Learning Disability Exercise
I am often asked “Why did you decide to specialise in training disabled people?” and the short answer is that I want to make a meaningful difference to peoples lives. The long answer can be found in the body of research I undertook as part of my undergraduate dissertation.
My 2012 Dissertation
Influence of an 8 week holistic training program on balance, co-ordination and health status in adults with a learning disability.
Introduction and Literature Review
The opportunities for individuals with learning disabilities (LD) to be physically active is limited as a result of fewer work and job opportunities, lack of knowledge of service providers and lack of holistic training programmes specific to their individual needs. This has led to the majority living sedentary lifestyles. By leading a sedentary lifestyle there is a greater risk of secondary conditions such as pain, fatigue, depression and obesity. Therefore, the need of a holistic training intervention for the treatment of these individuals is necessary to avoid any comorbidity associated with these conditions (Rimmer, Chen & Hsieh 2011). As a result a holistic training programme has been developed in order to improve key areas including balance, co-ordination and health status. The purpose of this 8 week intervention is to encourage adherence to physical activity and enable improved performance of activities of daily living (ADL’s). As a result enhance quality of life of these individual’s. (ACSM 2009)
The holistic training intervention will include a variety of techniques and strategies to elicit behaviour change to a more physically active lifestyle post intervention. These will include physiological training methods involving a variety of games to promote physical activity and enjoyment of exercise. Nutritional interventions will include visual aids promoting healthy eating. Finally, a variety of psychological theories including cognitive behavioural therapy (Beck 1960) and motivational interviewing (Rollnick & Miller 1995) will be implemented for the purpose of enhancing potential for long-term behaviour change.
The obesity epidemic is a cause for serious concern within the general population, with current levels at 26% in both men and women this is compared to just 13% in 1993 (Health Survey for England 2010). As a result many strategies have been implemented to curve this trend. The most noticeable of which is the “Change 4 Life” campaign. This scheme encourages healthy eating and physical activity utilising various methods to promote change including;
change4life-o-meter which rates current levels of activity by means of a questionnaire and upon conclusion offers suggestions to change current habits
Map of local sports clubs and fitness centres
Various information on portion control and “swaps”, changing bad for good
Easy to understand and navigate website.
However, this campaign is aimed at the general population but there are limited resources, strategies and service providers specifically for learning disability. A study (Stewart et al 2009) investigating the prevalence of obesity among children and adolescents with learning disability discovered 36% were obese. The methodology involved surveying 150 male students from 9 schools with mild-moderate LD in Scotland. These levels of obesity are vastly higher when compared to 14.3% of children in Scotland among the general population are either obese or morbidly obese (The Scottish Health Survey 2010). A larger study (de Winter et al 2012) involving 945 adults with mild-severe LD in the Netherlands resulted in obesity levels of 26% against 10% in the general population.
There can be no doubt that obesity presents and substantial threat to individuals with LD but why? There are three reasons for this. A government paper (Emerson & Baines 2010) analysed diet and exercise levels of individuals with learning disabilities in the UK. It discovered that less than 10% of adults with LD, despite living in supported accommodation, ate a balanced diet with correct volumes of fruit and vegetables and 80% are failing to engage in levels of physical activity as recommended by the Department of Health. Furthermore, one study (Rimmer & Yamaki 2006) discovered significantly higher levels of obesity when living in less supervised accommodation such as group homes and family households compared to individuals living within an institution. It concluded that community participation, independent living and health are significantly effected as a result of obesity. In addition, these effects are exacerbated as a result of insufficient weight reduction strategies, research and poor knowledge of public health recommendations by care providers. With obesity levels increasing annually there is a need for interventions to suit every demographic. Before an intervention can be written for individuals with learning disabilities, knowledge of the condition is required.
1.1 Overview of Learning Disability
There are numerous conditions under the umbrella term of learning disability. However, the physiological ability and characteristics of Down syndrome (Ds) varies to that of all other conditions. As a result LD’s will be discussed generally followed by more specifically for Ds. There are numerous potential causes of LD. Some of which include genetic (Moreno-De-Luca et al 2011) and nutritional disorders, birth or childhood trauma, infectious diseases and poisons such as foetal alcohol syndrome, maternal drug use and ingestion of other harmful substances. (ACSM 2009) However, not one potential cause has shown greater percentages in LD. (Lin et al 2009). A new area of research (Rigier, Friedman and Marra 2010) for investigating genetic causes of LD known as array genomic hybridization has shown to have a higher detection rate and is more cost effective, so potential causes may be clearer in the near future.
Learning disability is a lifelong chronic condition with a range of symptoms from mild to severe. The conditions symptoms are as a result of factors affecting the structure or function of the developing brain. An analysis (Mannerkoski et al 2009) of regional brain structure in individuals with LD compared to general population discovered several alterations. These alterations included smaller global brain white matter, cerebrospinal fluid and total brain volume. In addition greater regional grey matter volumes in the ventral and dorsal anterior cingulate cortex and smaller regional grey matter volumes in the left thalamus and cerebellar hemisphere were discovered. This decreases the efficiency of neural transmissions and as a result individuals with LD are cognitively impaired.
