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Special Considerations for Exercise Testing and Prescription for the Individual with an Intellectual Disability

Carter, Kathy M.S., R.D.; Swank, Ann M. Ph.D., FACSM, C.S.C.S, ACSM-CES, ACSM C-PD

doi: 10.1249/FIT.0000000000000016
COLUMNS: Clinical Applications

Exercise Testing and Prescription Considerations for Individuals With Intellectual Disabilities

Kathy Carter, M.S., R.D., is an instructor of exercise physiology at the University of Louisville Health and Sport Science program. She is a registered dietitian and is pursuing a Ph.D. in Kinesiology, with an emphasis in Adapted Physical Activity. Her research interests include how exercise affects individuals with special needs, especially in the area of intellectual disabilities. She has a black belt in taekwondo and teaches martial arts classes for individuals with special needs.Ann M. Swank, Ph.D., FACSM, C.S.C.S., ACSM-CES, ACSM C-PD, is a professor of exercise physiology, co-chair of the Health and Sport Science Department, and director of the Exercise Physiology Laboratory at the University of Louisville. Her research interests are exercise testing and prescription for special populations, with an emphasis on chronic heart failure. She is ACSM Program Director certified, ACSM Clinical Exercise SpecialistSM certified, and a fellow of ACSM.

Disclosure: The authors declare no conflicts of interest and do not have any financial disclosures.

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This column introduces a series of future articles that will address exercise testing and prescription considerations for various special populations. Arguably the most important aspect of exercise testing and prescription strategies involves individualizing the procedures to any given person and population. The factors of exercise testing include choosing an appropriate protocol, end point for test, and signs and symptoms to look for, among others, whereas the factors for the exercise prescription include any needed disease-specific changes in intensity, duration, frequency, and type of activity. Thus, the clinician needs to consider the unique characteristics of the special population, as well as the individual, when developing a plan for exercise testing and prescription. There are many ways to modify the factors associated with exercise testing and prescription to achieve a certain outcome for any given population or individual. This flexibility with exercise testing and prescription permits the exercise professional to add the “art” to the “science” of exercise programming for any given population. As long as safety considerations are primary, clinicians are limited in their exercise programming only by their imagination. The current column addresses special considerations for exercise testing and prescription for the individual with an intellectual disability.

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According to the American Association of Intellectual and Developmental Disabilities, a person with an intellectual disability (ID) is “characterized by significant limitations in both intellectual functioning and adaptive behavior, which cover many everyday social and practical skills. This disability originates before the age of 18” (1). An estimated 7 to 8 million Americans have an ID, which means that about 1 in 10 families in the United States is impacted by this condition. Most of the individuals with an ID live in communities, either at home with their families or in group homes, where they are able to function with varying levels of support that ranges from none to extensive. Exercise professionals should be aware that any limitation an individual with ID may have often will coexist with favorable attributes. For example, an individual with ID may have difficulty following directions, but he or she may be very motivated to improve. Thus, it is likely that a person’s level of functioning will improve if appropriate support is provided for a sustained period (1).

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Overweight and obesity are common comorbidities in individuals with ID. This observation likely is the result of decreased motor skills and physical abilities that ultimately leads to physical inactivity, as well as a genetic predisposition (4,6,7). Congenital heart defects and a greater susceptibility to respiratory infections also are common and should be taken into consideration when working with individuals with ID. Because of the potential presence of significant cardiovascular and pulmonary disease, it is recommended that preexercise screening follow American College of Sports Medicine guidelines (2). In addition, a careful health history completed by a parent/caretaker before exercise testing and prescription will help ensure safety (2).

