Dohsa-hou training improves bimanual

coordination among children with

Down Syndrome
Ebrahim Norouzi1 , Mehran Soleymani2 and Rasool Abedanzadeh3
1
Sleep Disorders Research Centre, Kermanshah University of Medical Sciences, Kermanshah, Kermanshah,
Iran; 2Department of Psychology, Faculty of Education and Psychology, Azarbaijan Shahid Madani University,
East Azarbaijan Province, Iran; 3Department of Sport Psychology, Faculty of Sport Sciences, Shahid Chamran
University of Ahvaz, Ahvaz, Iran

A child with Down syndrome (DS) is physically characterized by muscle hypotonia, joint instability, and poor
motor coordination. Here, we tested whether Dohsa-hou training could improve motor coordination among
children with DS, compared to a control condition. Forty children with DS were randomly assigned either to
Dohsa-hou training or to a control condition. All participants completed a bimanual coordination test, at the
following time points: baseline, seven weeks later at completion of the intervention, and again 4 weeks later
at follow-up. Bimanual coordination accuracy and consistency improved from baseline to intervention com-
pletion and to follow-up, but only in the Dohsa-hou training, compared to the control group. The findings
suggest that among children with DS and compared to a control condition, Dohsa-hou training has the
potential to enhance the bimanual coordination, thus contributing to improved motor control of children
with DS.
Keywords: Children with Down syndrome, Dohsa-hou training, muscle relaxation, motor control, coordination pattern

Introduction fitness such as lower aerobic capacity and lower muscu-

Down syndrome (DS) is one of the most common pedi-
atric diseases caused by autosomal chromosomal abnor-
mality. DS is a genetic disorder, and its prevalence is
about one per 1000 live births (Siebra and Siebra
2018). Children with DS are the largest group of chil-
dren with distinct clinical symptoms (Patterson 2009).
Further, DS is associated with physical growth delays,
and mild to moderate intellectual disability (Capio
et al. 2018).
There is evidence that shows, compared to typically
developing children (TDC), children with DS have
more difficulties in motor performance such as poor
balance control, reduced postural tone, immaturity of
motor skill patterns and motor development delays
(Block 1991, Capio et al. 2018, Stuberg et al. 2001,
Uyanik et al. 2003). Compared to TDC, in children
with DS motor functions such as balance performance
and also fundamental movement skills like throwing,
running and jumping are 50-70% lower (Shumway-
Cook and Woollacott 1985). Further, compared to
TDC, children with DS suffer from reduced physical
Correspondence to: Ebrahim Norouzi, Department of Motor Behavior,
Faculty of Sport Sciences, Urmia University, Urmia, Iran. Email: eb.nor-
ouzi@urmia.ac.ir, ebrahim.norouzi68@gmail.com
lar strength (Capio et al. 2018, Stuberg et al. 2001).
Most interestingly, also compared to children with intel-
lectual disabilities, children with DS are reported to
have lower motor functions (Fenwick 2018, Gonz
alez-
Ag€uero et al. 2010, Rao 2011).
More specifically, previous studies showed that chil-
dren with DS suffer from impairments of motor-percep-
tual skills and motor control (Siebra and Siebra 2018),
and indeed, the kinesthetic perception problem is one of
the specific characteristics of children and youths with
DS (Siebra and Siebra 2018). This kinesthetic percep-
tion problem presents in the impaired ability in motor
tasks and also integrating information processing during
motor behavior. Further, their hypotonicity has a nega-
tive influence on their proprioceptive feedback, which
is vital for optimal motor control (Aparicio and Bala~na
2009). Most importantly, their inefficiency of co-con-
traction during motor coordination patterns results in
poor motor coordination performance (Siebra and
Siebra 2018).
In children with DS, along with internal condition,
inadequate environmental stimuli were reported as the
one of reasons for motor development delays, reduced

