Jurnal Keterapian Fisik
Vol. 10, No. 2, November 2025
https://doi.org/10.37341/jkf.v10i2.417

Original Research

Sensorimotor-Enhanced Shoulder Stabilization Exercises to Improve
Their Hand Function in Children with Down Syndrome
Ni Luh Putu Gita Karunia Saraswati1*, Made Hendra Satria Nugraha2, Putu
Mulya Kharismawan3
1,2

Physiotherapy Department, Faculty of Medicine, Universitas Udayana, Denpasar, Indonesia
Physiotherapy Sudy Program, Faculty of Health Science, Science, and Technology, Dhyana Pura Bali,
Indonesia
3

ABSTRACT
Background: Down syndrome is a condition of a genetic
disorder caused by an abnormality of chromosome 21.
Statistical data shows that the average incidence of Down
syndrome worldwide is 1 in every 700 births. This incident will
increase with the increasing age of pregnant women. This
study aims to compare the addition of sensory motor training
to shoulder stabilization exercise to further improve upper
extremity strength and fine motor coordination in the Down
syndrome population.
Methods: This research is an experimental study with blocked
randomization. Group 1 (n=15) given the combination of
sensorimotor exercises and shoulder stabilization exercise,
while the Group 2 (n=15) were given shoulder stabilization
exercise. The sampling technique used in this study was
purposive sampling. The intervention was given 3 times a week
for 4 weeks. Measurements were carried out using the manual
muscle test (MMT) and the manual abilities classification
system (MACS). Data were analyzed using Wilcoxon Test and
the Mann–Whitney U test to compare differences between the
two independent groups.

ARTICLE HISTORY
Received: January 3rd, 2025
Accepted: November 27th, 2025
KEYWORDS
down
syndrome,
stabilization
exercise,
motor training;

shoulder
sensory

CONTACT
Ni Luh Putu Gita Karunia Saraswati
gitakarunia@unud.ac.id
Physiotherapy Department, Faculty
of Medicine, Universitas Udayana.
UNUD
Campus
Hill
Road,
Jimbaran, South Kuta District,
Badung Regency, Indonesia

Results: The MMT value was p=0.037 (p<0.05) and the MACS
value was p=0.041 (p<0.05). These results indicate a
significant difference between the two groups.
Conclusion: Adding sensorimotor training in shoulder
stabilization exercise intervention can improve upper extremity
strength and fine motor coordination in down syndrome
population. It is suggested to add sensorimotor training in
down syndrome population.
Cite this as: Sensorimotor-Enhanced Shoulder Stabilization Exercises to Improve Their Hand Function
in Children with Down Syndrome . (n.d.). Jurnal Keterapian Fisik, 10(2), 7077. https://doi.org/10.37341/jkf.v10i2.417

INTRODUCTION
In Indonesia, Down Syndrome (DS) occurs in approximately 1 out of every 600
live births. A significant factor linked to DS incidence is the mother's age during
pregnancy. The risk of having a child with DS increases notably in women over the age

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of 35, with the likelihood rising as maternal age advances. For instance, women who
give birth at age 40 have a 1 in 106 chance of having a baby with DS, and this risk
escalates to around 1 in 11 by the age of 49 (Lestari et al., 2025).
Down Syndrome is associated with a range of clinical features, including
intellectual impairments, congenital heart defects, and abnormalities in the endocrine,
gastrointestinal, and immune systems, along with characteristic facial features. It is a
leading cause of intellectual disability worldwide, with millions affected by
experiencing various health challenges such as difficulties with learning and memory.
These associated conditions occur regardless of race, nationality, religion, or
socioeconomic background (Lestari et al., 2025).
Children with DS are usually 5-18 years, generally experience delays in terms of
motor skills. Delays that often occur include weakness in the upper extremities and lack
of fine motor coordination such as pinching, tearing, grasping, and writing. Fine motor
skills are essential for achieving independence in daily tasks, self-care, and academic
activities.
In children with DS, the development of fine motor skills can be delayed, partly
due to cognitive impairments. Additionally, conditions like hypotonia (low muscle tone)
and/or joint hypermobility in the hands, wrists, or elbows can hinder their ability to
carry out fine motor tasks. Neuromuscular issues—such as hypotonia, persistent
primitive reflexes, and slow voluntary movements—also contribute to difficulties with
motor control, functional activities, and balance (Hartono et al., 2024).
Recent research discussing increasing upper limb strength and fine motor
coordination in children with DS states that shoulder stabilization exercises can stabilize
the shoulder girdle muscles which then impact on hand grip strength and rhythmic
movement of the fingers. Shoulder stabilization exercises aim to activate all upper
extremity muscles including stabilizing the shoulders and elbows which have an impact
on the grip strength and rhythm of the fingers (Elserty & Wagdy, 2020).
Research developments in interventions for children with Down Syndrome
indicate that a combination of exercise approaches can provide more optimal results
than a single method. The integration of shoulder stabilisation exercises with
sensorimotor stimulation is considered to have a synergistic effect because both target
muscle strength, movement control, and sensory integration simultaneously. This
multimodal approach has the potential to improve children's ability to perform activities
that require fine coordination and proximal stability, thereby supporting increased
independence in daily activities and academic tasks.
Thus, testing the effectiveness of adding sensorimotor exercises to the shoulder
stabilisation protocol is important to understand the contribution of each intervention to
improving the motor function of children with Down Syndrome (Rapisa & Damastuti,
2020). Approaches to the sensorimotor aspects can also help motor coordination. Recent
research states that sensorimotor exercises are significant in improving motor
coordination.
The series of sensorimotor exercises aims to optimize the biological processes in
the muscles in processing various sensory and motor information, which is then used as
well as possible, especially in increasing motor capacity in children with DS (Rapisa &
Damastuti, 2020). The research problem of this study is whether the addition of
sensorimotor exercises to shoulder stabilization exercise further increases upper
extremity strength and fine motor coordination in the DS population.

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MATERIALS AND METHOD
This study is an experimental study with blocked randomization. A blocked
randomisation experimental design was chosen to ensure a balanced distribution of
participant characteristics across groups, thereby making the intervention comparison
results more valid. This method also minimises selection bias, allowing for a more
accurate evaluation of the intervention's effects on the population of children with
special needs (Dahlan, 2021). The study was carried out in Private Development Clinics
for children with special needs in Denpasar and Badung areas from July to August
2022.
The population in this study consisted of all children with Down syndrome aged
5–18 years undergoing therapy at growth and development clinics in the Denpasar and
Badung areas. The sample size calculation in the research was obtained using the
(Pocock, 2008) formula. The number of subjects was determined based on previous
research by (Arianti & Fitri, 2018) which examined the effectiveness of play therapy on
the fine motor skills of children with Down syndrome.
The standard deviation and mean values of previous research include σ = 5.35; μ1
= 5.08, μ2 = 12.46. From the calculation results, a sample of 12 children per group was
obtained. To anticipate the risk of dropout, researchers added 25% to the number of
samples obtained. The sample was 15 subjects per group, and the total sample size was
30 subjects.
The sampling technique used in this study was purposive sampling, as subjects
were selected based on specific characteristics relevant to the research objectives. The
inclusion criteria for this study were: (1) Children are able to stand and walk
independently; (2) Have no visual or hearing impairments; and (3) Understand
instructions. While the exclusion criteria: (1) Experiencing pain and/or neurological
symptoms of the upper or lower extremities; (2) Cervical injuries and chest wall
abnormalities; (3) Experiencing Rheumatic and congenital heart disease; (4) Children
with a history of surgical operations; and (5) Having regular participation in every
sports activity. Criteria for dropping out: (1) Not doing therapy 2 times in a row, (2)
Samples who suddenly suffered injuries during the study, and (3) The patient's
condition worsened when the intervention was given.
Treatment group I received sensorimotor training and shoulder stabilization
exercise intervention, while treatment group II received shoulder stabilization exercise
intervention. Intervention was given 3 times a week for 4 weeks. Shoulder stabilization
exercise training is applied by maintaining each position in various ranges of motion of
the shoulder for 10 seconds.
Each movement is done for 10 repetitions with 3 sets and 3 seconds rest for each
repetition. Exercises are carried out 3 times a week for 4 weeks (Elserty & Wagdy,
2020). The sensorimotor exercises consist of 10 series of activities, namely ‘meronce’,
running following the line, jumping, throwing objects towards the basket, imitating
pictures, assembling puzzles, putting water in bottles, eating various kinds of fruit,
cutting patterns, and playing with sand. Exercises are carried out 3 times a week for 4
weeks (Rapisa & Damastuti, 2020).
Researchers select participants by block randomization. The study was conducted
with 30 participants. Research participants were divided into two treatment groups.
Before the intervention (pre-test) and after the intervention (post-test) an examination of
upper extremity strength was carried out which was measured by the Manual Muscle
Test (MMT) (Ince et al., 2020). In this study, hand strength was measured by elbow