Due to the variations in severity individuals with LD can split the level of required support time into the following subcategories:
Intermittent – Short-term support when needed
Limited – Episodic, longer-term low-intensity support
Extensive – Daily support is needed in some environments
Pervasive – Constant high-intensity support is needed across all environments
The identification of an individual support plan is made by the following four steps:
1.Identify relevant support areas; human development, teaching and education, home living, community living, employment, health and safety, behavioural, social and protection, and advocacy.
2.Identify relevant support activities for support areas in step 1.
3.Evaluate the level or intensity of support needs. This is done by an interview including a variety of questions including frequency of support time, type and activity
4.Write an individualised support plan
This process in evaluating individual client needs can be utilised by an exercise professional when prescribing amount of support time, type and activity. (ACSM 2009)
In addition to the characteristics already outlined in the overview for LD individuals with Ds also have clinical characteristics. The physical characteristics of Ds which affect physical performance and should be considered in exercise prescription include:
Hypotonic (poor muscle tone)
Short neck, legs, fingers, and arms in relation to torso
Broad hands and feet
Poor balance, vision, and audition
Immature respiratory and cardiovascular systems
In addition individuals with Ds are also likely to be hypotonic but especially in the flexor muscles. Due to laxation of ligaments an increase in flexibility compared to average is also likely. As a result greater care must be taken when stretching pre and post exercise to avoid hyperextension and injury. Another physical characteristic is approximately 10-20% of individuals with the condition sufferer from atlantoaxial instability between C1 and C2. As a result extreme care must be taken to avoid any neck flexion and extension when prescribing physical exercise/ activity to prevent injury to the spinal cord. Approximately 40% have heart defects at birth, most of which are repaired in infancy, such as atrioventricular, ventricular septal defects. Personal trainers should also be aware of the following conditions when prescribing a fitness programme; hypothyroidism, visual defects, hearing loss, digestive problems and respiratory problems. Adults with Ds also age more rapidly and are three to five times more likely of Alzheimer’s disease compared to the general population. Therefore a need for a detailed exercise screening document is essential to ascertain information on all medical conditions. (Horbelt 2007 & ACSM 2009)
1.2 Effects on Exercise Response
Due to the variations in severity of the disability individuals that require extensive or pervasive support have not been tested using conventional exercise testing and training methods. Those who require intermittent and limited support on average have lower maximal heart rate and peak oxygen consumption (VO2max). These statistics are irrespective of age. As a result an individual with a LD excluding Ds, achieves a maximal heart rate 8-20% lower than those without a disability. However, as a result of lack of motivation during the exercise testing, sedentary lifestyle and lower peak ventilation may partially be responsible for these results. Finally, individuals with LD typically have 30-50% less muscle strength than a nondisabled individuals. (ACSM 2009)
The effect on exercise response for individuals with LD has been outlined. However, individuals with Ds appear to be further affected and unable to reach those levels. Persons with Ds typically have a VO2max 30-35% lower and maximal heart rate 30-35 contractions per minute less than those with LD. Again, this is irrespective of age. In addition, individuals with Ds display an altered hormonal profile both at rest and during exercise. This is characterised by elevated levels of circulating catecholamines, insulin and leptin while lower levels of testosterone and cortisol compared to nondisabled. Further, anatomical anomalies that limit cardiovascular capacity include pulmonary hypoplasia, skeletal hypotonia, a high prevalence of circulatory abnormalities and heart defects and small nasal and oral cavities. (ACSM 2009)
1.3 Effects of Exercise Training
Exercise training has been shown to have beneficial effects to both the cardiovascular system and skeletal muscle in individuals with LD excluding Ds. An improvement of 10-20% in VO2max can be expected in addition to increased maximal work rate and increased time to exhaustion. The cardiovascular systems adaptations to training include improved stroke volume, cardiac output and muscle metabolism. Muscular strength and endurance may also be improved by 20-50% as a result of muscular strength training. (ACSM 2009)
Research into this area (Calders et al 2011) has shown significant improvements in individuals with mild LD following a training programme of 70 minutes twice a week for 20 weeks against no training. Improvements were made in the following areas; cholesterol, systolic blood pressure and muscular strength. Additional research (Carmeli et al 2005) resulted with significant benefits also while using a different training model of three times a week for six months.
A short-term intervention (Khalili & Elkins 2009) of just 8 weeks involving 30 minutes of aerobic activity, 5 days a week concluded significant improvements in lung function. The study examined 44 children, mean age 12 years, with an average IQ of 42. The exercise sessions involved supervised walking, running and cycling at a moderate intensity. An additional short-term study (Carmeli, Bachar & Merrick 2009) analysing biomarkers of muscle stress including creatine kinase, myoglobin, glutamine and uric acid discovered significant increase in plasma glutamate and uric acid. The methodology involved 22 adult subjects performing 30-40 minutes of treadmill exercise, 4 times a week for 4 weeks. This research concluded that individuals with LD have a physiological response to exercise and blood testing would be useful in measuring training responses.