# The British Society of Developmental Disabilities 2022

DOI 10.1080/20473869.2022.2052415 International Journal of Developmental Disabilities 2023 VOL. 69 NO. 6 926
 E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome
motor control and poor perceptual-motor skills (Bull
2011). Therefore, diagnosis and use of interventional
programs might be helpful for improving the percep-
tual-motor skills and motor control among children
with DS (Aparicio and Bala~na 2009). Considering the
many complications of drug therapy, it is reasonable to
use non-pharmacological methods that can improve
motor abilities in children with DS (Fidler and Nadel
2007, Parham et al. 2007). Such an interventional pro-
gram is the Dohsa-hou training. Dohsa-hou training is a
Japanese method of rehabilitation, which involves both
physical and mental training (Naruse 1992).
Specifically, Dohsa-hou training programs are based on
three elements including will, effort and movement
(Naruse 1992, Poursadoughi et al. 2015). Further, the
Dohsa-hou training can be divided into two parts; psy-
chological (including try and will) and physiological
(including physical training). With the Dohsa-hou train-
ing, people learn to respond to their own physical and
psychological experiences (Naruse 1992, Poursadoughi
et al. 2015). Dohsa-hou training leads to attention con-
trol and to the consciousness of the body's senses. This
attention control and the awareness of body segments
might enhance motor performance accuracy
(Poursadoughi et al. 2015).
Dohsa-hou is a process which consists of inner psy-
chological activities and of bodily movements. When
we wish to move a body part, we achieve this bodily
movement according to our own intention (Kabir et al.
2018, Poursadoughi et al. 2015). In other words,
Dohsa-hou helps to express the psychological and phys-
ical states of a person. A further aim of Dohsa-hou is
the enhancement of people’s self-control regarding their
psychological and physical activities (Imura et al.
2016). This can be seen in Dohsa-hou training for chil-
dren with cerebral palsy in which an increased sense of
body awareness and enhancement in motor performance
was observed (Dadkhah 1998).
Dohsa-hou training has also been effective in reduc-
ing hyperactivity symptoms, mental retardation, behav-
ior disorders and cerebral palsy, as well as improving
the social skills among children with DS (Imura et al.
2016) and autism spectrum disorder (Kabir et al. 2018,
Poursadoughi et al. 2015). Further, Dohsa-hou training
improved psychological dimensions such as depression
and stress (Kabir et al. 2018, Naruse 1992,
Poursadoughi et al. 2015). However, the effect of
Dohsa-hou training on motor behavior in individuals
with DS has not been investigated extensively (Imura
et al. 2016), and so far it remains unclear, which inter-
ventions might be most beneficial for improving motor
function of children with DS (Bull 2011). In addition,
people with Down syndrome are gentle in nature and
easily develop friendly relationships (Reynolds and
Fletcher-Janzen 2007). For the mentioned reasons, we
hold that focusing on Dohsa-hou which underlies the
International Journal of Developmental Disabilities
physical, emotional, and behavioral assessments. In the
Dohsa-hou training appropriate tasks are implemented
with the support of a trainer. Through the mutual efforts
in the trainer-trainee pair, the trainee can develop a
greater sense of self-control (Imura et al. 2016). Indeed,
it remains unclear whether and to what extent interven-
tions such as mindfulness, biofeedback and muscle
relaxation are superior to Dohsa-hou (Kabir et al. 2018,
Naruse 1992, Poursadoughi et al. 2015). Compared to
other training such as mindfulness, biofeedback, and
muscle relaxation, Dohsa-hou training has a distinct
character. In Dohsa-hou training, the role of the therap-
ist is most important. For instance, therapist must help
clients activate their inner power and respond to Dohsa-
hou interventions elements such as grasping objects,
gravity force and body posture. In other words, in
Dohsa-hou training participants were not asked to run a
training sessions independently and alone (Naruse
1992). In general, Dohsa-hou is a mutual act between
the trainer and the trainee, which makes trainer-trainee
communication very important (Imura et al. 2016).
Given that individuals with DS appear to have more
difficulties to verbally express their thoughts and feel-
ings compared to healthy controls (Vicari 2006),
Dohsa-hou appears particularly appropriate, as this
technique does not focus on verbal communication and
might be more appropriate due to the lower verbal
demands (Naruse 1992, Uyanik et al. 2003a).
Children with DS have more impaired motor coord-
ination (Mcloughlin et al. 2011). To illustrate, Macias
et al. (2017) observed poor visual-motor coordination
