Neurohabilitation Through LEGO^®-Based Therapy for Cognitive Functions in Down Syndrome

Abstract

The most prevalent chromosomal condition, Down syndrome (DS), is often linked to deficiencies in working memory, executive function, and visuospatial skills. Innovative approaches to promote cortical plasticity and improve cognitive development have been suggested, including play- and technology-based therapies like LEGO^®-based neurohabilitation. In this pre-experimental study, a 16-year-old adolescent with DS undertook 30 sessions of increasingly sophisticated LEGO^®-based therapy, covering everything from robotic assembly and programming to block creation. Before and after the session, a neuropsychological evaluation was carried out using the Rey complex figure, motor control, and five-digit tests. The reliable change index (RCI) was used to analyze changes in performance. Constructive praxis, processing speed, and overall efficiency all showed notable clinical improvements, especially in the copy score, total complexity, and total processing. These findings imply that LEGO^®-based neurohabilitation can provide significant gains in executive efficiency, visual–spatial abilities, and cognitive processing while offering a stimulating, developmentally appropriate therapy setting.

1. Introduction

The most prevalent chromosomal condition in the world is Down syndrome (DS). It is caused by an additional copy of chromosome 21, either entire or partial, and was first reported by John Langdon Down in 1866 [1,2]. Currently the most frequent cause of cognitive disability; this genetic illness affects about 1 in every 1000 to 1100 live births globally [3]. The prevalence in Mexico is thought to be one in 691 births, indicating a sizable population with difficulties in a number of developmental domains, including neurocognitive abilities [4].

People with DS generally have considerable challenges in cognitive development accompanied by muscular hypotonia, which impacts motor control and motor skill development [5]. Additionally, 40–50% of individuals with DS have comorbidities, such as congenital heart disease, gastrointestinal disorders, and hypothyroidism, which can exacerbate cognitive deficits [6,7,8].

Changes in morphosyntax, verbal short-term memory, and explicit long-term memory define the cognitive phenotype in DS. Nonetheless, implicit long-term memory, associative learning, and visuospatial short-term memory continue to work [9]. Children with DS struggle to retain recent verbal learning and to produce and understand complicated grammatical patterns. There may also be problems with working memory, temporal orientation, and spatial orientation. Despite these challenges, nonverbal short-term sequential memory, which involves the retention of visual or auditory patterns, may be better preserved, and receptive vocabulary appears to be comparatively better [10,11].

Attention, memory, and executive function are among the cognitive processes and connectivity that are impacted by developmental changes [12]. These procedures are essential for social engagement, academic success, and self-control. The orbitofrontal cortex is linked to reward-based decision-making and emotional regulation, while the dorsolateral prefrontal cortex is crucial for working memory and behavioral control [13]. These domains are interrelated and collaborate to synchronize adaptive reactions to intricate environmental requirements [14]. Adolescents with DS frequently have severely impaired executive function, which contributes to emotional and behavioral regulation issues that make it challenging for them to be independent and adjust to novel circumstances [15].

As of right now, both directed and non-directed technological therapy alternatives have been evaluated using exercises and external stimuli to create process interconnection and maximize learning in DS [16]. Video game-based therapeutic approaches have been demonstrated to improve people with DS’s motor, sensory [17,18,19], linguistic, and emotional development [20,21,22,23].

A treatment approach that uses technology is neurohabilitation based on LEGO^® therapy. Through cortical plasticity and the concepts of cognitive neurohabilitation, it makes use of external stimuli to optimize information processing and result in behavioral improvements in participants [24,25]. This therapy has demonstrated notable outcomes in improving a variety of neurocognitive processes and generating positive behavioral changes in a number of juvenile diseases, including autism, congenital heart disease, microtia, and epilepsy, thanks to its appealing and instructive material sets. With each exercise and session, the abstract play becomes more complicated [26,27,28,29].

