had still some deficit as to going downstairs, running clumsiness, and not biking without the support wheels.

Key words: Down syndrome, balance, gender prevalence, age, rehabilitation therapies, time course.

Testo in italiano

Down syndrome

Mental retardation

Stress symptoms

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In a preliminary note on the troubles of the balance in the Down person (Cocchi, 1991) I made a neurophysiological, neuropathological, clinical and rehabilitative frame of reference where these troubles can take place and their treatment possibilities.

I mentioned there, at that moment, the dysfunction state of vestibular, mid-brain and pons, and cerebellar areas as possible promoters of the balance troubles. Felicioli and Moretti, 1984, asserted them as treatable at least by a rehabilitative intervention.

As for me, the balance troubles in Downs are not secluded in a specific way from all motor skills of these subjects.

This clumsy and awkward motility, without any motor lesion, is enough similar to that of the children with mental retardation of other origin. On the other hand, the aspects of the balance control in Downs seem to have peculiar features, worthy of a punctual investigation. (Cocchi, 1991).

Only now, owning a database of 510 subjects (the limit of an old database) and having investigated this symptom during the first consultation, if the child had already reached the walking, or after at least six months, if he had it reached subsequently during drug therapies, I decided to face first this aspect from an epidemiological and clinical point of view.

Materials and methods.

This investigation used the clinical cards referring to a consecutive series of home reared and home living Downs as seen in outpatients' clinic by the present author. I excluded all psychotic subjects.

From all the records so pointed out, I discarded those of the autistic or other PDDs Ss because I saw that this second heavier pathology can modify every symptom or behaviour.

From the remaining records I collected:

- sex;

- chromosomal diagnosis;

- age at 1st consultation;

- age of the walking, if before the first examination, or before six months from the drugs taking;

- age of the walking when after at least six months of drugs taking;

- the gradation of the balance as current aspects, as it follows. I must remember that a child may anticipate a symptom of the following condition, (usually the biking without support wheels) or may maintain a symptom of the preceding condition (fear to be upon the basis of the scale to weigh).

(++++) a little uncertain walking; enlarged maintenance base; going upstairs downstairs by a simple footstep with the support of the adult or of the handrail; the child doesn't run, nor jumps, and he/she goes in panic if standing upon the basis of the scale to measure his/her weigh;

(+++) sure walking; less enlarged maintenance base; he/she climbs by alternating feet and go downstairs by simple footstep, without any support; awkward run; he/she doesn't know how to jump; and he/she goes in panic if standing upon the basis of the scale to measure his/her weigh;

(++) normal run or just a little awkward, with wavering of limbs; going upstairs and downstairs with alternating feet; jumps from at least two steps; he/she is biking with support wheels; no panic when he/she stands upon the basis of the scale to measure his/her weigh;

(+) like the preceding grade (++) but, as more, he/she is biking without support wheels. The balance trouble is nearly absent.

I elaborated the collected data by statistics for gender, chromosomal anomaly, age of walking and age bands, by evaluating them, when possible, with the Chi Square test.

Results.

I reported the data of the subjects to whom belong the records in the tables that follow.

Tab. 1: Epidemiological data.

Nr. of Ss	510	100.00%
Malesi	292	57.25%
Females	218	42.57%
M/F ratio	133.94/100
Chromosomal diagnosis
Standard trisomy 21	461	90.39%
Mosaicisms	16	3.14%
Translocations	16	3.14%
Unknown, only clinical diagn.	17	3.33%
Age at 1st consultation (months)
Range	6-510
Mean +/- SD	71.37 +/- 69.71

As we can see in Table 1, the M/F ratio overlaps the same known ratio of Italian live-born Down babies. Even the distribution of chromosomal anomalies fitted the variance range for Italian and International samples.

For these reasons we ought to maintain the present sample as representative at least of the Italian Downs population.

Tab. 2. Distribution for gender, chromosomal diagnoses and age as for subjects who had the balance evaluated. The not investigated Ss have been nearly all seen just once, before or having just reached the walking. So they did not have the balance evaluation.

Ss nr. of the whole sample	510			100.00%
Not investigated	127			24.90%
With balance evaluation	383			76.10%
Balance evaluation	383			100.00%
Males	219			57.18%
Females	164			42.82%
M/F ratio	133.54
Chromosomal diagnoses
Standard trisomy 21	347			90.60%
Translocations	12			3.13%
Mosaicisms	10	2.61%
Only clinical diagnosis	14		3.66%
Age at 1st. consultation
Average +/- SD (months)	83.53 +/- 71.23
Range (months)	6 - 506

The symptom had its evaluation in the 76.10 % of the subjects, with the usual male prevalence very close to what corresponded at the birth for Italian children (Camera and Mastroiacovo, 1984).

The distribution of the chromosomal anomalies is even close to what known for Italian and international Down populations.

The average age at the first consultation is higher than that of the general sample, because of the lack of evaluation of the symptom in subject nearly all seen just once, first or just they reached the walking (24.90%).

Tab. 3. Distribution for gender of the symptom "troubles of the balance" according to its severity.