in individuals with DS. Further, Fidler et al. (2005)
reported lower scores of motor coordination in children
with DS, compared to children with typical develop-
ment. Latash et al. (2008) showed that people with DS
suffered from deficits in motor control and coordin-
ation. However, early rehabilitation can help some chil-
dren with DS attain proper psycho-physical
development and motor coordiantion (Habib-Hasan
et al. 2020, Palisano et al. 2001, Walker et al. 2020).
Such psycho-physical rehabilitation is Dohsa-hou,
which is commonly include physical and psychological
approaches (Imura et al. 2016). An important part of
Dohsa-hou training is the physical activity component,
which is aimed at improving self-esteem, creativity and
perceptual-motor skills (Naruse 1992, Poursadoughi
et al. 2015). Although previous studies have been con-
ducted to improve motor skills and balance among chil-
dren with DS (Gonz
alez-Ag€uero et al. 2010), further
research is needed to determine the effects of rehabilita-
tion programs specifically regarding bimanual coordin-
ation. Bimanual movements require a continuous
updating of the perception-action cycle to maintain the
accuracy of motor behavior (Kelso 1984, 1997). Daily
motor tasks such as buttoning up a shirt and tying shoe-
laces, often demand using our hands simultaneously
2023 VOL. 69 NO. 6 927
E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome
Figure 1. CONSORT participant flow diagram.
rather than separately, thus necessitating performance
of bimanual coordination movements (Norouzi et al.
2018). Moreover, reception and integration of sensory
feedbacks are impaired among people with DS (Uyanik
et al. 2003). This is most important because sensory
feedback is needed to successfully complete bimanual
coordination tasks (Salter et al. 2004). However, little
attention has been paid to bimanual coordination in
people with DS. Furthermore, it is confirmed that
bimanual coordination and motor control have import-
ant roles in increase physical activity levels (Gonz
alez-
Ag€ uero et al. 2010, Rao 2011). Therefore, this is the
reason why children with DS would need an interven-
tion to target this bimanual coordination skill.
Additionally, knowledge of motor control impairments
of children with DS are important for psychologists and
occupational therapists (Fidler et al. 2005). Further,
motor control impairments in children with DS have
been neglected in most studies (Fenwick 2018, Rao
2011). Furthermore, research on motor control and
learning in children with DS is limited and most
importantly longer term retention has largely
neglected (de Mello Monteiro et al. 2017, de Menezes
et al. 2015). Accordingly, the main purpose of the pre-
sent study was to examine the effects of a 7-week
928 International Journal of Developmental Disabilities 2023
Dohsa-hou training on longer term retention bimanual
coordination in a sample of children with DS, compared
to a control condition.
The following two hypotheses were tested. First,
based on previous research (Dadkhah 1998, Fujino
2017, Gonz
alez-Ag€uero et al. 2010, Kabir et al. 2018,
Naruse 1992, Poursadoughi et al. 2015), we expected
that, participation in Dohsa-hou training would have a
more positive impact on learning and longer term reten-
tion (follow-up) of bimanual coordination accuracy and
second, on the learning and longer term retention of
bimanual coordination consistency compared to a con-
trol condition.
Methods
Participants
A total of 40 children with DS (mean age: 8.12 years;
SD ¼ 1.87) took part in the present study. Inclusion cri-
teria were: (1) children diagnosed with DS based on
genetic testing for Trisomy 21; (2) age between 6 and
10 years; (3) a diagnosis of poor motor coordination
(based on Movement Assessment Battery (MAB) crite-
ria; Manual dexterity total  22), and (4) the ability to
follow a minimum of two-step instructions. In the pre-
sent study we used Kaufman Brief Intelligence Test,
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 E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome
Table 1. Content of the sessions on Dohsa-hou intervention.
Session
1st to 2nd
3rd to 4th
5th to 6th
7th to 8th
9th to 10th
11th to 12th
13th to 14th
15th to 16th
17th to 21th
Second Edition (KBIT-II) as a customized battery of
Arizona Cognitive Test Battery (ACTB) to examine
intelligence quotient (IQ) in children with DS
(Kaufman and Kaufman 2004). Exclusion criteria were:
(1) neuromusculoskeletal disorders or severe sensory
impairments; (2) intake of arousal medications or sub-
stances; (3) lower and upper extremities orthopedic
problems (orthopedic surgery one year before interven-
tion); (4) injection of botulism toxin 6 months before
intervention; (5) uncorrected visual impairment and (6)
absenteeism in educational sessions (more than
2 sessions).
Participants’ parents were fully informed about the
