Research in Developmental Disabilities 33 (2012) 2236–2244

Contents lists available at SciVerse ScienceDirect

Research in Developmental Disabilities

Strength and agility training in adolescents with Down syndrome:

A randomized controlled trial§
Hsiu-Ching Lin a, Yee-Pay Wuang b,*
a
Department of Physical & Rehabilitation Medicine, Pingtung Christian Hospital, Pingtung, Taiwan
b
Department of Occupational Therapy, Kaohsiung Medical University, Kaohsiung, Taiwan

A R T I C L E I N F O A B S T R A C T

Article history: The purpose of this study was to investigate the effects of a proposed strength and agility
Received 30 April 2012 training program of adolescents with Down syndrome. Ninety-two adolescents were
Received in revised form 26 June 2012 recruited and evenly randomized to two intervention groups (exercise group vs. control
Accepted 27 June 2012 group). The mean age for the exercise and the control group was 10.6  3.2 and 11.2  3.5
Available online 21 July 2012 respectively. The exercise training program consisted of a 5-min treadmill exercise and one
20-min virtual-reality based activity administered three times a week for 6 weeks. Pre- and
Keywords: post-test measures were taken for muscle strength and agility performance. The measured
Down syndrome
muscle included hip extensor, hip flexor, knee extensor, knee flexors, hip abductors, and ankle
Dynamometer
plantarflexor. A handheld dynamometer was used to measure the lower extremities muscle
Muscle strength
Agility performance
strength, and agility performance was assessed by the strength and agility subtests of the
Bruininks–Oseretsky Test of Motor Proficiency-Second Edition. The exercise group had
significant improvements in agility (p = 0.02, d = 0.80) and muscle strength of all muscle group
(all p’s < 0.05, d = 0.51–0.89) assessed in comparison to the control group after the 6-week
intervention. Knee muscle groups including both flexors and extensors had the greatest gains
among all the muscles measured. A short-term exercise training program used in this study is
capable of improving muscle strength and agility performance of adolescents with DS.
ß 2012 Elsevier Ltd. All rights reserved.

1. Introduction

Down syndrome (DS) is a chromosomal anomaly with incidence of around 1/700 to 1/1000 live births (Roizen, 2002). DS
is the most common single cause of intellectual disabilities (ID) (Menkes & Falk, 2005), with between 70% and 75% of
individuals with DS attaining an IQ of between 25 and 50 (Vicari, 2006). Individuals with DS are mainly characterized by
several clinical symptoms including orthopedic, cardiovascular, musculoskeletal, and perceptual impairments. DS are
associated with a distinct profile of developmental outcomes regarding body functions and activity performance (Fidler,
Hepburn, Mankin, & Rogers, 2005), with evidence for great variation in the range and level of deficits resulting from
biological and environmental factors (Turner & Alborz, 2003).
Individuals with DS generally show deficits in motor skills throughout development (Palisano et al., 2001). Most infants
and toddlers with DS show extreme delays relative to age-matched typically developing infants, moving through stages of
early motor development more slowly and exhibiting more within-group variability than typically developing infants

§
No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s)
or upon any organization with which the authors is/are associated.
* Corresponding author at: Department of Occupational Therapy, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. Tel.: +886 7 3121101x2658;
fax: +886 7 3215845.
E-mail address: yeepwu@cc.kmu.edu.tw (Y.-P. Wuang).

0891-4222/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ridd.2012.06.017
 H.-C. Lin, Y.-P. Wuang / Research in Developmental Disabilities 33 (2012) 2236–2244 2237

(Bertoti, 2008). In older children with DS, motor problems persist. Adolescents with DS have specific impairments in fine
motor function, including difficulty with precise finger movements as well as gross motor tasks such as sit-ups and push-ups.
Other studies have described their deficits in visual motor integration, agility, muscle strength, motor control, and
movement reaction time (Rigoldi, Galli, Mainardi, Crivellini, & Albertini, 2011; Welsh & Elliott, 2001; Wuang & Su, 2012).
Among the motor impairments demonstrated by individuals with DS, muscle strength is one of the essential abilities of
individuals to achieve effective and functional movements. Muscle weakness and hypotonia are theorized to impair upper
extremity midline movements and gaits (Lewis & Fragala-Pinkham, 2005). Particularly, the lower extremity muscle
strength of individuals with DS is of fundamental importance to their overall physical health, and ability to perform daily
activities (Gupta, Rao, & SD, 2011). Further, because their workplace activities typically emphasize physical rather than
cognitive skills, decreased strength can negatively impact the vocational and social development of adults in the workforce
(Shields, Taylor, & Dodd, 2008). However, individuals with DS demonstrate lower levels of muscle strength than those with
ID without DS and those without ID (Cioni, Cocilovo, & Di Pasquale, 1994; Horvat, Pitetti, & Croce, 1997; Mercer & Lewis,
2001).
Agility is the ability to move and change direction and position of the body quickly and effectively while under control,
and requires the integration of isolated movement skills using a combination of balance, coordination, speed, reflexes,
strength, endurance, and stamina (Sheppard & Young, 2006). Individuals with ID including DS are deficient in carrying out
tasks requiring agility such as shuttle run and vertical jump (Wuang, Wang, Huang, & Su, 2009). Additionally, comparing to
other developmental disabilities, individuals with DS have poor performance in praxis skills which are the key elements to
agility performance (Fidler et al., 2005).
Studies done to determine the effect of strength training in DS have focused on the child and adult population. In adults
with DS, Tsimaras and Fotiadou (2004) found a significant increase in leg muscles strength following a 12-week intervention
while Shields et al. (2008) demonstrated gains in upper extremities muscles strength after completing a 10-week group
progressive resistance training program. A recent study (Gupta et al., 2011) suggested that a 6-week exercise training
program may improve the lower limb muscle strength in children with DS. Agility training in children with DS is less
discussed, Wuang, Wang, et al. (2009) found the improved performance on the BOTMP agility subtests after a 6-month
sensorimotor training in children with general ID including DS. They also implemented virtual-reality based programs in DS
lately and found significant gains on the BOT-2 strength and agility subtests comparing to those receiving traditional
occupational program only (Wuang, Chiang, Su, & Wang, 2011).
Even though the above-mentioned programs documented benefits in improving the muscle strength and agility
performance in DS, however, the programs might not be sustained because of the long intervention period or complicated
program contents. For example, in Lewis and Fragala-Pinkhams’s study (2005) on the effects of aerobic conditioning and
strength training program, most participants switched to a simple treadmill training program after the study ended. As well,
participant compliance with exercise decreased rapidly over time (Schutzer & Graves, 2004). