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RESEARCH REPORTS

The Benefits of Group Aquatic Therapy for Young Children With Down syndrome

Milligan, Helen PT, DPT, PCS; Glanzman, Allan PT, DPT, PCS; Waasdorp, Ilana PT, DPT, PCS; Kinslow, Tricia OT; Hagenbaugh, Michelle OT; Pipan, Mary MD; Harrington, Ann PT, DPT, PhD, PCS; Palombaro, Kerstin PT, PhD

Author Information
The Journal of Aquatic Physical Therapy: January/April 2022 - Volume 30 - Issue 1 - p 12-21
doi: 10.1097/PXT.0000000000000011
  • Free

Abstract

Down syndrome (DS) is the most common chromosomal condition diagnosed in the United States, with an incidence of approximately 1:700 live births.1 Those with DS tend to be less active and have higher rates of obesity than their age-matched peers.2 Swimming is an activity that promotes physical fitness3 and participation. It provides opportunities to compete on swim teams and swim safely with family and friends and can facilitate an active lifestyle.

Individuals with DS require more repetition and practice to learn new motor skills including swimming skills such as blowing bubbles, floating, kicking, and reaching in the pool. Learning these skills is the result of a reproduction of a visual motor task, which is a particular weakness in individuals with DS.4 Narawane et al5 assessed airway protection and patterns of dysphagia in babies with DS and found that 89.8% demonstrated disorder during the oral stage and 72.4% had disorders in the pharyngeal phase of swallowing. Aquatic therapy can be dangerous for babies with DS if they do not protect their airway. Babies may swallow water or have challenges blowing out and blowing bubbles while in the pool. Therapists should be aware of this increased risk when bringing babies with DS in the pool and assess their ability to protect their airway with lip closure and blowing toys or bubbles. The aquatic environment is a place where respiratory and oral motor skills can be practiced and improved. Casey and Emes3 studied the effects of swim training on respiratory aspects of speech in adolescents with DS and found a significant increase in the mean phonation duration in the participants with DS. This highlights possible respiratory and speech benefits swimming may provide in the DS population.3

Children with DS tend to have sensory processing considerations such as sensitivity to noise or certain sounds, sensitivity to water, hypersensitivity to tactile stimulation on their face, resistance to handling, or resistance to deep pressure input on their hands or feet. Will et al6 studied sensory processing disorders in children with DS and reported that the underresponsiveness found in many children with DS is linked to maladaptive behaviors. These considerations and impairments may make it challenging for families to participate in a community swim program as a first pool experience. A community swim program typically uses demonstration and verbal directions and moves at a fast pace. There are many sensory stimuli that need to be processed while in a pool including temperature, pressure, the tactile feeling of the water, sound, vestibular and visual stimulation, as well as the auditory changes in sound quality often found in a pool environment. The child may have challenges processing all of these new stimuli. Children with DS require more time to process information and more repetitions to practice new skills than children without DS. Our experience is that children with DS benefit from increased practice and repetition including closing their mouth, breathe holding, and exhaling in order to protect their airway before being submerged in water. They benefit from repetition and practice closing their mouth, holding their respirations, and exhaling so that they respond appropriately when submerged as they are at an increased risk for aspiration. This additional sensory input in the pool may also improve responsiveness and lead to less maladaptive behaviors. Therapists should be aware of how stimulating the aquatic environment can be and provide strategies to help the child with their mental adjustment and ability to be comfortable in the pool.

A small physical and occupational therapy (PT/OT) aquatic group that used pictures, signs, and verbal communication, as well as a consistent routine with skilled aquatic physical and occupational therapists, has been successfully used at the Children's Hospital of Philadelphia for the past 10 years. The goal of the program is for the participant to learn sufficient pool skills to transition to a community swim program and be able to swim and be safe around water environments. The aquatic setting is particularly motivating for children with DS; however, caregivers often feel unprepared to safely assist their children in swimming activities or overwhelmed in a swim class, thus limiting participation in community programs. Here, we present a standardized program that can be implemented in the clinic with carryover to community-based participation.

CASE SERIES DESCRIPTION

The Children's Hospital of Philadelphia held the Trisomy 21 Aquatic Groups in the spring and fall of 2019. There were 4 groups, with a maximum of 6 participants in each group. Twenty children between the ages of 10 months to 5 years were included in the groups. The children were divided into 3 groups based on age: Starfish, which had children between 10 and 18 months; Guppy, which consisted of children between the ages of 18 months and 3 years; and Dolphin, which included children between 3 and 6 years. There were 3 children from the Starfish group (aged 10-18 months), 13 children from the Guppy group (aged 18 months to 3 years), and 4 from the Dolphin group (aged 3-6 years).

Children received medical clearance, a PT and OT prescription, and completed an OT/PT co-evaluation before starting the group. A postgroup evaluation was completed during the last 2 sessions by both PT and OT. The pre- and postgroup evaluations consisted of a parent survey, WOTA-1, the GMFM-88,7 and a standard PT and OT evaluation. The WOTA-1 and WOTA-2 are aquatic evaluations based on Halliwick principles, which have been found to be valid and reliable measures for assessing both aquatic function and mental adjustment in the water for children with disabilities. The WOTA-1 was used as it was developed to evaluate children who have challenges following or understanding directions. It assesses general adjustment, entry/exit from the pool, bubble blowing, side/back floating, “splashing,” submerging, vertical position, progression along a wall, standing, holding rope, and sitting.8 The GMFM-88 has been shown to be a reliable and valid tool at predicting gross motor change in children with DS between the ages of 5 months and those with motor skills below the typical 5-year level. The GMFM scores were summed and percentages were calculated in 5 areas of development including lying and rolling, sitting, crawling and kneeling, standing and walking, and running and jumping. If the child was not demonstrating a skill, at the time of the evaluation, parent report was also used.

Parents’ goals for the group were documented, and a parent survey was administered where they rated their child's skills on a 1- to 10-point scale (see Appendix 1). This survey was compiled by the author (HAM) to gauge overall parent perception of their child's skills and changes made during the groups.

Caregivers were given an information sheet that included information regarding swim diapers, songs and signs used during the group, as well as general information regarding benefits of aquatic therapy. This was provided at the time of evaluations. The groups consisted of individuals of all ethnicities, socioeconomic backgrounds, and cultures. The Children's Hospital of Philadelphia provided interpreters during the groups when English was not the primary language of the family. Both Japanese and Spanish interpreters were used.

Participants were from the Philadelphia area. Recruitment was from the Trisomy 21 clinic listserv at the Children's Hospital of Philadelphia. The pool group flyer was distributed to the Trisomy 21 listserv and distributed in the clinic 2 months prior to each group.

Comorbidities included the following: 8 participants had diagnosed cardiac conditions and previous cardiac surgery; 4 were diagnosed with autism and DS; 10 had a gastrointestinal diagnosis including gastroesophageal reflux or feeding issues; 1 had a club foot; and 19 participants wore surestep orthotics for land ambulation due to increased ankle and foot pronation. All participants obtained PT and OT prescriptions and medical clearance. One patient was not medically cleared because of requiring oxygen and other cardiac and respiratory precautions. He was not admitted to the group.

INTERVENTIONS

The group used a consistent routine that included aquatic skills such as protecting the airway with activities such as blowing toys, blowing pinwheels, blowing bubbles, climbing in and out of the pool, kicking, prone and supine floating, turn taking, and core strengthening. The group also addressed mental adjustment to the water and acceptance of a variety of sensory experiences. A caregiver participated and was provided feedback from the therapists. The children and caregivers were able to watch each other and learn new skills through modeling using a social learning approach.

The groups used pictures that were laminated and attached by Velcro to a waterproof board propped at the pool side. The pictures depicted a visual schedule as well as song and activity choices. Pictures, sign language, and verbal communication were used as a total communication approach to improve participation and provide choice, predictability, and consistency during the group.

The pool at the Children's Hospital of Philadelphia is a therapeutic pool with a temperature maintained around 93 °F. The height of the floor is changeable and adjusted during the group. For the first 30 minutes of the group, the pool depth was between 3 and 4 ft and for the last 15 minutes of the group the pool floor was typically adjusted to a height where the water was at chest level for the smallest child in the group. This allowed for standing and ambulation activities. The change of the floor height was at the therapist's discretion.

Twenty participants attended 8 sessions of a 45-minute OT/PT aquatic group. The group used a consistent routine each week. The therapist provided subtle changes and advanced the program based on the improvement in the skills of the children in the group and on an individual basis. Emphasis was placed on full participation even when an individual child or caregiver found the routine difficult to follow. This established a predictable routine that may help improve participation as community classes require conformation to routines. The group provided repetition and practice of the same aquatic skills each session with a predictable routine. The routine of the group was similar each week and consisted of the following (Figures 1–6):

  • Entry into the pool: The child sat at the edge of the pool and waited for the caregiver to enter the pool, make eye contact, and count to 3; the child then reached forward to enter the pool. This method encouraged the child to wait, make eye contact, and reinforced safe entry practices. Children with DS tend to be impulsive and have attention challenges. This entry ensured that the child is safe waiting and entered only when a caregiver is available to assist them into the pool. After mastery of the forward entry, the child is advanced to posterior entry, where the child transitioned from sitting at the edge of the pool to prone position and pushed back into the pool. This entry is typically taught and practiced during the dolphin group (3- to 5-year-old), after the child is successful and safe with a forward entry.
  • Hello song: Once all of the participants were in the pool, they gather in a circle to sing a hello song where each child was encouraged to acknowledge themselves and their friends. Each participant's name was mentioned in the hello song. Parents performed Halliwick maneuvers for water acceptance and trunk strengthening while singing. Parents were instructed to turn their child, so they were facing away from them and to support them at their trunk. The child was then moved side to side in the water activating their core and neck muscles while becoming acclimated to the water and singing a song. As the child became more comfortable and stronger, the parent was encouraged to lower the support to the low trunk or pelvis and bring the child up out of the water and then back in, submerging their ear. This provided movement and sensory input to the child's trunk with resistance provided by the water. These are lateral side-to-side movements. The Halliwick method includes mental adjustment, disengagement, sagittal rotation, and transverse rotational control. These techniques are demonstrated by the therapists and modified for each parent and child.
  • Oral motor activity: Participants blew toys, pinwheels, and bubbles. Face and mouth submersion was practiced after the child demonstrated the ability to protect the airway. The therapist provided verbal and tactile cues and demonstrated strategies to facilitate the blowing pattern using lip rounding and exhalation while blowing in preparation for blowing bubbles in the pool (Appendix 2).
  • Magic carpet ride: A floating mat was brought into the pool and each child was assisted with climbing up on the mat and reentering the pool. The mat was moved in the water in a variety of directions and the child was encouraged to clap, lift their upper extremities, and sing during the “magic carpet ride.” The floating mat provided a challenge to the child's sitting balance and transition skills. This activity was designed to build postural stability and strength.
  • Circle time: Participants came together in a circle for circle time. Pictures, signs, and songs were used during circle time. Children were given a choice of song, with a 2- to 3-picture choice presented by the therapist. Once the child chose a picture, the group sang the song while the parent moved the child in certain Halliwick patterns or followed the song directions. Sign language and gestures were used during the songs. Similar songs were sung each week, and families were provided suggestions regarding using signs and pictures at home to carry over the group activities and to facilitate communication. Parents were provided with YouTube sign language video links such as signing times and videos. Short videos were uploaded on the YouTube channel: Helenmilligansigns (https://www.youtube.com/results?search_query=helen+milligan+signs). Each you tube video included 10 signs that were used during the group. The sign language vocabulary was expanded each week (Appendix 3).
  • Obstacle course or a group standing activity: The floor was typically raised after 30 minutes of the group in preparation for standing and a group activity or obstacle course. The obstacle course included ambulation with flotation devices such as dumbbells or kickboards or parent support; steps; balance and single-leg stance activities; a fine motor activity such as ring stacking, building with blocks, ball skills, or pouring was included at the end of the obstacle course.
  • Goodbye song and summation of the day's activities: The group came back together into a circle and sang the goodbye song. The participants were encouraged to wave goodbye and make eye contact with each friend in the group. This was a clear signal that the group was ending. Home activities to carryover from the session were reviewed, and caregivers were encouraged to comment or ask questions.
  • Pool exit: The caregiver exited the pool, and the therapists assisted each child with climbing out of the pool and transitions to standing to be received by the parent. Individual towels were placed on the floor at the edge of the pool to designate the exit area.
F1
Fig. 1.:
Starfish group activity on the floating mat.
F2
Fig. 2.:
Obstacle course: Walking with a barbell up and down steps.
F3
Fig. 3.:
Oral motor activities: Blowing a ping-pong ball in the pool.
F4
Fig. 4.:
Dolphin group obstacle course: Stepping in and out of a weighted Hula-Hoop.
F5
Fig. 5.:
Magic carpet ride: Practicing sitting balance and transition skills climbing on and off the floating mat.
F6
Fig. 6.:
Starfish group practicing sitting and reaching skills with container play.

A brief outline of week 1 and week 4 is included in Appendices 4 and 5.

Data Analysis

The GMFM and WOTA-1 tests were administered by the therapists who participated in the groups. Changes in the WOTA-1 and the GMFM-88 pre- and postgroup tests were analyzed by a paired t test to determine whether there were statistically significant differences demonstrated in the child's gross motor skills and the child's water orientation. The parent questionnaire was analyzed with a Wilcoxon signed rank test to determine whether there were changes in the child's performance on a variety of activities as rated by the parent pre- and postgroup tests.

OUTCOMES

Pre- and postgroup paired t-test analyses revealed statistically significant changes from pre- to postgroup tests. The postgroup GMFM initial mean score was 154 and the postgroup mean was 179.45; this was an improvement of 24.65 points (P < .00001), with an SD of 18.93. The WOTA-1 initial mean was 25.53 and postgroup mean was 37.33, with a difference of 12.2 points (P < .000001) and an SD of 8.13. The minimal detectable change for the WOTA is 4.2 (Table 1).8

TABLE 1 - Paired t Test Comparing Initial GMFM and WOTA Scores With Postgroup Follow-up GMFM and WOTA Scores
Gross Motor and Water Acclimation Skill: Average
n Initial Follow-up Difference SD Significance
GMFM 20 154.8 179.45 24.65 18.93 P < .000001
WOTA 15 25.533 37.733 12.2 8.13 P < .000001
Abbreviations: GMFM, Gross Motor Function Measure; WOTA, Water Orientation Test Alyn.

Pre- and postgroup parent questionnaires revealed a significant change in the child's method of moving about the home (Z = 2.35, P = .02) and trend toward improvement in the time spent walking in the home (P = .0544) and improved transitional skills (P = .08). There were also significant improvements in the ability to follow simple directions and take turns with a mean change of 2.31 (Z = 2.157, P = .030), a change in the ability to blow bubbles in the water with a mean change of 2.32 (Z = 2.157, P = .030), and an improvement in the number of signs that the child used at home to communicate with a mean change of 6.8 signs (P = .005) (Table 2).