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flexion. The results of this measurement consist of 5 scales, namely: Score 0 which
means there is no muscle contraction and movement; Score 1 which means there is
muscle contraction but no movement; Score 2 which means able to move with a full
range of motion, but not yet able to resist gravity; Score 3 which means able to move
with a full range of motion, able to resist gravity but not yet able to resist resistance;
Score 4 which means able to move with a full range of motion, able to resist gravity and
able to resist minimal resistance; and Score 5 which means able to move with a full
range of motion, able to resist gravity and able to resist optimal resistance (Manikowska
et al., 2018).
Fine motor coordination in this study was assessed using the Manual Abilities
Classification System (MACS). MACS is generally used to assess children's hand
functions in daily activities. This assessment consists of five levels: level 1, which
means they can handle objects easily and successfully; level 2, which means they can
handle objects but require time; level 3, which means they need some assistance and
sometimes adaptive equipment to handle objects independently; level 4, which means
they need continuous assistance and adaptive equipment; and level 5, which means they
need total assistance. In this study, MMT and MACS were measured by field assistant
physiotherapists (Eliasson et al., 2006; Skoutelis et al., 2020).
The results of the pre-test and post-test were tested using statistical tests using the
Statistical Program for Social Science (SPSS). The data analysis to be carried out
includes: (1) Normality test, (2) Homogeneity test (distribution of data homogeneity),
(3) Comparative Analysis, and (4) Difference Test. The researcher applied for an ethical
permit to the ethics committee of the Faculty of Medicine, Udayana University. This
research has passed ethical qualifications with No: 1858/UN14.2.2.VII.14/LT/2022.
All research procedures were carried out with the utmost respect for the principles
of confidentiality, anonymity, and data security of participants. In addition, researchers
ensured that parents or guardians of children provided written consent (informed
consent) after receiving a full explanation of the objectives, procedures, benefits, and
potential risks of the research.
RESULTS
The research findings are comprehensively presented and described in Table 1 and
Table 2.
Table 1. Characteristics of Participants in Group 1 and Group 2 (n = 30)

Characteristics
Sex, n (%)
Male
Female
Age (years)
Mean ± SD

Group 1 (n = 15)

Group 2 (n = 15)

7 (46.7%)
8 (53.3%)

6 (40.0%)
9 (60.0%)

11.40 ± 5.20

10.50 ± 3.30

Note: n = number of participants; SD = standard deviation.

It was found that the number of samples in Group 1 were 7 men (46.7%) and 8
women (53.3%), based on the results of the descriptive test. Whereas in Group 2 there
were 6 men (40%) and 9 women (60%). For the age of the sample in group 1, the
average was 11.3 ± 5.2, while in group 2 it was 10.5 ± 3.3. (Table 1).

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Table 2. Pre- and Post-Test Comparison of the Manual Abilities Classification System (MACS) and the
Manual Muscle Test (MMT) Scores Within and Between Groups (n = 30)

Variable

Group

Pre-Test
Mean ± SD

Post-Test
Mean
Mean ± SD Change

Wilcoxon
Test
(p-value)

MACS

Group 1
Group 2
Group 1
Group 2

3.40 ± 0.82
3.27 ± 1.03
3.00 ± 0.53
3.00 ± 0.65

2.22 ± 0.67
2.93 ± 0.88
3.93 ± 0.79
3.33 ± 0.61

–1.18
–0.34
+0.93
+0.33

<0.001
0.025
0.001
0.025

MMT

Mann–
Whitney
U Test
(p-value)
0.037
0.033

Note: SD: Standard Deviation; Group 1: Shoulder Stabilisation Exercise and Sensorimotor;
Group 2: Shoulder Stabilisation Exercise only