Symptom gradation	Ss no.	%
Severe trouble (++++)
Males	49	12.79
Females	43	12.23
Moderate trouble (+++)
Males	110	28.72
Females	96	25.07
Light trouble (++)
Males	57	14.88
Females	25	6.53
Nearly abstent trouble (+)
Males	3	0.78
Females	0	0.00
Totals	383	100.00

Chi Square M vs F = 9.120 with 3 df and p = 0.036.

The gender distribution of the symptom is significantly different, in particular for what concerns the light trouble (++), where we can observe more than double male prevalence.

Tab. 4. Distribution of the balance troubles for age bands in months, according to the already acquired walking at the first consultation, or even gotten within five months from the starting of the drugs' therapy.

Ss total	248 = 100.00% with median = 65 months
Age (months)	Grade ++++ Ss nr.	%	Grade +++ Ss nr.	%	Grade ++ Ss nr	%	Grade + Ss nr	%
13-24 ( 153 Ss)	134	54.03	15	6.05	4	1.61	0	0.00
25-36 (82 Ss)	19	7.66	52	20.97	11	4.44	0	0.00
37-48 (9 Ss)	3	1.21	5	2.02	1	0.40	0	0.00
49-60 (4 Ss)	1	0.40	2	0.81	1	0.40	0	0.00

Tab. 5. Distribution of the balance troubles for age bands in months, according to the acquired walking not before six months from the starting of the drugs' therapy, and evaluated after 6-7 months from the beginning of walking.

Ss total	49 = 100.00% with median = 24 months
Age (months)	Grade ++++ Ss nr.	%	Grade +++ Ss nr.	%	Grade ++ Ss nr	%		Grade + Ss nr	%
13-24 ( 30 Ss)	19	38.77	9	18.36	2	4.08	0			0.00
25-36 (17 Ss)	13	26.53	4	8.16	0	0.00	0			0.00
37-48 (2 Ss)	1	2.04	1	2.04	0	0.00	0			0.00
49-60 (0 Ss)	0	0.00	0	0.00	0	0.00	0			0.00

The median of the age at the first consultation, is much higher in the subjects already walking, or that reached walking before six months from the starting of the drugs' therapy. It could justify a more favourable distribution of the gradation of the balance, which surely is linked to the age and then to the duration of rehabilitation therapies. Therefore a better understanding of the approximated time course of the balance development, may be reached by evaluating its gradations as compared with the ages at first examination (partly corrected).

Tab. 6. Distribution of the balance troubles for age bands in months, evaluated in infants, at least five months after the acquisition of walking if the age at the first consultation preceded walking, or followed it non more than four months (evaluation at five or more months after the acquisition of walking). Subjects were not in treatment with drugs.

Ss total	248 Ss = 100.00%
Age (months)	Grade ++++ Ss nr.	%	Grade +++ Ss nr.	%	Grade ++ Ss nr	%		Grade + Ss nr	%
13-24 ( 9 Ss)	8	3.23	1	0.40	0	0.00	0			0.00
25-36 (48 Ss)	22	8.87	24	9.68	2	0.81	0			0.00
37-48 (27 Ss)	9	3.63	15	6.05	3	1.21	0			0.00
49-60 (36 Ss)	6	2.42	25	10.08	5	2.02	0			0.00
61-72 (21 Ss)	3	1.21	16	6.45	2	0.81	0			0.00
73-84 (14 Ss)	1	0.40	10	4.03	3	1.21	0			0.00
85-96 (9 Ss)	1	0.40	7	2.82	1	0.40	0			0.00
97-108 (10 Ss)	0	0.00	6	2.42	4	1.61	0			0.00
109-120 (!6 Ss)	2	0.81	8	3.23	6	2.42	0			0.00
121-132 (9 Ss)	0	0.00	5	2.02	4	1.61	0			0.00
133-144 (13 Ss)	1	0.40	5	2.02	7	2.82	0			0.00
145-156 (4 Ss)	0	0.00	1	0.40	3	1.21	0			0.00
157-168 (5 Ss)	0	0.00	3	1.21	2	0.81	0			0.00
169-180 (8 Ss)	0	0.00	4	1.61	3	1.21	1			0.40
181-240 (12 Ss)	0	0.00	10	4.03	2	0.81	0			0.00
241-360 (7 Ss)	0	0.00	3	1.21	4	1.61	0			0.00
Totali	53	21.37	143	57.67	51	20.56	1			0.40

Graphic 1.

How we can see from the graphic one, the more precarious balance state is that of the first years of life, from 1-2 to 5-6 years, (>2%) which hardly could be considered near to the normal motor development.

Graphic 2.

A more favourable condition, but always abnormal, we can see again from the years 2-3 till the years 10-11 (>2%), as we can observe in the graphic 2. A delay is already evident in the development of the balance. Unfortunately even 13 persons with more than 15 years (181-360 months ) belongs again in this phase.

Graphic 3.