TABLE 2 - Parent Questionnaire Resultsa
Parent Questionnaire Results
N Mean Change (SD) Median Change (25/75) t Test Wilcoxon Signed Rank Z stat Wilcoxon Signed Rank W stat Sign Test
How would you rate your child's acceptance in the following areas?
Being in the pool? 14 0.57 (2.56) W = 12.5
0 (−1.5/1) P > .05
Having face and hair washed? 14 −0.64 (3.69) Z = −0.05099
0 (−2/2) P = .61006
Transition between daily activities? 14 0.64 (1.46) W = 16.5
0 (−1/1.5) P > .05
Climb into an adult chair and sit safely? 14 1.64 (3.62) Z = −1.5025
1 (−1/3.5) P = .13362
Engage in novel or unfamiliar activities? 14 0.57 (2.42) Z = 1.0225
1 (−0.5/2) P = .13362
Participate willingly in social activities? 14 0.57 (2.74) Z = 0.5099
0 (−1/1.5) P = .61006
Follow simple directions/take turns? 14 1.57 (2.31) Z = − 2.1573
2 (0/3.5) P = .03078
Ease of transition between positions (eg, sit/stand etc) 12 2.25 (2.14) Z = 1.77
2 (0/4) P =.08
Able to blow bubbles in the water? 13 1.46 (1.56) Z = − 2.50
1 (0/3) P = .01242
How does your child move around at home (method)? 14 0.79 (0.83) Z = 2.35
1 (0/1) P = .02
What percentage of time is your child walking (hands-free)? 13 13.6 (24.48) P =.0544
How is your child communicating at home? 11 0.27 (1.01)
0 (0/1)
Insufficient sample size Insufficient
sample size
Insufficient
sample size
Insufficient sample size
How many signs does your child know? 10 11.4 (6.8) P = .0005
aA Wilcoxon signed rank test was used for analysis of paired data; for data that failed to meet skewness criteria, a sign test was applied with a Z statistic if a sufficient number of subjects showed a change from T1 to T2 and a W statistic for those items that have insufficient variability from T1 to T2. For normal ratio data, a paired t test was used. Significant comparison is italicized, underlined, and bolded; those of marginal significance are underlined.

DISCUSSION

During the Trisomy 21 Aquatic Group, both the caregiver and the child use the social learning theory and Halliwick aquatic therapy methods to influence a change in behavior and improvements of gross and fine motor skills. The social learning theory developed by Albert Bandura in 1977 states that “most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action.”9p22

The Trisomy 21 Aquatic Group activities encouraged social learning through example. One example is the safe entry routine used. Each child sat at the edge of the pool and the parent waited for the child to give them eye contact or attention. Then the caregiver verbally counted to 3 and verbalized “go.” The child was then encouraged to reach out to the caregiver, and the child was assisted into the pool. Each child had to wait their turn and watched the entry of the other children in the group. Parents observed other parents performing this technique. The routine practiced turn taking and encouraged social engagement, water safety, and communication, all skills required to participate in a community swim class.

When the parent and the child participated in the group, they were able to observe, imitate, and model activities that were designed to improve core strength, respiratory control with various bubble-blowing activities, communication, and fine and gross motor skills. The therapist leading the group modeled the activity with one child and then the parent followed through with the activity. Often a parent provided tips to other parents. Caregivers shared ways they followed through with activities outside of the group in their community pool. Having other children in the group was a way for them to observe the skill with another child. This may have improved success with the activity. Parents were surprised at how successful their child was at learning new skills in the pool and at how social their child was with other children.

There is documentation of the social and visual strengths of those with DS by Sue Buckley from Down Syndrome Education International.10 The aquatic group provided visual schedules, pictures choices for songs, and visual demonstration of skills, as well as opportunities for modeling and socialization. These methods supported the visual and social strengths of those with DS while improving aquatic and gross motor skills, communication, and attention with the goal of preparing the child with DS for attendance in a community swim class.

The parents used social learning theory during the class. Some parents were more comfortable than others in the pool. Those who were not as comfortable could observe how other parents handled and assisted their children. Caregivers who were not swimmers themselves often required more therapist support during the first few sessions.

The aquatic therapy group is an example of how social learning theory can be used through modeling, imitation, and encouragement to assist children with trisomy 21 and their caregivers with safe water skills. The group encouraged comfort in the water with the hope that the family will participate in community water activities and swimming.

This article describes improvements in gross motor skills and water orientation in a group of children with DS following a group aquatic therapy and an aquatic exercise program. The 24.65-point improvement in GMFM from 154 to 179.45 (P < .00001) and the 12.2-point improvement in the WOTA-1 from 25.53 to 37.33 (P < .000001) (Table 1) represent improvement in motor skill and water orientation. The GMFM is divided into 5 sections. Skills in all 5 areas were included in our aquatic group activities. Sitting skills such as side sitting and sitting without support and lowering to prone position were practiced on a floating mat, with suggestions provided to the parents regarding carryover to the home environment. Climbing in and out of the pool and onto the floating mat as well as transitions to sitting position are activities similar to GMFM items. Skills that improve water adjustment and balance on the WOTA-1 may also improve postural control and strength with carryover to sitting, standing, and walking. Using an aquatic- and land-based assessment provided information related to both aquatic and gross motor skills. This case series of group aquatic therapy is example of a model for children with DS in which both gross motor and aquatic skills were impacted simultaneously.

The program was well received by the children and parents. Some of the survey parent comments included the following:

My child improved with turn taking and core strengthening in the pool group.

My child has improved stamina and strength.

The socialization was fantastic!

The pool group helped her accept water on her face and comfort in the water and it taught us both some sign language.

We noticed major improvements with walking, strengthening, confidence, mobility and sensory issues. This was an excellent group.

LIMITATIONS

Future studies are needed to determine the change in gross motor skills relative to a control group and to determine longitudinal changes and differences in aquatic participation of those who participated in early aquatic therapy. Follow-up studies should examine carryover into facilitating community participation and learning to swim, swim classes, and participation on a swim team. Additional areas of study might include the use of this intervention in children with a dual diagnosis of DS and autism and the potential social impact of the group approach. Studies should also be conducted to investigate using this approach with older children and those with challenges other than DS. Considerations should also be made regarding rater influence in testing as the therapists leading the groups were the same therapists completing the testing.

SUMMARY

The development of a standardized aquatics program for individuals with DS is presented. This is an important step toward the establishment of effective treatment strategies regarding aquatic therapy for those with DS. Swimming is a safe and effective way to promote lifetime physical activity and community participation for individuals with DS.

ACKNOWLEDGMENTS

The authors give special thanks to the Children's Hospital of Philadelphia Physical and Occupational Therapy Departments and the Trisomy 21 Program for their support on the aquatic groups over the past 10 years; Christina Thompson, PT, DPT, Stephanie Walters, PT, DPT, PCS, Kimberly Anderson, OT, and Heather Ruthrauff, OT, who have all participated as therapists in the groups; Meagan Milligan, who provided statistical support. Helen Milligan would also like to acknowledge and thank Jane Styer-Acevedo PT, DPT, C/NDT for being her son Aidan's aquatic physical therapist when he was receiving early intervention and for her mentorship and inspiration for the aquatic groups.

