PROMPTING INDIVIDUALS WITH DOWN SYNDROME TO USE A TREADMILL

Abstract

LEARNING OBJECTIVES 

This article discusses strategies practitioners can implement in a health and fitness setting to communicate effectively with individuals who have Down syndrome. Readers will learn how to conduct a task analysis and the proper implementation of prompting when consumers with Down syndrome begin an exercise program that involves the use of a treadmill.

INTRODUCTION

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Down syndrome (DS) is a condition caused by a chromosomal abnormality that occurs in approximately 1 in 691 births, generally resulting in moderate levels of intellectual disability (ID) (^5,6). Individuals with DS are at a heightened risk for becoming obese later in life when compared the general population partially because of low levels of physical activity (PA) (¹⁰). In addition, the population has a higher prevalence of muscle weakness and low bone mineral density, and more than 50% are born with structural cardiac abnormalities such as atrioventricular and ventricular septal defects (³).

Because obesity is associated with a number of health conditions including heart disease and type 2 diabetes (⁷), encouraging and promoting activities such as walking in this population is important. However, fitness professionals may experience unique challenges during training sessions such as effectively communicating how to properly use new exercise equipment clients are unfamiliar with. Therefore, fitness professionals need practical strategies to address these challenges to work with individuals with DS effectively.

Communication Deficits

Studies of language abilities in people with DS report general delays in language development, along with specific dissociations among different linguistic domains or subdomains (¹). Moreover, Rondal and Comblain (¹¹) state that individuals with DS tend to use simple sentences in which function words (articles, prepositions, pronouns, etc.) frequently are omitted. These language patterns may present significant challenges in communication between an individual with DS and fitness professionals. However, communicating effectively with clients in the fitness setting is imperative to ensure safety and determine if the individual is comfortable using training equipment, if there is any presence of pain or discomfort, as well as to observe other signs and symptoms that would contraindicate exercise.

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Cognitive Functioning

An ID, formerly referred to as mental retardation, is characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills (¹²). All individuals with DS exhibit some type of deficit in intellectual functioning, ranging from mild to severe, but most often in the moderate range (⁵). Fitness professionals should be explicit with instructions when teaching new concepts (e.g., exercise technique). For instance, instead of instructing the client to get on a treadmill and start walking, the health and fitness professional might need to instruct the client to walk toward the front of the treadmill, swing arms by the side while walking/running, avoid holding onto handrail, and so on. Being explicit with instructions means the health and fitness professional should be specific with instructions and leave nothing for the client to assume (e.g., is holding handrails allowed). Furthermore, exercise instructions might have to be modified when teaching how to use equipment properly during an exercise session. For example, a health and fitness professional may first teach a new exercise technique by providing verbal instruction to the client. If the client finds the skill too difficult or does not understand the instructions, the fitness professional could then modify the instructions by breaking down the skill into smaller tasks, demonstrating the exercise, or demonstrating each step of the exercise individually.

Generalization and Maintenance

People with DS often have difficulty with generalization and maintenance. For example, individuals with DS might be able to walk or run on a track. However, that does not result in the individual being able to apply the skill of walking or running on a treadmill. Therefore, fitness professionals should take this into consideration and realize that additional instruction and/or alternative strategies may be required when teaching new tasks (e.g., walking on treadmill).

Increasing the Use of Treadmills

The authors of this article have chosen to provide strategies for increasing exercise participation using a treadmill because walking is the most common mode of exercise and may elicit a greater energy expenditure as opposed to other exercise modalities such as cycle ergometry (^8,9). The proposed instructional strategies are suggested for teaching adolescents and adults with DS but could more generally be applied to individuals with ID who do not have DS, as well as to other modes of exercise, such as cycle ergometry.

It should be noted that other modes of exercise such as cycle ergometry and elliptical use in some cases might be more appropriate than a treadmill because individuals with DS tend to experience muscle hypotonia, joint hypermobility, and atlanto-axial instability (⁴). Because of these conditions, caution should be used when prescribing exercise to avoid potentially serious injury to the individual with DS, and fitness professionals should take the individual needs of a client into consideration when planning an exercise program to determine the most appropriate mode of exercise. The authors of this article suggest that health and fitness professionals who work with this population refer to the third edition of ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities to gain a better understanding of some of the necessary precautions that should be taken before working with individuals who display these conditions (⁴).

STRATEGIES

Task analysis and prompting have been effective in teaching individuals with ID a variety of skills including recreation and leisure activities (^13,15). Although applied behavior analysis techniques such as task analysis and prompting are used often in an education setting, they also can be used successfully within a fitness setting as described on the next page.

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Task analysis involves identifying the simple steps involved in completing a complex skill and then teaching the smaller components of the task. Table 1 provides a task analysis of using a treadmill. Once these subordinate skills have been identified, the next step is to determine how to introduce each one.

TABLE 1: Task Analysis for Using a Treadmill

Prompting is providing a cue before or during a particular behavior, which in turn facilitates the behavior (²). There are several types of prompts. The least intrusive, requiring less support than others, and easiest prompts to implement are verbal, gesture, and model. A verbal prompt is a spoken reminder to engage in some aspect of the behavior. An example is offering a verbal reminder to press the start button after getting on the treadmill. A gesture is a physical action by the fitness professional to cue the behavior. A trainer may point to the incline button on a treadmill to cue an individual to increase the grade of the treadmill. Modeling the behavior to demonstrate how to engage in a skill also can be used as a prompt. For example, a fitness professional may stand on a treadmill close to the monitor as the client stands on a treadmill to show the client the appropriate location to stand.