As a result of the physical alterations including those to body structure some Ds patients have effected responses to exercise training and may not show the same improvements which would be expected. A combined training method of cardiovascular endurance and progressive strength training would be recommended for maximal performance gains in VO2max. Training methods alone have shown an inability to reduce mass. Therefore, training should be combined with caloric restriction and promotion of healthy living/ diet for maximal mass reduction (ACSM 2009)
One study researching the influence of a 12 week training program on fat mass percentage in adolescence with Down syndrome (Ordonez, Rosety & Rosety-Rodriquez 2006) discovered exercise training was beneficial. The study involved 22 male participants (mean age 16.2±1.0 years) undergoing a 12 week physical exercise intervention consisting of three, one hour sessions per week. Anthropometric measures were taken before and after the intervention. The body mass index before the study showed 31.8% were overweight and 27.3% were obese. Final analysis of fat mass percentage showed the mean value reduce from 31.8±3.7% to 26±2.3%. It was concluded that not only could individuals with Down syndrome reduce their fat mass percentage it was important to reduce the impact of comorbidity associated with obesity and improving their quality of life.
Individuals with a learning disability also suffer with other issues regarding physical performance. A meta-analysis into this area (Lahtinen, Rintala & Malin 2007) examined the physical performance of 33 female and 44 male participants with a learning disability over the course of 30 years. Data was collected from four data collection periods (1973, 1979, 1996 and 2003) with the participant age range of 11-16, 17-22, 34-39 and 41-46 years old respectively. The results showed an improvement in early to late adolescence followed by declining results in adulthood in abdominal strength/ endurance, static balance and manual dexterity. The body mass index (BMI) of participants was also recording and showed that males with a learning disability were moderately overweight while females were obese. The participants IQ had a significant effect on the results of balance and manual dexterity.
Balance and co-ordination are important areas to maintain in individuals with a learning disability as incidence of falls have increased progressively with age. A study analysing the effect of a therapeutic training method over the course of 6 months (Carmeli et al 2003) resulted in a lack of improvement. The study involved 13 female and 4 male participants (mean age 56.5 years) undergoing therapeutic training involving dynamic ball exercises and treadmill walking on a 2-3% incline. Balance was recorded before and after the intervention using a variety of tests; modified get-up-and-go, full turn, forward reach, sit-to-stand and one-legged standing. It resulted in participants showing little to no improvement. Therefore, additional research is required in the area.
1.4 Management and Medications
The role of an exercise training programme for individuals with LD is to improve quality of life. This will enable completion of everyday task and promoting independence. Therefore, training methods should be tailored to meet the individual client’s needs. Due to the high risk of co-morbidities and secondary disease, those with LD may be on the following medication and allowances should be made when prescribing an exercise programme:
Anticonvulsive and antidepressant medication and stimulants. These medications may negatively affect motor performance; alter heart rate and cause irritability, lethargy, fatigue, headaches, blurred vision, dizziness, drowsiness and mood swings. These effects may influence concentration, motivation and ability to understand instruction.
Antianxiety medication may cause blurry vision, contraction of pupils and decreased sweating, salivation and dizziness.
Cardiac medications may suppress heart rate responses.
Thyroxin replacement therapy can produce palpitations, chest pain, muscle cramps and sweating until the correct dose has been prescribed. (ACSM 2009)
1.5 Recommendations for Exercise Programming
Training intensities will be specific to each individual. However, as a result of the sedentary lifestyle of the majority of individuals with LD, low-moderate intensity screening and training should take place. The aim is to increase the quality of life and this should be considered throughout the training process. Motivational issues may become an issue and the following are strategies which can be used when necessary (ACSM 2009):
Individual client’s preferences to exercise
Activities appropriate for ability and mental age
Progression from familiar to unfamiliar task must occur gradually as applying past experience can be difficult and must constantly be reinforced
Physical demonstration of exercises while giving key verbal instructions
Use pictures as reminders of activities
Train in an environment the client is comfortable in
Consistency in exercise plan (training times, location and trainer)
Use specialist equipment to aid completion of activity and advance skill
Reduced session length but increased frequency
Simplify demonstrative and verbal instruction
Relate exercise performance to benefits in everyday tasks
Make the activity fun, if the individual client finds the activity enjoyable it will increase all areas including adherence, frequency, motivation and intensity.
Table 1. ACSM (2009) exercise guidelines for individuals with LD.