REFERENCES

1. Mai CT, Isenburg JL, Canfield MA, et al. National population-based estimates for major birth defects, 2010-2014. Birth Defects Res. 2019;111(18):1420–1435. doi:10.1002/bdr2.1589
2. Bull MJ; Committee on Genetics. Health supervision for children with Down syndrome. Pediatrics. 2011;128(2):393–406. doi:10.1542/peds.2011-1605
3. Casey AF, Emes C. The effects of swim training on respiratory aspects of speech production in adolescents with Down syndrome. Adapt Phys Activ Q. 2011;28(4):326–341. doi:10.1123/apaq.28.4.326
4. Foti F, Menghini D, Alfieri P, et al. Learning by observation and learning by doing in Down and Williams syndromes. Dev Sci. 2018;21(5):e12642. doi:10.1111/desc.12642
5. Narawane A, Eng J, Rappazzo C, et al. Airway protection & patterns of dysphagia in infants with Down syndrome: video fluoroscopic swallow study findings & correlations. Int J Pediatr Otorhinolaryngol. 2020;132:109908. doi:10.1016/j.ijporl.2020.109908
6. Will EA, Daunhauer LA, Fidler DJ, Raitano Lee N, Rosenberg CR, Hepburn SL. Sensory processing and maladaptive behavior: profiles within the Down syndrome phenotype. Phys Occup Ther Pediatr. 2019;39(5):461–476. doi:10.1080/01942638.2019.1575320
7. Russell D, Palisano R, Walter S, et al. Evaluating motor function in children with Down syndrome: validity of the GMFM. Dev Med Child Neurol. 1998;40(10):693–701. doi:10.1111/j.1469-8749.1998.tb12330.x
8. Tirosh R, Getz M. Halliwick-based aquatic assessments: reliability and validity. Int J Aquat Res Educ. 2008;2:2244–2236. doi:10.25035/IJARE.02.03.04
9. Bandura A. Social Learning Theory. General Learning Press; 1977.
10. Buckley S, Bird G. Cognitive Development and Perspectives on Down Syndrome From a Twenty-Year Research Program. Whurr; 2002.

APPENDIX 1

Parent Survey

figure7

APPENDIX 2

-
Mirror play: Make a big smile and relax while facing mirror. Practice making silly faces (kisses, “fish lips). Imitation is key! Blowing a pinwheel
Use vibration or various textures to rub cheeks and tongue. Z-vibes and vibrating toothbrushes work great for this! Encourage use of straw to reduce tongue protrusion and facilitate lip closure. Once drinking from a straw, try drinking thicker fluids like smoothies and shakes.
Rub lollipop onto lips and have child use tongue to lick off lips to taste. Blow bubbles off wand
Blowing cotton balls, tissue, pom-poms, or balloon on table or high chair tray Blow kazoos, noise makers, party favors
Model bubble blowing—in bath, water table, bowl of water Model blowing ping-pong balls or Easter eggs—on table surface or high chair tray

APPENDIX 3

-
-In/out -cat
-Up/down -dog
-Mom, Dad, Friend -wait
-Grand Mom, Pop Pop -fish
-Hello/goodbye -cow
-Ball -horse
-More/all done -duck
-Colors: red/yellow/green/blue -music
- Cold/hot -again
- My turn -stand/walk/jump/dance
- Swim -bubbles
- Baby -little
- Shark

APPENDIX 4

Weekly Routines: Week 1 and Week 4 Guppy Group

Week 1

Water Entry: The child sits at edge of the pool on a towel. The parent gets in the water and stands in front of the child providing eye contact. The parent counts to 3, prior to entry, with support at trunk or under arms. Stress importance of the child waiting for safety. Encourage the child to count with you and maintain eye contact. Repeat the entry if the child enters prior to the count of 3.

Hello Song: Help the child feel comfortable facing away from parent, as the group forms a circle. Each child is addressed by name in the song in an effort to obtain eye contact and reciprocal waving. Signs typically used: hello, Mom, Dad, friends.

Oral Motor Assessment: Child faces a parent or away from a parent assessing mouth closure when in contact with water. Explore with ball pit, balls, or toys floating on surface for the child to blow. One therapist can walk around the pool with a mirror for visual feedback. Pay close attention to oral motor control, airway protection, and ability to blow and control breathe. Provide parents with tips for lip closure and handling.

Orientation/Transitional Movements: Child should be facing away or toward the parent with ear placement in water using side-to-side movement. Allow the child to self-correct and provide support as needed to regain upright trunk control.