Color recognition, visual–motor coordination, attention, fine motor development, communication, and social relationships have all been found to be improved by LEGO^® educational tools in DS [30]. Children with neurological disorders, such as DS, autism, and attention deficit hyperactivity disorder (ADHD), among others, may find that the construction and manipulation required in LEGO^® play helps accelerate the development of fine motor skills in an interactive and enjoyable way [31]. Thus, a pre-experimental study of a 16-year-old Mexican adolescent with DS who received neurohabilitation based on LEGO^® therapy is presented in this publication. The Battery of Frontal and Executive Functions (BANFE-3) scale was used in the study to assess her verbal fluency, constructive praxis, motor control, visual–spatial planning, processing speed, sequential planning, attention, and memory.

2. Materials and Methods

2.1. Patient Description

In this prospective, interventional and pre-experimental study, we analyzed a 16-year-old girl with a diagnosis of DS, regular trisomy, congenital heart disease (intrauricular connection), anorectal malformation without fistula, posterior sagittal anorectoplasty, and a closed colostomy. She attends the Down Art School Foundation and does well academically. She respects her classmates and abides by the rules at school. She can carry on a conversation, takes gymnastics courses in person, and is independent in all of her endeavors. She works around the house. She talks of having good relationships with her mother, brother, and grandmother. For a cognitive assessment and intervention, she has been referred to the National Institute of Pediatrics’ Neurohabilitation and Behavior Unit in Mexico City [32].

2.2. Neuropsychological Assessment

Subtests were chosen from cognitive subtests that have been tested on children and adolescents with DS in the past. Patients were reported to find it easier to complete specific sections of the neurocognitive battery rather than the entire battery during these assessments. The following are these sections:

Sequential planning, motor control, and verbal fluency were the executive functions assessed in adolescents. The BANFE-3 sub-scales were used to assess these functions. The BANFE-3 has been verified in the Mexican population and is a thorough and accurate neuropsychological assessment appropriate for children [28]. It is a comprehensive tool that integrates a large number of valid and reliable tests for assessing cognitive functions that primarily rely on the prefrontal cortex. With a Cronbach’s alpha of more than 0.80, it has a high level of reliability. Planning, physical control, and verbal fluency were the chosen exercises. The associated age-range chart is used to convert the subscales from normal scores to coded scores, which range from 1 (extremely low) to 5 (very high) [28].

The Rey Figure Test exercise from the Neuropsychological Battery of Attention and Memory, which has been validated in the Mexican population, was selected to assess construction praxia [29]. This subtest, which has been standardized for Mexican children, assesses spatial memory and visual-constructive abilities. Cronbach’s alpha reliability was found to be 0.765 for copying and 0.664 for remembering, with variances of 46.6% and 38.6%, respectively, for children between the ages of 8 and 18. Forms are categorized based on the points earned during copy and evocation execution. They are divided into three categories: unrecognized or nonexistent (0 points), distorted or incomplete (1 or 0.5 points), and correct form (2 points). After that, they are categorized by age group based on the percentile in the table.

Additionally, the five-item digital test was utilized to evaluate cognitive processing speed, focus, attention redirection, and distraction tolerance. Verbal fluency, sustained attention, and the capacity to transition between mental activities are among its subscales. The administration of the test takes about 45 min [30]. The test’s validity and reliability have been validated by studies using youngsters, which showed substantial differences (p = 0.000) and strong reliability with a Cronbach’s alpha better than 0.898. In accordance with the categorization table, the diagnostic ranges are first split into percentiles and then categorized into decatypes. The following categories apply to the diagnosis: (1) extremely low, (2–3) low, (4–5) moderately low, (6–7) moderately high, (8–9) high, and (10) extremely high.

2.3. Neurohabilitation Intervention

Following the evaluation, thirty intervention sessions were conducted using LEGO^® sets and the neurohabilitation program [24,25]. The objective of each 45 min session was to enhance cognitive function. The third phase was completed following the sessions. To assess the child’s cognitive development, a post-test was administered using the same assessments as the initial phase (Table 1).

Table 1. Description of neurorehabilitation through LEGO^®-based therapy.

Sessions	Objectives	Tasks	Sets
(1) Free game with programming	During the first interaction, familiarize the participant with the content and conduct the therapeutic exchange.	Recognize colors blocks and assemble them freely First robotics programming and assembly. In extreme circumstances, start with the animal sets’ assembly. First robotics programming and assembly; in extreme situations, start with the animal sets’ assembly. Robotic programming challenges: forward and backward sequence at 10 s; simple machine assembly	▪ LEGO® DUPLO® bricks ▪ WeDo 2.0 ® Set ▪ LEGO® Simple machines Set ▪ Bingo LEGO® Education Bingo Set
(2) and (3) Working and visuospatial memory, inhibitory control	To enhance short-term memory, inhibitory control, and selective attentional effort, gradually activate the cerebral cortical regions.	Working memory tasks, such as assembling blocks of two or three pieces; Visuospatial system stimulation; Working memory template, such as blocks of the same color. Challenges configuration and turns assembly. The difficult task of assembling and programming robots. Easy disassembly and reassembly of a robotic task or machine without the assistance of a therapist or template.	▪ LEGO® DUPLO® bricks ▪ WeDo 2.0 ® Set ▪ LEGO® Simple machines Set ▪ Assembled blocks template
(4) to (8) Working memory, inhibitory control, risk selection and planning	Stimulation of the cerebral cortex to enhance the linked functions’ effort investment process	Start with building blocks of three to four pieces and working memory activities. Color the blocks and use a visual–spatial working memory template to stimulate. Classifies blocks according to color and label. The difficult task of assembling and programming robots.	▪ LEGO® DUPLO® bricks ▪ WeDo 2.0 ® Set ▪ Assembled blocks template
(9) to (16) Follow-up and executive function integration	Monitoring cognitive function and development	Robot arm and assembly. Six-piece memory set assembly. Practice both progressive and regressive mathematical order; solve a challenging problem with the robot; and classify animals into concrete and abstract categories.	▪ LEGO® DUPLO® bricks ▪ WeDo 2.0 ® Set or SPIKETM Set ▪ LEGO® Education Animals Set ▪ LEGO® Education More to Math Set

This intervention starts with basic block-based workouts and moves on to building basic non-motorized devices. Next, programming and robotic assembly are presented. Each session’s assembly and programming level rises in accordance with the child’s development.

The evaluation was carried out by a psychologist with training in neurocognitive assessment and neurorehabilitation, and LEGO^® treatment was used by psychologists with expertise in cognitive-behavioral treatment and neurotherapy. Prior training in the intervention model was provided to these psychologists.

2.4. Reliable Change Indices (RCI)

To determine whether the difference in scores between the baseline and follow-up tests represented actual change beyond measurement error, the Reliable Change Index (RCI), as described by Jacobson and Truax, was employed. The standard error of the difference (SEdiff), which is generated from test–retest reliability and the standard error of each instrument measurement, is divided by the difference between the two test scores to calculate the RCI. Higher confidence levels produced more conservative estimates, and critical values based on 80% and 90% confidence intervals were employed as thresholds. Changes that were greater than these thresholds were seen as signs of consistent, clinically significant change.

2.5. Ethical Considerations

On 18 July 2022, the National Institute of Pediatrics’ Research Ethics Committee accepted the intervention protocol under reference number 2022/45. Prior to the intervention, the mother signed the informed consent form. The adolescent was given an explanation of the informed consent form for children over twelve and signed it.

3. Results

3.1. Neuropsychological Profile Pretest and Post-Intervention Subtest Scores

All measures showed improvements in verbal fluency. Overall fluency climbed from 3 to 5 (low to medium), the number of verbal perseverance increased from 1 to 2 (very low to low), and the total verbal score increased from 2 to 3 (very low to medium). Constructive praxis showed notable improvements. Both the copy and recall times significantly decreased (from 176 s to 20 s and from 60 s to 20 s, respectively), and the copy score increased from 3 to 9 (from very low to low). The overall complex figure score increased from 3.5 to 12, indicating consistent improvements in visual memory and visuospatial organization.

Although it is in the low range, maze performance improved from 1 to 3 (from extremely low to low) for motor control, demonstrating improved motor coordination and task-solving abilities. The overall score in visuospatial planning increased from 2 to 4 (very low to low), while the “no exit” score increased from 1 to 2 (very low to medium). Time performance, however, continued to be poor, indicating a modest increase in temporal efficiency.