aims and the procedure of the study, and the anonymous
data handling. They all signed the written informed con-
sent sheet and children gave their assent (verbally or by
gesture) to participate in the present study. At baseline,
bimanual coordination accuracy and consistency were
tested. Next, the participating children were randomly
assigned to one of the following conditions: (1) Dohsa-
hou training, and (2) control condition. The intervention
lasted 7 weeks including three training sessions per week.
Participants’ bimanual accuracy and consistency were
tested immediately after completion of the intervention,
as well as after a 4-week follow-up period (Figure 1).
The Review Board of the … … . University ( … ., … .)
approved the study, which was performed in accordance
with the ethical principles laid down in the seventh and
current edition (2013) of the Declaration of Helsinki.
A power analysis (using GPower 3.1 software)
indicated that in order to detect an effect of moderate
magnitude (f ¼ 0.25; a-error ¼ 0.05, power ¼ 0.8,
Content of sessions
Relationship building with trainees. Relaxation tasks in form of
twisting trunk activities and active horizontal relaxation.
Sitting crossed leged (Agura-Zai) for relaxation, bending forward
and returning straight to straighten the curvy back portions.
This task helps the trainer check how flexible the trainee's hip
joints are and if they can keep their back and head upright.
Kneeling (Hiza-dachi) tasks for balancing and body image. This
task is important for testing flexibility. This task is sometimes
also applied to one knee.
Opening of the shoulders (Kata-biraki). In this task, the trainer
opens the trainee's shoulders and helps him to relax them.
This task is performed while the trainee is sitting on a chair.
Shisei (posture making) for attainment of straight and stable
sitting, kneeling, and walking with coinciding images of the
patient himself and in others’ perception
Leaning back (Se-sorase). In this task, the trainee sits cross-
legged and leaning back against the trainer's knees. The trainer
also sits cross-legged and supports the trainee's torso and
head with his/her hands.
Twisting of the torso (Kukan-no-hineri). This task is performed on
the floor while the trainee lies on his side. The trainer helps the
trainee twist his torso so that the back of his shoulder reaches
the floor.
Arm lifting Dohsa-hou exercises are performed lying down and in
a sitting posture. The trainers help the trainee raise his arm by
following the imagery line of the arm's proper movement.
The trainer and trainee review all of the tasks, which they had
previously performed.
groups ¼ 2, number of measurements ¼ 3, correlation
among repeated measures ¼ 0.50) in mixed ANOVA, at
least 28 participants are required (14 per group).
A computer-generated random-number sequence was
prepared, and tickets were consecutively numbered, put
in a ballot-box, and drawn by an independent researcher
not further involved in the study. Once a ticket was
drawn, it was put aside.
Intervention
Trained clinical psychologists led the Dohsa-hou train-
ing sessions, which lasted between 45 and 60 min. The
training was implemented three times per week under
supervision of a clinical psychologist in small groups of
six to nine participants for 7 consecutive weeks. The
training procedure followed the manual of Dohsa-hou
(Naruse 1992). The focus was on the subjects' desire
(1) to move or relax their body voluntarily, (2) to
increase their awareness of moving or relaxing alone,
and (3) to help the children to convert the extension or
flexion pattern of a particular postural deviation to a
correct pattern. The principles of the training tasks
focused on relaxation of body (especially the rigid
parts), gait, standing on the knees, and lying down, all
naturally imposed. The content of the single Dohsa-hou
intervention sessions is described in more detail in
Table 1.
All intervention activities were performed in a slow
pace; in doing so, the children learned to judge and
cope with the information of body movements, and to
monitor a movement. Relaxation tasks were performed
in lying positions through twisting the trunk, active
International Journal of Developmental Disabilities 2023 VOL. 69 NO. 6 929
E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome
Figure 2. The bimanual wrist coordination task.
horizontal relaxation, and lifting the arms upward,
downward and in different directions (Imura
et al. 2016).
The control condition session was designed as an
active control condition. Children assigned to the con-
trol condition met three times per week in small groups
of six to nine participants for 7 consecutive weeks (dur-
ation: 45–60 min per session). During the meetings,
children engaged in socio-therapeutic group events such
as playing board games, and checking blood pressure,