Explain how parent support should change as trunk control improves. Support at upper trunk allows the child to work on head and upper trunk control and support at lower trunk allows the child to work on improving strength through the whole trunk. Parent support influences the amount of trunk activation and movement the child performs. Parents tend to want to support high under the arms and the therapists should encourage support at mid to lower trunk or as low on the core as the child can tolerate.

-Transitions: Supine position <-> prone position transitional movement with support at upper trunk.

*Look for patient comfort with ears in the water in supine position and ability to extend at the neck with mouth closure while they are in prone position. May need cheek-to-cheek support for comfort and head extension at first. Some babies with DS have difficulty isolating their head and upper trunk for extension and rotation.

Move floor up to chest height while standing.

Circle Time:

Present the board with pictures and explain each picture and how it represents a song. One of the children can choose a song from the board or therapists can present a choice of 2 cards.

Roly Poly: While in a circle, complete the Roly Poly song using appropriate motions while maintaining standing balance. Note bilateral coordination and comfort getting face and hair wet while splashing.

Balance with walking: Allow children to explore standing and walking in the pool, provide the child with floating barbells or a kickboard to hold with bilateral hands to stabilize while walking around the pool. Instruct the caregiver to provide assistance as needed.

Goodbye Song: Like Hello Song. Provide feedback to the group stating goals of the first week and some home activities to practice such as:

Blowing through a straw

Blowing tissues

Blowing bubbles off a wand

Mirror for feedback

Get face wet in tub, pouring water over head

Practice songs: Roly Poly, swimming, and hello and goodbye song

Water Exit: The therapist assists the child with climbing out of the water on a towel placed at pool side. The therapist should provide the least amount of support while maintaining safety and transition into sitting position before standing. Caregivers are outside of the pool receiving the child.

Week 4

Floatation WEEK!!!! This is a favorite week!

  • -Entry: Parent assist and therapist observe
  • -Hello song
  • -Water orientation with transitional movements and bubble blowing
  • -Therapist explains why they may use various types of flotation devices. Also emphasize the NO diving policy with people with trisomy 21 and atloaxial instability.
  • -Each child tries 2 different floatation devices or vests. The group should have time for one switch. Therapists assist with donning/doffing and explains benefits of each device and assists with handling.

Noodle: Talk about the various ways to use a noodle in the pool: Under chest, horsey ride, under trunk in supine position, etc.

Music Time

Bring the Floor UP:

  • -Walking in pool
  • -Sing Head shoulder and other songs.
  • -Obstacle course: Set up benches like stairs and practice alternating feet and stepping up and down.

OT activity: Stringing noodle pieces at end of obstacle course.

Goodbye song and suggestions for home activities.

APPENDIX 5

Group Routines for the Preschool Group: Dolphin Group

Week 1

  1. Pool Entry
    1. Parents enter pool
    2. Rainbow entry on count of 3
  2. Circle Time
    1. “Hello Song” (signs: Hello, Mom, Dad, friends)
    2. Hokey Pokey
  3. Basic Swim Skills
    1. Side to side
    2. Forward/Back
    3. Supine position
    4. Prone position
  4. Oral Motor
    1. Assess for mouth closure
    2. Blow bubbles
    3. Blow eggs/ping-pong balls across surface
  5. Circle Time
    1. Kids choose song
    2. Ball passing

**Raise Floor**

  • 6. Obstacle Course (length of pool)
    1. Step up and down on platforms × 4
    2. Reach for rings × 2-4; don on upper extremities and lower extremities—place on cones
    3. Step in and out of Hula-Hoops
  • 7. Circle Time
    1. “Goodbye” song
    2. Exit: Climb out at edge of the pool one by one
Keywords:

aquatic therapy; Down syndrome; trisomy 21

© 2021 APTA Academy of Aquatic Physical Therapy