Changes were mainly evident in the processing speed domain. Counting, inhibition, and flexibility—all regarded as extremely low to medium—improved from 1 to 5, 1 to 4, and 1 to 4, respectively. The overall score increased from 5 to 16, reaching a medium level and demonstrating a notable improvement in general cognitive control and processing efficiency (Table 2).

Table 2. Pretest and post intervention test scores.

Cognitive Process	Pretest	Posttest	Qualitative Descriptive Pretest	Qualitative Descriptive Label Posttest
Verbal Fluency
Perseveration Verbs	1	2	Very Low	Low
Total Verb Score	2	3	Very Low	Medium
Total Verb Fluency	3	5	Medium	High
Constructive Praxis
Direct Punctuation Copy	3	9	Very Low	Low
Copy Time	176”	20”	Longer time	Short time
Direct Punctuation Evocation	0.5	3	Very Low	Low
Evocation Time	60”	20”	Longer time	Short time
Total in Complex Figure	3.5	12	Low	Low
Motor Control
Total Cross Maze	1	3	Very Low	Medium
Visual–spatial planning
No exit	1	2	Very Low	Medium
Time	1	2	Very Low	Low
Total	2	4	Very Low	Low
Processing Speed
Conference	1	1	Very Low	Very Low
Counting	1	5	Very Low	Medium
Choice	1	1	Very Low	Very Low
Alternating	1	1	Very Low	Very Low
Inhibition	1	4	Very Low	Medium
Flexibility	1	4	Very Low	Medium
Total Processing Speed	5	16	Low	Medium

Note: ” = seconds.

3.2. Differences Between Pretest and Posttest Assessments

Several neuropsychological tests showed statistically significant differences between the pre- and post-intervention evaluations, according to the RCI analysis. The Direct Score (z = 2.68, p = 0.01), Copy Time (z = 6.97, p < 0.001), Recall Time (z = 1.79, p < 0.001), Total Complexity (z = 3.63, p < 0.001), and Total Processing (z = 4.69, p < 0.001) domains all showed notable improvements. Consistent changes that are uncertain to be the result of chance or measurement error were seen in several domains. The remaining measurements, on the other hand, maintained within the expected range of stability and did not exhibit any notable variations. Overall, these results imply that while other functions were unaltered, the intervention especially affected processing speed, cognitive complexity, and efficiency (Table 3).

Table 3. RCI scores.

Test	SE	z	p Value
Perseveration Verbs	3.16	0.32	0.75
Total Verb Score	3.16	0.32	0.75
Total Verb Fluency	3.16	0.63	0.53
Direct Punctuation Copy	2.24	2.68	0.01 *
Copy Time (s)	2.24	69.77	0.00 *
Direct Punctuation Evocation	2.24	1.12	0.26
Evocation Time (s)	2.24	17.89	0.00 *
Total in Complex Figure	2.24	3.80	0.00 *
Total Cross Maze	3.16	0.63	0.53
No exit	3.16	0.32	0.75
Time	3.16	0.32	0.75
Total	3.16	0.63	0.53
Conference	2.35	0.00	1.00
Counting	2.35	1.71	0.09
Choice	2.35	0.00	1.00
Alternating	2.35	0.00	1.00
Inhibition	2.35	1.28	0.20
Flexibility	2.35	1.28	0.20
Total Processing Speed	2.35	4.69	0.00 *

Note: 95% confidence (p < 0.05, Z = ±1.96): ∣RCI∣ ≥ 1.96 Reliable change. 90% confidence (p < 0.10, Z = ±1.645): ∣RCI∣ ≥ 1.645 Reliable change at 90%. 80% confidence (p < 0.20, Z = ±1.28): ∣RCI∣ ≥ 1.28 Reliable change at 80%. * Statistically significant data.

4. Discussion

This pre-experimental study shows that LEGO^®-based neurohabilitation therapy can help adolescents with DS achieve clinically significant improvements in specific cognitive domains. Previous research has shown that comorbidities, such as congenital cataracts or hypoperfusion in heart disease, might affect cognitive ability [33,34]. In this case, no previous cognition test scores were provided because this was the patient’s first evaluation. Therefore, scores for comparison before and after therapy were not possible to obtain [5,6,7,8].