Other factors related to exercise testing that need to be considered for individuals with ID are that they may tend to have short attention spans, poor comprehension of directions, and lack motivation for physical movement, especially when physical effort becomes uncomfortable. Thus, it is crucial that the staff working with an individual with ID familiarize him or her with testing personnel and all procedures before the test. Personnel should demonstrate the exercise test first and then verbally guide the person with ID using short simple instructions until the individual can perform the tasks on cue without undue stress. Additional personnel may be required for the testing if there are issues associated with balance. When performing a clinical exercise test for the individual with ID, provide adequate warm-up and cooldown activities, adhere to all safety precautions, provide a positive testing environment, and tailor the protocol to the individual to help ensure that the test is safe and provides the needed information for prescribing exercise. Treadmill-walking protocols, leg ergometer, and dual-action cycle tests (e.g., Airdyne) all represent effective modes of exercise testing for the individual with ID.

If laboratory-based testing is not feasible for the individual with ID, there are several field tests that have been validated to evaluate cardiorespiratory fitness in this population — assuming that there is no significant underlying disease present. For children with an ID, the 20-m shuttle run, 600-yard run/walk, and 1-mile Rockport Walking Fitness Test have been validated and shown to be reliable. The 1-mile Rockport Walking Fitness Test and 1.5-mile run/walk have been validated for adults with ID (3).

When testing muscular strength in individuals with ID, using weight machines instead of free weights may prevent any possible issues associated with balance. Testing personnel first should provide a physical demonstration of the movement and then physically move the individual through the proper motions. Short simple verbal cues for proper lifting technique and breathing likely will be required for initial testing and for the early phases of training.

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The factors of exercise prescription (intensity, duration, frequency, and type of activity) are the same for the individual with ID because they are for the client without ID; however, the application of these variables will need to be modified based on the individual. For example, individuals with Down syndrome have a lower maximal heart rate, lower cardiac output, and lower peak aerobic capacity than normal individuals. Therefore, age-predicted maximal heart rate should not be used when developing an exercise prescription. Because of the high prevalence of obesity and sedentary lifestyle among individuals with ID, emphasis on daily physical activity also should be encouraged. Once a physical activity “habit” has been established, increasing intensity and duration of physical activity can be emphasized. Because of motivation issues, it will be important for the exercise professional to provide a positive atmosphere and schedule the frequent rotation of exercises as a means to negate any need for extended periods of concentration on one activity. Games and partner activities will enhance the social aspect of physical activity and encourage individuals to continue the activity for a longer period (3). While exercising, individuals with ID need to be supervised initially, making small group exercises or personal training preferable to large group programs.

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Social interaction is essential for motivating a sedentary population to participate in physical activities and maintain physical functioning. Because of their lower levels of physical fitness as well as cognitive and social skills, individuals with ID have a greater need for social support to become physically active (5). Sports programs (e.g., Special Olympics) provide activities where individuals with ID feel comfortable and accepted while increasing their physical activity level. Other programs that may be beneficial would be activities that a person participates in a group, but outcomes depend solely on themselves. Such activities would include dance, bowling, and martial arts.

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Individuals with ID can enjoy the benefits of regular exercise if the unique care and supervision concerns identified above are considered. The next Clinical Application column will address how the factors of exercise testing and prescription can be used to develop exercise programming for individuals with spinal cord injury.

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1. American Association of Intellectual and Developmental Disabilities Web site [Internet]; [cited 2013 Oct 7]. Available from:
2. ACSM. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2013. p. 301–305.
3. Durstine JL, Moore GE, Painter PL, Roberts SO. ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities. 3rd ed. Champaign: Human Kinetics; 2009. p. 359–366.
4. Frey GC, Chow B. Relationship between BMI, physical fitness, and motor skills in youth with mild intellectual disabilities. Int J Obes. 2006; 30: 861–7.
5. King M, Shields N, Imms C, Black M. Participation of children with intellectual disability compared with typically developing children. Res Dev Disabil. 2013; 34 (5): 1854–62.
6. Temple V, Frey GC, Stanish HI. Physical activity of adults with mental retardation. Am J Health Promot. 2006; 21 (1): 2–12.
7. Yamaki K . Body weight status among adults with intellectual disability in the community. Ment Retard. 2005; 43: 1–10.
© 2014 American College of Sports Medicine.