Intensity/ Frequency/ Duration
Time to Goal
· Weight control or loss
· Improve Cardiovascular fitness
· Improve work capacity
· 60-80% VO2max
· 60-80% heart rate max
· 3-7 days/week
· 20-60 min/session
· Increase strength of large muscle groups
· 70-80% of 1RM
· 3 sets of 8-12 reps
· 1-2 min rest
· Closely monitor to prevent injury
· Improve ROM of selected joints
· Improve flexibility about a joint
· Hold stretch to a position of mild discomfort
· 3-5 reps not to exceed 30 sec
· Monitor closely to prevent injury
Not recommended for individuals with Ds
Current levels of physical activity recommended by the American College of Sport Medicine for individuals with a learning disability.
1.6 Obesity and Related Co-morbidities
Research into the association of comorbidity and obesity is significant. One such paper (Wake et al 2010) examined the links between obesity and metabolic and cardiovascular risk in adolescence. Data was collected from the Health of Young Victorians Study (1997, 2000, 2005) measuring multiple outcomes such as; blood pressure, body mass index, psychological distress, physical symptoms, mental health, sleep, asthma and diet and healthcare needs. The results showed that of the 923 adolescence 20.2% were overweight and 6.1% were obese. It was concluded that current health status of those overweight and obese in later life was poorer than those not overweight or obese. However, no link to morbidity and adolescent obesity could be made. Rather, morbidity was associated with those currently overweight or obese.
Additional research (Schelbert 2009) associated obesity with comorbidity and mortality through endocrine and mechanical processes. Obesity has clinical manifestations on the respiratory, musculoskeletal, immune, cardiovascular, gastrointestinal and integumentary systems. The prevention and treatment of obesity is necessary to improve the prevention of associated diseases with these conditions.
The research supporting exercise when treating obesity is numerous. As individuals with a learning disability are at greater risk of this condition, a specific exercise training program which takes into account their physiological needs would be beneficial. One such study researching the influence of a 12 week training program on fat mass percentage in adolescence with Down syndrome (Ordonez, Rosety & Rosety-Rodriquez 2006) discovered that this was beneficial. The study involved 22 male participants (mean age 16.2±1.0 years) undergoing a 12 week physical exercise intervention consisting of three, one hour sessions per week. These sessions took place either on land or in water. Anthropometric measures were taken before and after the intervention. The body mass index before the study showed 31.8% were overweight and 27.3% were obese. Final analysis of fat mass percentage showed the mean value reduce from 31.8±3.7% to 26±2.3%. It was concluded that not only could individuals with Down syndrome reduce their fat mass percentage it was important to reduce the impact of comorbidity associated with obesity and improving their quality of life.
1.7 Psychological Theories to Promote Behaviour Change
The incorporation of psychological theories in interventions to elicit long-term behaviour change and resolve client ambivalence has increased over the last decade; the benefits have been well recorded. The two psychological theories that have shown to have positive affects within studies promoting these outcomes are Cognitive Behavioural Therapy (Beck 1960) and Motivational Interviewing (Rollnick & Miller 1995). Research into increased exercise adherence utilising Cognitive Behavioural Therapy (CBT) includes (van Koulil et al 2010, Schneider, Cook & Luke 2008, and Redondo et al 2004). Motivational Interviewing has also been shown to have positive effects in resolving client ambivalence (Sjoling et al 2011, Perry & Butterworth 2011 and Martins & McNeil 2009).
These two psychological interventions are similar in outcome but vary in strategies and techniques used. A deep understanding of each theory is required to guide the client through consultations in a manner that is best suited to their individual needs. The theoretical underpinning of CBT includes, identifying and correcting irrational behaviour. In order to do this the counsellor needs an understanding of and analyse each client’s individual cognitive errors and replace them with a positive thought process. Cognitive errors may be conscious or unconscious involving voluntary or automatic responses and are resolved by introducing a schema to resolve the irrational thought process with a guided response. Techniques and strategies used within a CBT consultation session include; Identification of cognitive errors, building cognitive structure (schema), relaxation training (breathing techniques), creation of an anxiety hierarchy and desensitisation. Potential cognitive errors include:
Personalisation – Blaming yourself for external events
Polarised Thinking – Thinking in Absolutes
Selective Abstraction – Focusing on one negative instance
Arbitrary Inference – Drawing negative inference with no evidence
Overgeneralisation – Drawing a general rule from a few isolated incidence
Magnification – Perceiving a minor event to be more important
Minimising – Discounting positive accomplishments
Techniques used by CBT counsellors to encourage behaviour change include:
Co-investigate clients cognitive errors through questioning
Encourage to participate in feared activities
Build Rationale Responses
(Hofmann & Reinecke 2010, Bieling, McCabe & Antony 2009)
Motivational interviewing is implemented to elicit behaviour change by exploring and resolving a client’s ambivalence. The theoretical underpinning to this theory is centred on goal orientated direction and therefore, the counsellor intentionally directs the session in pursuit of individual client goals established through in depth consultations. The theory originally for addiction cessation was discovered to have positive effects on both exercise and diet eliciting behaviour change. The strategies used by counsellors to promote positive outcome include:
Reviewing a typical day – Builds rapport and focuses on the client’s entire lifestyle opposed to specific damaging behaviour
Looking back – Exploration of a previous time when physically active and/or without health issues
Pros and Cons – Highlighting both pros and cons for behaviour change and no change
Discussing stages of change – Introduction to stages of change, client encouraged to provide an action plan to change behaviour
Assessment feedback – Summarise statements made within each section of the session
Values explorations – Explore “Ideal Self”
Looking forward – Discuss the future with and without behaviour change
Exploring importance and confidence – Discover whether change is important and whether they perceive themselves to be able to achieve goals set
These strategies encourage behaviour change by discussing the benefits of change and the consequences if no action is taken. In addition, they provide a means for the counsellor to evaluate “stage of readiness” of each client. (Hagger & Chatzisarantis 2005, Miller & Rollnick 2002)
1.8 Research Aims and Hypothesis
The need for a holistic training intervention has been well justified. The key areas needing to be addressed in an intervention are; reduction in mass and in turn obesity rates among individuals with learning disability, balance and dexterity to increase ADLs and reduce chance of injury from falling and adherence to physical activity long-term with the goal of eventual performance being unsupervised. The aim of this research is to discover whether an 8 week holistic training intervention affects these main areas. The training outcomes will include balance, co-ordination and physiological measures (body mass index, resting blood pressure, resting heart rate and fat mass percentage). The purpose is to discover whether incorporating physical training and psychological and nutritional interventions improve these measures. It is hypothesised that by implementing this training strategy all measures will significantly improve.