This intervention produced significant improvements in visuospatial organization, processing speed, and executive functioning, which is consistent with previous studies highlighting the benefits of technology- and play-based therapies for neurohabilitation. Because these domains are frequently compromised in DS and have a direct impact on autonomy, academic success, and day-to-day functioning, improvements in copy accuracy, recall time, and overall processing speed are especially pertinent. Playing with LEGO^® bricks improves children with DS fine motor abilities, communication, and social relationships, according to a cross-sectional, exploratory, and descriptive study [26,27]. Additionally, a quasi-experimental study shown that LEGO^®-based therapy enhances social skills, communication, and emotional well-being in individuals with DS and other neurological conditions across a range of age groups and disabilities [35]. A child with DS showed improved performance and motivation in a single-subject trial utilizing educational robotics with LEGO^®, indicating potential benefits for cognitive function [36].

Recall and performance exercises, such as the Rey Figure and sequential planning, showed an improvement in overall performance as well as in these ranges, execution speed, and instruction comprehension [28,29]. Similarly, because the selected tests were interesting and well-suited to short attention spans, it was determined that they were appropriate for people with DS.

These results support the idea that visuomotor integration, sequential planning, and cognitive flexibility are all successfully stimulated by LEGO^®-based therapy [20]. However, in order to address broader cognitive areas, it might need to be combined with language-focused or socially mediated interventions. These findings align with the notion that LEGO^®-based therapy effectively stimulates visuomotor integration, sequential planning, and cognitive flexibility [20]. However, it may need to be supplemented with language-focused or socially mediated interventions to target broader cognitive areas.

5. Limitations and Future Research

There is currently not enough information to support the use of LEGO^® treatment as a neurohabilitation aid for individuals with DS. A limitation is that the results of this study are based on a single pre-experimental study, which limits how broadly the conclusions can be applied. Furthermore, the intervention requires thirty or more sessions, requiring significant time and financial resources, depending on the initial scores. As a result, a large number of participants failed to finish it. The absence of a comparison between LEGO^®-based neurohabilitation and other traditional therapy is another limitation. Future neurohabilitation research will take into account the use of robotic tools and artificial intelligence, which may improve social cognition, language, communication, and/or executive functions in individuals with DS and other neurological disabilities. This research will take into consideration larger samples, longitudinal follow-ups, control groups, and the impact of comorbidities as an experimental study. Additionally, children with DS may perform more effectively and be more motivated if these educational tools are used, providing them with new educational chances.

6. Implications of the Study

According to research, LEGO^®-based neurohabilitation is an effective strategy for improving language and cognitive skills. More studies in this field may result in more thorough, personalized, and inspirational therapy approaches meant to enhance the functional independence and quality of life of people with DS.

In neurohabilitation, the use of visually stimulating objects can greatly improve therapy adherence. In this instance, it was noted that the participant and the mother enthusiastically attended the interventions, which significantly helped in their adherence. Concrete and abstract play-based therapies can promote cognitive development and stimulate a variety of skills; however, in developing nations such as Mexico, other factors need to be taken into account, such as the distance to the healthcare facility and the significance of maintaining constant contact with family members who can explain the progress observed in cognitive processes both in the classroom and in different environments.

The previously described LEGO^® therapy-based neurohabilitation model has produced significant results in a variety of demographics, with participants and their families reporting positive behavioral and academic gains. These results have an immediate impact on the concepts of cognitive intervention techniques, cortical plasticity produced by external stimuli, and neuropsychological habilitation.

7. Conclusions

This pre-experimental study suggests that adolescents with DS can reliably and significantly improve their processing speed, visuospatial skills, and cognitive efficiency with LEGO^®-based neurohabilitation therapy. The intervention’s promise as an additional tool for cognitive neurohabilitation was demonstrated by the adolescent’s easy acceptance of it because it was interesting and appropriate for his developmental stage. Despite being preliminary, the results emphasize how crucial it is to include entertaining, technology-mediated methods in neurorehabilitation programs for people with DS.