The more intrusive and difficult prompts to implement are partial physical and full physical prompts. A partial physical prompt involves the fitness professional shadowing or lightly touching the individual with DS to guide him or her to engage in the desired behavior. A full physical prompt, however, is the most intrusive and involves physically manipulating the individual to engage in the behavior (²). For example, if an individual with DS does not know how to walk on the treadmill, the trainer may perform a full physical prompt by emphasizing movement of the leg by gently assisting with gait pattern at a very slow speed (e.g., 0.5–1.0 mph) and 0% grade. After several repetitions with a full physical prompt, the health and fitness professional could hover his or her hand behind the knee or use less pressure when assisting with the gait cycle (i.e., a partial physical prompt).

It is important to note that there is no specialized training required to prompt an individual with DS during exercise. Therefore, effectively using prompting simply takes practice. However, the health and fitness professional should take all necessary precautions to prevent accusations of misconduct when using any type of physical prompt, which might mean making sure other individuals (i.e., fitness members, staff, etc.) are around and the practitioner and client are never left alone. Furthermore, this might involve letting both the participant and his or her legal guardian know ahead of time that prompting involves physical contact to help the participant successfully carry out exercises.

One or more types of prompts may be necessary to ensure an individual’s accuracy in engaging in the skill. For example, a verbal prompt (“Remember to stand up straight”) and partial physical prompt (lightly touching the individual’s back) may be necessary to increase the likelihood of using proper form when walking (e.g., standing straight, moving arms, etc.). To begin, allow the individual to attempt the skill without a response prompt. If the first attempt is unsuccessful, try the least intrusive prompt first, such as a verbal or gesture prompt. If unsuccessful again, add the next intrusive prompt until the individual can engage in the skill. Remember, each individual may have varying responses to prompts. The types of prompts that can be used frequently to teach individuals with DS to walk on a treadmill are provided in Table 2.

TABLE 2: Prompts Hierarchy

Once the appropriate prompt is determined, the fitness professional must identify under what circumstances the prompt will be implemented if the natural cue (e.g., “the big green button that says ‘start’” or “the treadmill is moving”) is unsuccessful. General guidelines for increasing assistance with prompts should allow an individual 0 to 5 seconds to respond when initially learning a behavior before repeating a prompt or moving onto the next type of prompt (e.g., wait 3 to 5 seconds before you partially physically move the individual’s arm toward the button) (²). Health and fitness professionals may want to consider establishing a limit to the number of times they use one type of prompt. For example, if the trainer is limited to three to five verbal prompts, it is less likely to come across as nagging than if a verbal prompt is used repeatedly. If the individual has the potential of getting hurt by not engaging in the step correctly, then it is appropriate to implement a more intrusive prompt if the behavior does not immediately occur after the initial prompt. For example, if the individual is not moving his or her feet when the treadmill starts and though they are gestured to move, then it would be appropriate to start with a partial physical or full physical prompt to move the individual’s legs to initiate walking.

One goal of training individuals with disabilities is for participants to engage in the prescribed exercise program independently. Therefore, individuals with DS should not become reliant on the fitness professional to provide prompts to engage in the behavior. To prevent prompt dependence, a plan must be created to fade the prompts or wean individuals off prompts after consistent responding so that they perform the skill independently. One method for doing this is to wait increasing amounts of time before the prompt is implemented. Once behavior is occurring consistently with a prompt (e.g., if the behavior occurs almost immediately after the prompt for three consecutive times), the trainer should increase the amount of time before implementing the prompt by 1 or 2 seconds. Another method is to prompt with a decreasing amount of assistance by changing to less intrusive prompts after consistent responding (²).

Fitness professionals also can make prompting procedures more effective if the following considerations are taken into account (¹⁴). First, make sure the individual is paying attention before providing the prompt. Second, use prompts to focus attention on the natural cues in the environment. If a green button is used typically as a cue for the general population to start the treadmill, then the prompts to start the treadmill should incorporate the green button in some manner (e.g., “press the green button” instead of “touch here” and pointing to the green button instead of using another gesture to indicate starting). Third, fitness professionals must provide feedback after the behavior occurs. The feedback should be very positive and descriptive so that individuals know exactly what they did right. Without feedback, the prompting procedure is likely to be ineffective. Using traditional positive feedback and rewards, such as high fives or fist bumps also can be useful as feedback and rewards. Fourth, most individuals with DS will gain a better understanding of the behavior if they are provided one instruction at a time instead of multiple cues.

Summary

Because of low rates of PA, individuals with DS are at a heightened risk for becoming overweight and obese and developing hypokinetic disorders such as heart disease and type 2 diabetes earlier in life compared with those without DS. Like with any population, health and fitness professionals can play a vital role by helping consumers with DS avoid these issues through personalized exercise training programs. Most individuals with DS have moderate deficits in intellectual functioning (5). As a result, health and fitness professionals might face unique challenges when delivering instructions to this population on how to use fitness equipment properly such as treadmills during an exercise session. Using the aforementioned task analysis and prompts can be beneficial during fitness-related activities and other recreational or leisure skills for individuals with DS.

BRIDGING THE GAP

Working with individuals who have Down syndrome (DS) in a health and fitness setting can be challenging for practitioners who are not trained or have limited experience working with the population. These issues might be caused by communication deficits and cognitive disabilities individuals with DS typically experience. As a result, teaching proper technique on various forms of exercise can be challenging. To overcome these obstacles, practitioners can use task analysis and prompting strategies to communicate effectively and teach consumers with DS how to use a treadmill when beginning an exercise program.