which were organized by social workers and psycholo-
gists from the same hospital center.
To assess bimanual coordination, we used the fol-
lowing valid and reliable procedure (Kelso 1984, 1997):
Participants sat on an adjustable chair at a table covered
by a grown laminated poster board (50 cm deep and
86 cm wide); see Figure 2. Attached in parallel to the
slides were linear potentiometers (Bourns Instruments,
Riverside, CA), which encoded the displacement of the
handle over a 20-s trial. In the present study, we used a
bimanual coordination task that consisted of flexion and
extension movements with both wrists in an anti-phase
mode. The continuous nature of the bimanual coordin-
ation movement in the present study requires partici-
pants to control the limb extensively in an online
manner, through visual and proprioception feedback
loops. Wrist movements were permitted in only the
extension and flexion orientation from midline. Data
were sampled using a microprocessor (80486) with a
sampling rate of 50 Hz. (National Instrument
Corporation, version 2.2.1) initiated and terminated 20-
s trials and also provided data capture and recording of
limb position (Norouzi et al. 2018). The metronome
paced the required speed or frequency of limb move-
ment beginning at a slow speed equivalent to a fre-
quency of 30 beat in minute for 20 s. After completion
of the 20-s trial at slow speed, the same required coord-
ination task was paced at a medium metronome fre-
quency (60 beat in minute), and subsequently at a fast
metronome frequency (90 beat in minute). Wrist move-
ments were permitted in only the extension and flexion
930 International Journal of Developmental Disabilities 2023
orientation from midline. Data were sampled using a
microprocessor (80486) with a sampling rate of 50 Hz.
Lab Windows software (National Instrument
Corporation, version 2.2.1) initiated and terminated 20-
s trials and also provided data capture and recording of
limb position (Norouzi et al. 2018). We encouraged
children with DS to perform anti-phase pattern as
quickly as possible during the experiment. Children
with DS received a general orientation to the task. The
task required them to grasp two handles attached to the
moving slides and displace them horizontally in the
left-right dimension (wrist extension and flexion).
While grasping the two handles, participants produced
a180 relative phase (anti-phase) pattern. Moreover,
visual feedback (seeing their own hands) was available
for all participants.
We used the absolute error for coordination accuracy
and standard deviation of relative phase as a marker for
within subject variability. These calculations were done
on the continuous relative phase time vector (with a
Bartlett). A MATLAB procedure for this purpose has
been developed. The MATLAB inputs had the two time
series vectors that represent the hand movements.
Before the calculation of relative phase we normalized
the amplitude and speed of hands. The motion data
were low-pass filtered (second-order Butterworth with
cut-off frequency at 8 Hz, with zero-lag).
The position signals were smoothed with a symmet-
rical Bartlett (triangular) filter. Velocity time series
were derived from the position signal using a two-point
central difference algorithm and then smoothed with a
Bartlett window. The Bartlett has a triangular window
with the zero end points. The smoothed position and
velocity time series were then used to calculate each
component of the near-continuous phase state for each
trial according to the formula:
uR ¼ tan 1 fðdXR =dtÞ=XR g
where uR is the phase of the right wrist in each sample,
XR is the position of the right wrist rescaled to the inter-
val, f1, 1g for each cycle of oscillation and (dXR/dt)
is its normalized instantaneous velocity. The same for-
mula was used to calculate uL from the position and
velocity signals of the left wrist. The relative phase (u)
between the two wrists, was then expressed as:
u ¼ uRuL
The mean absolute error of relative phase (AEu)
reflected the deviation from the target relative phase
180 for the anti-phase mode (“coordination accuracy”).
The standard deviation of relative phase (SDu) referred
to the spread of relative phase measures around the
mean (“coordination consistency”).
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 E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome
Table 2. Descriptive and statistical overview of socio-demographic information, separately for the Dohsa-hou
training and control groups.
Group
Dimension Dohsa-hou training
N 20
Age (years) 8.2 (1.65)
Age range (years) 6–10
Score on the IQ test 81.62 (1.14)
Data analysis
After examining the normality of the data, we compared
age and IQ scores between the two groups via a series
of t-tests. Next, two analyses of variance (ANOVA) for