The study involved a variety of different strategies and techniques over a period of 8 weeks. All participants involved in the study were diagnosed with a mild-moderate learning disability including individuals with Ds. Subjects were adults mean age of 35.5 years ±12.5. A large sample size was used for the purpose of measuring effectiveness of the intervention at all stages of adulthood. Current levels of activity were not required for participation in this study. However, individuals were required to have a reasonable level of mobility but the training intervention was specific to the individual participant. Sampling was made through referrals from Transform Housing and Support. Total sample size was 6 participants made up of a combination of 3 male and 3 female.
Each session began by each participant performing a warm-up and at the end a cool down to reduce the risk of injury (Woods, Bishop & Jones 2007). As the sample group are at a high risk of other secondary conditions blood pressure was recorded before each training session and if this resulted in ≥140/90mmHg that training session was rearranged for another day (ACSM 2009). If the issue persisted then the participant was withdrawn from the study. All participants completed a consent form (Appendix I) and PAR-Q (Appendix II) before beginning the physical intervention and contact with a GP was made where necessary (medication, medical conditions etc). All communication with relevant professionals was made in strict confidence as was all records and data pertaining to the study. Finally, each subject had the right to withdraw from the study at any time with verbal notification. This was made known on the participation consent form.
The first week of the study included the completion of a consent form (Appendix I), Par-Q (Appendix II), nutritional hand-outs and a psychological consultation. This consultation involved methods and techniques from both CBT and motivational interviewing. The purpose was to ascertain the knowledge and motivation level to exercise and healthy eating and elicit long-term behaviour change to a healthier lifestyle. The consultation took the format of a motivational interview including personal goals, description of typical day, pros and cons and assessment feedback while investigating cognitive errors and building rapport as outlined in CBT. The Par-Q involved health screening, current levels of activity, preferred training methods and a section to assess the stage of change using the transtheoretical model (Prochaska & DiClemente 1983) of the participant. The nutritional hand-outs (Appendix III) were to encourage healthy eating habits. These images were placed in locations where food is kept as to act as a constant reminder of which foods to be eating. Initial physiological testing also took place within the first week (Appendix IV). These tests included physiological measures; body mass index (BMI), mass, resting blood pressure, resting heart rate and fat mass percentage using the Katch & McArdle protocol (1973). Balance was measured using two techniques, a revised sit-to-stand procedure (Lipsitz et al 2000) to record dynamic balance and the one legged procedure for static (Vellas et al 1997) up to 30 seconds. Co-ordination was measured by balancing a ball on a tennis racquet, firstly static and timing till it falls up to 30 seconds in each hand. This was followed by balancing a ball on a tennis racquet while moving to and from two cones 5m apart counting the number of times the ball was dropped and duration to complete.
Equipment used to record these measures includes:
5m measuring tape
Scale (Salter 9063WH3R)
Blood Pressure Monitor (Omron M2 Basic)
1.5m Textile Measuring Tape
Stopwatch (Ultrachron Lite)
Kit Bag (Thomas Sports, Activity Keykit Three)
These weeks were used for training sessions in which participants performed physical activities or games (Appendix V) for 1 hour, followed by a 15 minute psychological based consultation. All training sessions were logged on the participants own workout cards (Appendix VI) outlining the exercises performed and the challenges involved in that session. Each session involved the following format for physical training:
1.10 minute warm-up including mobility, pulse raiser and stretches
2.2 x 10 minute cardiovascular conditioning games
3.10 minute muscular endurance game
4.10 minute balance and co-ordination game or game such as hockey of football
5.10 minute cool-down including pulse adjuster and stretches
Re-testing of all physiological measures outlined in week one as well as balance and co-ordination tests and psychological consultation.