The normality test was conducted using the Shapiro–Wilk test because the sample
size in each group was fewer than 50 subjects. The results showed that the data for both
MACS and MMT variables were not normally distributed (p < 0.05), indicating that
non-parametric tests were required. The Wilcoxon test in each group and measurement
obtained p<0.05. There was a significant difference after giving interventions in each
group as measured by MACS and MMT. The MACS and MMT measurements obtained
p<0.05 in Mann Whitney U test. There was a significant difference between group 1
and group 2.
Based on the results of data processing, in group 1 with the MACS measurement
there was a decrease in score with an average of 1.18 and an increase in MMT with an
average of 0,93. Meanwhile in group 2 with a MACS measurement there was a decrease
with an average of 0.34 and an increase in MMT with an average of 0.33. This shows
that group 1 showed a better difference than group 2.
DISCUSSION
It was shown that the addition of sensorimotor exercises to the shoulder
stabilization exercise intervention showed better results than just shoulder stabilization
exercises in increasing upper extremity strength and fine motor coordination in the
Down syndrome population. This research is strengthened by previous research
conducted by (Elserty & Wagdy, 2020) in which shoulder stabilization exercises had a
positive effect on grip strength in children with Down syndrome. They further explained
that the movement develops from proximal to distal.
If there is a stability problem in the shoulder, it can affect the movement and
function of the hand. If the stability of the proximal shoulder is good, it will optimize
muscle recruitment in the distal part and improve the function of the hand. Another
study about effect of shoulder stability exercise on functional hand grips showed that
shoulder stabilization exercise is effective in increasing the stability of the shoulder and
functional of the hand. Giving this exercise increases the activation of the upper
trapezius, serratus anterior, and lower trapezius muscles which are muscles with a very
important role in stabilizing the shoulder (Olczak et al., 2022).
In addition, there is also an increase in hand strength and hand function. Shoulder
stability exercises help improve shoulder stability, strengthen shoulder function, and
strengthen the stabilizing muscles, which in turn benefit in hand function. This training
distributes the workload evenly between the hands, which can further improve grip
strength and overall hand function (Yadav & Kanase, 2025).

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Several studies have shown that shoulder stabilization exercise can increase the
strength and function of the hands. In this study, shoulder stabilization exercise was
combined with sensorimotor exercises, and the results were better than just shoulder
stabilization exercise. Based on previous research related to sensorimotor exercise and
hand and upper extremity function, it showed that the provision of sensorimotor
exercises improved sensorimotor function in the upper extremities and hands in patients
with Cerebral Palsy (Kleeren et al., 2024).
It was further explained that the provision of tactile sensory stimulation is very
important in fine motor development. Sensory stimulation also directly through the
mechanism of motor function affects the plasticity of the nerve. In one of the pilot
studies on cerebral palsy, patients who were given sensorimotor exercises caused
structural changes in sensory and motor areas (Poitras et al., 2021).
Another study showed that sensory integration exercises have a positive effect on
attention and motor skills. A child with DS has problems with attention. Lack of
attention related to the lack of cognitive ability to receive learning (Raharjo et al.,
2023). Sensory integration exercises aim to improve attentional ability, eye and hand
coordination, strengthen tactile sensory system, orientation, selective attention, and
body awareness. This exercise can help to raise attention and improve motor skills in
children with DS (Hartono et al., 2024).
The results of this study have important implications for rehabilitation
interventions in children with Down syndrome. A combination of shoulder stabilisation
exercises and sensorimotor exercises may be considered a more effective therapeutic
option for improving upper extremity strength and fine motor coordination. These
findings can also serve as a basis for occupational therapists and physiotherapists to
design more comprehensive exercise programmes that take into account proximal
stability and sensorimotor integration.
This study has several limitations. First, the sample size was relatively small, so
the results should be generalised with caution. Second, the limited duration of the
intervention meant that the researchers were unable to assess the long-term effects of
the exercises. Third, this study was only conducted in two clinics in the Denpasar and
Badung areas, so the diversity of subject characteristics may not have been fully
represented.
Further research is recommended using a larger sample size and involving various
health care facilities to improve population representativeness. A longer intervention
duration and post-intervention follow-up are also recommended to assess the
sustainability of the exercise effects. Additionally, the use of more objective assessment
instruments, such as motion capture analysis or electromyography, could strengthen
findings related to muscle activation and motor function changes.
CONCLUSION
The addition of sensorimotor exercises to the shoulder stabilization exercise
intervention showed better results than just shoulder stabilization exercises in increasing
upper extremity strength and fine motor coordination in the Down syndrome population.
The addition of this exercise can be given to achieve good results in patients with Down
syndrome. This effectiveness demonstrates that sensorimotor stimulus integration can
maximise proximal stability, increase muscle activation, and improve the sensorimotor
integration process, which plays an important role in hand function. These findings
provide a more comprehensive understanding that strengthening shoulder stability needs

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to be combined with sensorimotor modulation to produce more significant functional
changes.
ACKNOWLEDGEMENT
Authors would like to thank Lembaga Penelitian dan Pengabdian kepada
Masyarakat (LPPM) Universitas Udayana for funding this research.
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