repeated measures were performed with the factors
Time (baseline, study end, follow-up), Group (Dohsa-
hou training vs. controls), and time by group inter-
action, with absolute error of relative phase (AEu) and
standard deviation of relative phase (SDu) as dependent
variables. Post-hoc analyses were performed using
Bonferroni corrections for p-values. Due to deviations
from sphericity, the repeated measures ANOVAs were
performed using Greenhouse–Geisser corrected degrees
of freedom, though the original degrees of freedom are
reported with the relevant Greenhouse–Geisser epsilon
value (e). For the interpretation of the ANOVAs, effect
sizes were reported via partial eta squared (gp2) values,
with 0.01  gp2  0.059 indicating small, 0.06  gp2 
0.139 indicating medium, and gp2  0.14 indicating
large group differences. For single t-tests, Cohen’s d
effect sizes were reported. Effect sizes can be evaluated
as trivial (0–0.19), small (0.20–0.49), medium
(0.50–0.79) and large (0.80) (Cohen, 1992). The level
of significance was set at alpha ¼ 0.05 across all analy-
ses, and all statistics were processed using SPSSV 20.0
R
(IBM Corporation, Armonk, N.Y., USA) for
Apple McIntoshV.
R
Results
Table 2 reports the descriptive and inferential statistical
indices of the sociodemographic data and IQ scores for
the Dohsa-hou training and control group. The two
groups did not differ with respect to age and IQ scores.
The absolute error of relative phase (AEu) and
standard deviation of relative phase (SDu) for bimanual
coordination at baseline, post-intervention and follow-
up are shown in Figures 3 and 4, separately for children
assigned to the intervention and control conditions.
Table 3 also displays the inferential statistics of the
repeated measures ANOVAs, whereas Cohen’s ds are
reported in text.
As shown in Table 3, across the whole sample, AEu
scores decreased from baseline to study completion and
to follow-up (significant Time effect). However, the sig-
nificant effect of Time was due entirely to a reduction in
AEu scores in the Dohsa-hou training group, whereas
error remained unchanged in the control group across all
International Journal of Developmental Disabilities
Statistics
Control condition
20
8.4 (1.49) t(38) ¼ 1.32, p ¼ 0.65, d ¼ 0.20
6-10
80.20 (2.9) t (38) ¼ 1.43, p ¼ 0.12, d ¼ 0.21
measurement points (significant Time  Group inter-
action). In other words, improvement of coordination
accuracy (i.e. lower AEu scores) was observed in
Dohsa-hou training condition (Figure 3). Effect size (ES)
calculations and t tests corrections were used to examine
the interaction effects. ES calculations and t tests correc-
tions showed that in the Dohsa-hou training group error
relative phase decreased substantially from baseline to
post-intervention (large ES ¼ 2.58, t(19) ¼ 8.96, p ¼ .01),
and from baseline to follow-up (large ES ¼ 2.08,
t(19) ¼ 4.25, p ¼ .01). Within the control group, relative
phase error remained unchanged from baseline to post-
intervention (small ES ¼ 0.43, t(19) ¼ 1.85, p ¼ .07), and
from baseline to follow-up (small ES ¼ 0.41,
t(19) ¼ 1.67, p ¼ .11). Effect size calculations comparing
means of the Dohsa-hou training and the control group
showed that relative phase error did not differ at baseline
(small ES ¼ 0.32, t(38) ¼ 0.77, p ¼ .44), but the groups
did differ at post-intervention (large ES ¼ 2.87,
t(38) ¼ 7.33, p ¼ .01) and at follow-up (large ES ¼ 1.83,
t(38) ¼ 4.21, p ¼ .001).
A similar pattern of results was observed for the
SDu scores (Table 3). Across the sample as a whole,
SDu scores decreased from baseline to study comple-
tion and to follow-up (significant time effect).
However, the significant effect of Time was due
entirely to a reduction in relative phase error in the
Dohsa-hou training group, whereas error remained sta-
ble in the control group across all measurement points
(significant time  group interaction). Moreover, the
lower SDu scores (i.e. higher consistency) were
observed in the Dohsa-hou training condition (Figure
4). ES calculations showed that in the Dohsa-hou train-
ing group SDu scores decreased substantially from
baseline to post-intervention (large ES ¼ 2.32,
t(19) ¼ 7.61, p ¼ .01), and from baseline to follow-up
(large ES ¼ 1.53, t(19) ¼ 3.84, p ¼ .01). Within the con-
trol group, relative phase error remained unchanged
from baseline to post-intervention (small ES ¼ 0.38,
t(19) ¼ 1.51, p ¼ .14), and from baseline to follow-up
(small ES ¼ 0.39, t(19) ¼ 1.37, p ¼ .18). ES calculations
comparing means of the Dohsa-hou training and the
control group showed that SDu scores did not differ at
baseline (small ES ¼ 0.41, t(38) ¼ 0.63, p ¼ .53), but the
groups did differ at post-intervention (large ES ¼ 2.19,
t(38) ¼ 4.67, p ¼ .01) and at follow-up (large ES ¼ 1.51,
t(38) ¼ 3.74, p ¼ .01).
2023 VOL. 69 NO. 6 931
E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome

Figure 3. Bar chart showing the group means for relative phase errors (AEu scores) in the anti-phase mode across the two
group and three assessment (p < 0.05, p < 0.01).

Figure 4. Bar chart showing the group means for relative phase variability (SDu scores) in the anti-phase mode across the
two group and three assessments (p < 0.05, p < 0.01).

Table 3. Descriptive statistics for the accuracy, and consistency of bimanual coordination, separately for groups and
measurement points, and tests for time  group interaction effects.

Group Time Time  group interaction

F gp 2
F gp 2
F gp2
Absolute error of relative phase (AEu) 18.03 0.32 39.70 0.51 30.00 0.44
Standard deviation of relative phase (SDu) 10.64 0.21 19.55 0.34 18.89 0.33
Notes: Degrees of freedom: Time: (1, 38), Group: (1, 38), Time  Group (1, 38).
p < 0.05.
p < 0.01.
p < 0.001.

Discussion standard deviation error of relative phase of bimanual

The key findings of the present study are that among coordination, compared to a control condition. Most
children with DS, a 21-session Dohsa-hou training pro- importantly, such motor control improvements were
gram reduced absolute error of relative phase and maintained 4 weeks after completion of the intervention

932 International Journal of Developmental Disabilities 2023 VOL. 69 NO. 6

 E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome
program. The present findings add to the current litera-
ture in an important way in that Dohsa-hou training
proved to be successfully applicable to children with
DS. Such findings are relevant because children with
DS are at increased risk for reduced motor control, and
to our knowledge few programs or counseling options
have been established for this specific population to
enhance motor control and prevent motor function
impairments so far. We believe that the Dohsa-hou
training intervention has the potential to help psycholo-
gists and coaches improve motor control of children
with DS.
Our first hypothesis was that, compared to a control
condition, Dohsa-hou training would reduce absolute
error of relative phase over time, and this expectation
was fully confirmed. The present results therefore con-
cur with numerous previous studies (Dadkhah 1998,
Gonz
alez-Ag€ uero et al. 2010, Naruse 1992,
Poursadoughi et al. 2015). Further, according to the
second hypothesis we expected that compared to a con-
trol condition, a Dohsa-hou training intervention would
lead to reductions in standard deviation of relative
phase error. This hypothesis was also supported. The
present results thus are in accord with previous findings
related to this hypothesis (Dadkhah 1998, Fujino 2017,
Gonz
alez-Ag€ uero et al. 2010, Kabir et al. 2018, Naruse
1992, Poursadoughi et al. 2015). However, the present
results do expand upon previous results, in that Dohsa-
hou interventions have the potential to impact the motor
control of children with DS successfully and positively
through physical and mental training including muscle
relaxation. Dohsa-hou has proven effective for motor
rehabilitation because it helps the children promotes
motor behavioral development such as maintain proper
sitting and standing postures as well as walking skills
(Fujino 2017). As Dohsa-hou interventions directly tar-
get the children body, it is generally considered a phys-
ical and exercise-based rehabilitation method (Imura
et al. 2016).
The results of present study show that after a well-
designed Dohsa-hou training the motor coordination of
children with DS is improved. This finding is in accord-
ance with Fujino (2017), who concluded that under-
going Dohsa-hou training has a positive impact on
motor function. Dohsa-hou training decreased muscle
tension and increased awareness of body senses
(Dadkhah 1998). In Dohsa-hou training, the body is
considered as a key to understanding the problems and
treatment processes of disability (Naruse 1992,
Dadkhah 1998). Thus, Dohsa-hou training increases the
interaction between mind and body (Fujino 2017). In
addition, while traditional interventions appear to
improve single and disparate parts of the body (Rao
2011), Dohsa-hou training claims to impact the entire
body (Fujino 2017). Dohsa-hou training improves the
individuals’ skill to respond to their own physical and
International Journal of Developmental Disabilities
psychological experiences. Awareness of the body that
results from the Dohsa-hou training might lead to atten-
tion control and more consciousness of the body's per-
ception (Dadkhah 1998, Fujino 2017). This attention
control enhancement might lead to improved motor
function, especially motor coordination. It is confirmed
that bimanual coordination is strongly affected by per-
ceptual skills and sensory feedback from executive
limbs (Salter et al. 2004). Further, perceptual and sen-
sory processes are highly dependent on experience and
training. It is believed that training interventions
improve perceptions and sensory feedback inputs
(Salter et al. 2004). Likewise, Dohsa-hou training might
enhance the child's body perception (Imura et al. 2016)
and thereby improve the motor control and bimanual
coordination (Fujino 2017, Gonz
alez-Ag€uero et al.
2010, Naruse 1992, Poursadoughi et al. 2015).
Another explanation for the decrease of bimanual
coordination errors might be the muscle relaxation fol-
lowing Dohsa-hou training (Fujino 2017). Other studies
show that Dohsa-hou training improves muscle relax-
ation and proprioception (Kabir et al. 2018).
Additionally, it is claimed that such improved muscle
relaxation and proprioception might lead to changes in
behavioral and motor responses to environmental stim-
uli and sensory feedback (Kabir et al. 2018).
Accordingly, it is confirmed that optimal bimanual
coordination depends on a higher proprioception sense
(Salter et al. 2004); therefore, Dohsa-hou training might
have led to improved bimanual coordination in children
with DS. Further, the hypotonicity affects children with
DS's movement, coordination, and lead to difficulty in
simultaneous activation of homologous muscle groups
thus lead to the decreased in motor control. Most
importantly, their inefficiency of co-contraction during
motor coordination patterns results in poor motor
coordination performance (Siebra and Siebra 2018).
The kinesthetic perception problem refer to difficulties
or dysfunctions in tactile (proprioception)/kinesthetic
(movement) processing system in which resulted in
problems during performing motor tasks such as note-
taking, manipulating buttons or tools and equipment.
This kinesthetic perception problem presents in the
impaired ability in motor tasks and also integrating
information processing during motor performance