These weeks included further training following the same method as outlined in week 2-4.
This week involved final testing of all physiological measures as well as movement along the transteoretical model using the same questionnaire located in the PAR-Q (Prochaska & DiClemente 1983).
The mean and standard deviation of all physiological measures both pre and post intervention will be calculated. All measures will then be tested for normality. After testing for normality all parametric data (between -2 and +2) will be compared using the paired samples T-test. All non-parametric data will be compared using the 2 related samples wilcoxen test. This will allow for interpretation of data and test for any significant results (p<0.05).
The tables including the raw data collected of all physiological measures pre and post intervention and raw statistical data post analysis including frequencies, paired sample t-test and wilcoxen 2 related samples test have been included in Appendix VII. Right static ball and racquet balance time was not analysed as all results across all participants were the maximum of 30 seconds.
Figure 1. Group mean (± SD) mass (kg) pre and post intervention
The group mean mass pre intervention was 104.4(±14.8)kg and post intervention was 101.9(±13.7)kg. Therefore, there was a reduction in mass of 2.5kg. After testing for normality and using the paired samples t-test (p>0.05) and therefore this reduction is not significant.
Figure 2. Group mean (±SD) BMI pre and post intervention
The group mean BMI pre intervention was 36.4(±5.3) and post intervention was 35.7(±5.8). Therefore, there was a reduction in BMI score of 0.7. After testing for normality and using the paired samples t-test (p>0.05) and therefore this reduction is not significant.
Figure 3. Group mean (±SD) body fat percentage pre and post intervention
The group mean body fat percentage pre intervention was 55(±10.6)% and post intervention was 51.3(±10.3)%. Therefore, there was a reduction in body fat percentage of 3.7%. After testing for normality and using the paired samples t-test (p>0.05) and therefore this reduction is not significant.
Figure 4. Group mean (±SD) sit-to-stand time pre and post intervention
The group mean sit-to-stand time pre intervention was 1.55(±0.43)sec and post intervention was 1.11(±0.18)sec. Therefore, there was a reduction in time taken of 0.44 seconds. After testing for normality and using the paired samples t-test (p<0.05) and therefore this reduction is significant.
Figure 5. Group mean (±SD) right one legged balance time
The group mean right one legged balance time pre intervention was 17.8(±13.2)sec and post intervention was 20(±15.5)sec. Therefore, there was an increase in balance duration of 2.2 seconds. After testing for normality and using the paired samples t-test (p>0.05) and therefore this increase is not significant.
Figure 6. Group mean (±SD) left one legged balance time
The group mean left one legged balance time pre intervention was 7.4(±11.7)sec and post intervention was 13.4(±13.7)sec. Therefore, there was an increase in balance duration of 6 seconds. After testing for normality and using the wilcoxen signed ranks test (p>0.05) and therefore this increase is not significant.
Figure 7. Group mean (±SD) left static ball and racquet balance time
The group mean left static ball and racquet balance time pre intervention was 27.8(±5.3)sec and post intervention was 30(±0)sec. Therefore, there was an increase in balance duration of 2.2 seconds. After testing for normality and using the wilcoxen signed ranks test (p>0.05) and therefore this increase is not significant.
Figure 8. Group mean (±SD) 10m dynamic ball and racquet time
The group mean 10m dynamic ball and racquet in favoured hand time pre intervention was 22.8(±7.8)sec and post intervention was 16.5(±7.8)sec. Therefore, there was a reduction in time taken of 6.3 seconds. After testing for normality and using the paired samples t-test (p<0.05) and therefore this reduction is significant.
Discussion and Conclusion
After the 8 week holistic training intervention all physiological measures have improved. The purpose of this intervention was to analyse the effect of a holistic training programme on health status, balance and co-ordination. With elevating levels of obesity within the general population and especially in individuals with LD (Health Survey for England 2010) the physical measures of BMI, mass and body fat percentage were areas of keen interest and whether it would be possible to achieve a reduction with 60 minutes of supervised physical activity, over the course of 8 weeks. Other studies with longer durations and increased levels of supervised physical activity (Carmeli et al 2011, Ordonez, Rosety & Rosety-Rodriquez 2006 and Carmeli et al 2005) recorded significant reductions in these measures after interventions ranging from 2-6 months, with a minimum of 140 minutes of supervised physical activity per week. These studies used conventional training methods such as walking and swimming with the focus on aerobic activity. These structured programmes are ideal as levels of physical activity match those of recommended levels (ACSM 2009). However, with supervised sessions comes expense. This 60 minute supervised training intervention was developed for a more cost effective training strategy. Analysis of data post intervention showed a reduction in group mean mass of 2.5kg, BMI score of 0.7 and body fat percentage of 3.7%. While these findings are not statistically significant they are a crucial step in the right direction for these high risk individuals. The practicality and cost effectiveness of a 1 hour physical training session per week far outweighs those of increased training sessions to a special population that largely require additional support with such activities. It is believed that with increased duration of the intervention significant reductions would have been recorded. However, the greatest reductions in mass, BMI and body fat percentage were in individuals currently in work or engaging in other modes of physical activity. Therefore, the importance of a structured intervention alongside other modes of physical activity which can be performed un-supervised is crucial for maximal training outcomes. Levels of physical activity per week should reach recommended levels (Emerson & Baines 2010 and ACSM 2009) of 150 minutes of moderate aerobic activity.