In graphic 3 there is an increase of the less unfavourable balance development (>2%) from the 9-10 years, but, at least for this sample, this is not linear. Between the 12 and 15 years, less of the 2% reached this good situation. I found even this phase again in six persons with more than 15 years (181-360 months)

Tab. 7. Distribution of the balance troubles for age bands in months, till 60 months, evaluated 6-7 months after the acquisition of walking in subjects in treatment with drugs. Then: Age in months of walking + six months.

Ss total	49 = 100.00%
Age (months)	Grade ++++ Ss nr.	%	Grade +++ Ss nr.	%	Grade ++ Ss nr	%		Grade + Ss nr	%
13-24 ( 3 Ss)	2	4.08	1	2.04	0	0.00	0			0.00
25-36 (38 Ss)	26	57.14	12	24.49	0	0.00	0			0.00
37-48 (7 Ss)	4	8.16	1	2.04	2	4.08	0			0.00
49-60 (1 Ss)	1	2.04	0	0.00	0	0.00	0			0.00
Totali	33	64.34	14	28.58	2	4.08	0			0.00

The lacking of subjects between 61 and 72 months, is creditable to the fact that there were not Ss of this age for first evaluation, but will be part of another evaluation after one year, during drugs' treatment. They will form the object of the next investigation.

Discussion.

It is not easy to get literature on specific investigations of the Balance troubles in the Downs. On Internet (Google) and Medline from 1960 to today (key words: "Down syndrome, balance" or "Down syndrome, equilibrium" I did not find any help.

Felicioli and Moretti, 1984, found again a varying percentage from the 41.4 to the 48.9% out of an altogether modest casuistry.

They think that the smaller percentage, as related on subject persons born a five-year period later, is already the result of a wider and earlier neuro-psychomotor rehabilitation intervention. From it they argue that the trouble is not stabilized, but malleable, a fact that I completely agree.

In my casuistry on 16 Down subjects with mosaicisms, I considered the motility as normal in 10 of them (Cocchi, 1996 ).

However I think that this current investigation is the first with so wide casuistry, evaluated either according to the chronological age at the first consultation, either according to the age of reaching walking.

Besides a significant greater rate of the balance troubles in males, even this research can be debatable. So, because the evaluation at the first consultation implicates even a wider spontaneous experience and a greater period of neuro-psychomotor rehabilitation in older subjects.

In spite of that, after 10 years there are still 57 out of 248 subjects (about 23%) with meaningful Balance disturbs. This subjects did poor rehabilitation, or the troubles are not 100% "malleable" 100%?

Even more, the age, in its turn, works however as a great exercise or there exists also an exceeding fear of the balance loss, which would prevent in several subjects the attainment of a nearly optimal condition?

To this question we have tried, in past, to give an answer, about the balance when Downs learn to bike.

On 101 Down subjects of 10 or more years the investigation showed that 1. about 54% of the sample doesn't ride a bicycle; 2. among who were biking, about 40% still the support wheels.

Then, biking seemed already a difficult task for many Down subjects and to learn it did not correspond to the whole psychomotor reached development. (Cocchi and Favuto, 1994).

Ever now, it is not clear if we can speak of a fear without any reason, or, in fact, there are troubled signals, deriving from various receptors involved in the and/or in their brain elaboration. <----

Conclusion.

The investigation on the balance troubles in 383 Down subjects showed a male prevalence, an improvement with the age and, in part, even creditable to the rehabilitative therapies, but this doesn't happen in all the subjects. In this sample 19 subjects (about 5%), seen for the first time after they were 15 years old, had still deficits in this field, like going downstairs, run awkwardness, and not biking, without support wheels.

References.

Camera G., Mastroiacovo P.: Epidemiologia della sindrome di Down. In. Ce.Pi.M. (ed): Aspetti epidemiologici, genetici, clinici, riabilitativi e sociali della sindrome di Down. Ce.Pi.M., Genova 1984: 225-230

Cocchi R. Mosaic forms in Down's syndrome: A survey on sixteen cases. It. J. Intellect. Impair. 1996, 9: 45-54.

Cocchi R.

On difficulties of equilibrium control in Down children (A preliminary note). Printed in Italian on Riv. It. Disturbo Intellet. 1991, 4: 267-270. First posted on Internet on December 2002 into <www.stress-cocchi.net/Down30.htm>.

Cocchi R., Favuto M. Study on bike riding in Downs aged 10 or more. It. J. Intellect. Impair. 1994, 7: 159-162.

Felicioli F., Moretti A.: Sviluppo motorio, comunicazionale linguistico ed evoluzioni dei livelli di apprendimento. In: Ce.Pi.M.: Aspetti epidemiologici, genetici, clinici, riabilitativi e sociali della Sindrome di Down. Ce.Pi.M., Genova 1984: 307-342. 

Posted on Internet on October 2003. Copyright by Renato Cocchi 2003.

Corrispondenza: dr Renato Cocchi, via Rabbeno, 3

42100 Reggio Emilia.

renatococchi@libero.it

Testo in italiano

Down syndrome

Mental retardation

Stress symptoms

Home Page / / / Pagina iniziale