(Aparicio and Bala~na 2009). Moreover, coupling
between the limbs and co-contraction rely on feedback
from tactile/kinesthetic processing system.
Another interpretation of the effectiveness of Dohsa-
hou training can be considered to be the type of inter-
vention. There is evidence that children with DS do not
have sufficient ability to express their inner feeling and
experiences verbally (Bull 2011). Therefore, Dohsa-hou
training, which emphasizes the non-verbal conscious-
ness of the body and is performed by the active trainer
(Fujino 2017), might be more beneficial to these
2023 VOL. 69 NO. 6 933
E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome
individuals, compared to other verbal interventions such
as psychological counseling. Most psychological coun-
seling emphasizes the verbal intervention. However, in
the Dohsa-hou training, using muscle relaxation techni-
ques can have more effect on the motor and perceptual
aspects of children with DS. Furthermore, it would be
recommend in future studies for a measure to assess
muscle relaxation following Dohsa-hou training with
electromyography (EMG) outcomes that may be related
to bimanual coordination and motor control.
Briefly, the relaxation resulting from Dohsa-hou
training might improve the process of sustainability
between the body and the mind, attention control, and
eventually motor control (Dadkhah 1998). Further, the
active involvement of participants in Dohsa-hou train-
ing is an important part of this intervention (Kabir et al.
2018, Poursadoughi et al. 2015). Moreover, Dohsa-hou
training lead the patients to become aware of their body
movements and adjust them (Kabir et al. 2018). Again,
it would be recommend in future studies to assess
mind-body awareness and attentional control following
Dohsa-hou training that may be related to motor coord-
ination and control.
Finally, Uyanik et al. (2003) shows that there is a
close relationship between physical activity and life
expectancy in children with DS, which indicates the
importance of designing an exercise-based intervention
to increase life expectancy and promote health in chil-
dren with DS. Quality of life as well as physical and
psychological outcomes improve in children with DS
undergoing physical training interventions compared to
children with no physical training interventions (Capio
et al. 2018). For example, Andriolo et al. (2005)
showed that life expectancy and potential for active
functioning in society were improved after aerobic
exercise training programs (Siebra and Siebra 2018).
This holds even more true, as poor motor control in
children with DS can be attributed to their inactive life
style (Gonz
alez-Ag€uero et al. 2010, Rao 2011).
Accordingly, the present data show that Dohsa-hou
training, as a physical activity program, is recom-
mended to enhance motor control of children with DS
and consequentially this is a first step toward our ultim-
ate goal to increase their quality of life.
The novelty of the findings should be balanced
against the following limitations. First, the sample size
was rather small, though we focused on effect sizes
when interpreting our findings as effect size calcula-
tions are not sensitive to sample size. Second, it is con-
ceivable that other latent but unassessed physiological
and psychological factors might have biased the present
pattern of results in the same or opposite directions.
Third, we note that there was also a gradual drift
upwards for consistency in the control group. This may
be attributable to motor learning over time. Fourth,
most participants do meaningfully benefit from Dohsa-
934 International Journal of Developmental Disabilities 2023
hou training at follow-up. However, outcome variables
the trajectory of change was toward baseline levels after
4 weeks, therefore, it is suggested that Dohsa-hou train-
ing be used continually. Fifth and major limitation of
current study, we only assessed male children with DS;
accordingly, it is unclear whether the present results
would also be obtained for female children with DS.
Sixth, the findings indicate that, among children with
DS, Dohsa-hou is able to facilitate motor control and
learning. Therefore, the findings may be generalizable
to real life capacities and to other motor control skills
requiring similar levels of visual-motor control. Despite
we focused on the measures of change, however a main
limitation of the present study was that we did not
assess any phase transition variables of bimanual coord-
ination and skills of the child such catch a ball.
Seventh, multitudes of factors have been identified in
previous research that can influence the improvement
of motor control such as sensory feedback enhance-
ment, visual feedback, etc. These factors should be
more systematically assessed in future studies. Eighth,
in future studies, Dohsa-hou training might be com-
pared with other forms of interventions such as motor-
perceptual training, visual training, core stability train-
ing, handwriting training, or clinical interventions with
respect to effects on bimanual coordination, motor func-
tion, psychological and cognitive function among chil-
dren with DS. Last, it remains to be determined
whether and if so to what extent the present patterns of
results can be replicated with other children with dis-
ability populations such as children with autism, or
attention deficit and hyperactivity disorder.
Conclusion
Among children with DS, Dohsa-hou training had posi-
tive impacts on accuracy and consistency in bimanual
coordination, when compared to a control condition.
Notably, this impact was still apparent four weeks after
the intervention had ended. Our findings are important
because children with DS are at increased risk of devel-
oping motor control disorders, and because the study
provides a viable means of facilitating and enhancing
motor control. While our findings support the efficacy
of Dohsa-hou to improve the bimanual coordination of
male children with DS, the question regarding mecha-
nisms for the promising findings remains open and war-
rants further investigation in future research.
Acknowledgements
We are grateful to Mr. Sajad Darabi (Allameh
Tabatabei University) for his skilled technical assist-
ance, and Mr. Yazdan Norouzi (Islamic Azad
University of Kermanshah) for providing the data.
VOL. 69 NO. 6
 E. Norouzi et al. Dohsa-hou training improved accuracy and consistency of bimanual coordination among children with Down syndrome
Disclosure statement
No potential conflict of interest was reported by
the author(s).
ORCID
Ebrahim Norouzi http://orcid.org/0000-0003-
1091-9371
Rasool Abedanzadeh http://orcid.org/0000-0002-
3629-8465
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