Of all the training outcomes the most significant improvement was seen in the sit-to-stand time. The sit-to-stand testing method was used to analyse two key areas; muscular strength and balance as these are areas affected by individuals with LD (Lahtinen, Rintala & Malin 2007). All participants reduced time taken to stand out of a chair unassisted. This reduction will improve both the ability to perform ADLs and reduce the risk of failing which is a great cause for concern in individuals with LD especially as they exceed in age. The significant effect this training intervention has had on this training outcome is shown when compared to a study analysing the effect of a therapeutic training method over the course of 6 months (Carmeli et al 2003) concluded with a lack of improvement. It resulted in participants showing little to no improvements in a variety of areas including sit-to-stand and one legged balance test. The group mean of the one legged balance test also increased on both right and left legs. However, 33.3% of participants were unable to balance on either leg pre or post intervention. This explains the negative standard deviation bars of Figure 6. These participants had Ds and therefore, this training intervention may not be suited for individuals with Ds looking to improve one legged balance but in the case of other LD would be. A study (Jankowicz-Szymanska, Mikolajczyk & Wojtanowski 2012) utilising exercises performed on unstable surfaces resulted in young participants with Ds increasing one legged balance time. However, this result was not significant. As balance deteriorates with age (Lahtinen, Rintala & Malin 2007) any form of balance training that does not result in a negative effect would be beneficial.
Another significant reduction was in the time taken to complete a 10m course while balancing a ball on a tennis racquet. This was analysed to measure improvements in co-ordination which was highlighted as another affected area (Vuijk et al 2010 and Lahtinen, Rintala & Malin 2007). All participants reduced the time taken to complete the course. As a result this training method significantly improves ability to perform dynamic co-ordination tasks. However, analysis of data collected post intervention has shown that the majority of participants involved in the study, with the exception of one, were able to perform all static co-ordination tests for the maximum time pre and post testing. It is believed that the result of the one participant who recorded a lower left handed static ball balance time is an anomaly. This is as the right balance time was the maximum and the result post testing was recorded as the maximum time allowed within test procedures. Therefore, the static ball and racquet balance test is not an effective testing method for co-ordination as 83.4% of participants, excluding anomaly, for the left hand and 100% for the right hand attained maximum results pre and post testing. A testing method to analyse manual dexterity would be more beneficial.
Another area of concern with individuals with LD is current levels of physical activity. Less than 80% of individuals with LD currently participate in recommended levels of physical activity of 150 minutes, moderate intensity aerobic exercise per week (Emerson & Baines 2010 and ACSM 2009). With this in mind techniques and strategies should be implemented within any physical training intervention to improve adherence to exercise post intervention. Psychological interventions which have shown increased adherence to exercise are CBT (Beck 1960) and motivational interviewing (Rollnick & Miller 1995). However, no research could be found specific to LD. Research reviewing CBT (van Koulil et al 2010, Schneider, Cook & Luke 2008, and Redondo et al 2004) and motivational interviewing (Sjoling et al 2011, Perry & Butterworth 2011 and Martins & McNeil 2009) concluded that both are effective when treating non-disabled patients with medical conditions where physical activity is essential to their treatment programme in encouraging adherence to exercise. A combination of the two psychological theories was implemented as CBT is affective as part of a long term intervention. However, a meta-analysis resulted in CBT having insufficient effectiveness in achieving lasting remission after less than 20 sessions (Leichsenring 2001).
Adherence to exercise was measured by analysing movement along the Transtheoretical Model (Prochaska & DiClemente 1983) and levels of physical activity pre and post intervention. These variables were measured using the questionnaire within the PAR-Q (Appendix II). Pre intervention all participants were in the preparation phase. This was because none were currently participating in physical activity at recommended levels (ACSM 2009). Post intervention 66.6% had increased physical activity levels to 60 minutes per week but still fell below recommended levels. This meant progression into action phase had occurred but more encouragement to participate in physical activity was required. 33.3% had increased levels of physical activity per week to 150 minutes of moderate intensity aerobic activity. Therefore, these participants had moved through the action phase and into maintenance. All participants have continued levels of physical activity, while being supervised, post intervention of 60 minutes per week at a minimum. However, for maximal health and training outcomes increased levels of physical activity is required.
A nutritional intervention was also included. This is as less than 10% of individuals with LD eat a balanced diet with correct levels of fruit and vegetables (Emerson & Baines 2010). Research (Maiano et al 2010) in this area suggests that this is as a result of lack of knowledge of what components are included within a healthy diet. Therefore, the focus was to promote correct levels of macronutrients and increase intake of fruit and vegetables to “5 a day” (Health Survey for England 2010). This was done by producing two visual aids (Appendix III). The first is the “eatwell plate” visually displaying correct macronutrient levels and suggestions of foods which can be ingested for each including; carbohydrate, fat and protein in an easy to understand pie chart. Another visual aid was to specifically highlight good vs. bad. This was done by separating “good” or healthy food from “bad” or un-healthy foods. Colour-emotion associations were also used by “good” being light and bright colours and “bad” dark. This was to reinforce positive emotion association to the bright colours of the healthy food (Bankhead et al 2003 and Hemphill 1996). However, outcomes were not measured. Though it was reported by each participants key worker, social worker or parent that eating habits have improved including; smaller portion size, increase in fruit and vegetables and decrease in fatty and glucose rich snacks.
In conclusion, the 8 week holistic training intervention improved all tested measures. It also improved adherence to exercise post intervention and it is believed that the nutritional intervention had a positive effect on eating habits, though this was not a tested outcome. Despite these positive improvements in lifestyle factors the majority of tested measures did not show a statistically significant improvement. Therefore, the hypothesis is rejected as all measures were not significantly improved.
The main focus of this intervention was towards the physiological aspects incorporated within this training method. However, only 33.3% of participants involved within the study progressed to the recommended, 150 minutes of physical activity per week (ACSM 2009). Therefore, the focus of subsequent studies should be to increase supervised training time of individuals who are currently sedentary to recommended levels. However, for a more beneficial effect long-term, a strategy to encourage physical activity outside of structured sessions to promote behaviour change would be recommended. The reasons for this are twofold. Firstly, remaining at 1/60 minute supervised session per week is far more cost effective than multiple sessions per week. Secondly, promote independents and improve lifestyle and quality of life of each participant. This strategy should include a variety of different elements including encouragement and motivation, education of the importance of exercise, alongside the health benefits and ideas for potential activities which could be performed. However, in the case of physical activity being unable to be performed without supervision, an increase in supervised sessions would be strongly recommended.
Analysis of health status including BMI, mass and body fat percentage post intervention showed that all reduced, however not significantly. This is believed to be as a result of the short duration of the intervention and had it been longer as the levels of other research (Carmeli et al 2011, Ordonez, Rosety & Rosety-Rodriquez 2006 and Carmeli et al 2005) the results of these variable would be been significant. Therefore, it is recommended that any physiological intervention should be a minimum of 12 weeks in order to fully evaluate effectiveness.
A psychological and nutritional intervention was also included for a more holistic approach. However, the nutritional aspects could have been broader to cater for a wider variety of individuals. As less than 10% of individuals with LD eat a balanced diet with correct quantities of fruit and vegetables (Emerson & Baines 2010) this is an area in need of further research. The reason for this lack of healthy eating habits is believed to be as a result of lack of knowledge (Maiano et al 2010). Therefore, a strategy to teach principles of healthy eating and techniques to make healthy eating fun, alongside psychological theories to elicit behaviour change would be recommended. The teaching strategy could include a wider variety of visual aids including the health benefits, the different food types, portion control techniques and a recipe book including pictures of healthy meals displayed in light and bright colours. Portion control would be an essential part of any intervention as individuals with Ds have an inability to feel a sensation of a full stomach. Calculations including basal metabolic rate would therefore be necessary to calculate calorie intake. Portion size guides could also be included in order to aid in the cooking process. As a large majority of individuals with LD live within supported accommodation these nutritional techniques can be supplied and taught to service providers. This will promote healthy eating while remaining cost effective.
As part of the intervention static co-ordination was measured using a ball and tennis racquet and timing the time in which the ball could be balanced. It was discovered that this was not an effective test as all participants completed the task to the maximum time allowed. Therefore, as motor skills are still affected as a result of LD (Vuijk et al 2010, Hartman et al 2010 and Lahtinen, Rintala & Malin 2007) a more diverse and accurate measure would be recommended. An alternative and more beneficial test would be the Test of Gross Motor Development (Hoskins & Squires 1973). This test has shown to be beneficial when assessing motor skills and manual dexterity (Hartman et al 2010).
In closing, this holistic training intervention has demonstrated the ability to improve physiological measures as part of a short term intervention, while improving adherence to exercise and other physical difficulties faced by individuals with LD, including balance and co-ordination. However, more research is required in the areas of duration of intervention and frequency of sessions in order to achieve maximal training outcomes across all measures. In addition to nutritional strategies developed to meet the specific needs of LD as a whole and tailoring those strategies to the individual. Finally, development of a training method that will significantly improve motor performance and in turn lifestyle of a special population, in much need of support and techniques to resolve the issues as statically represented.
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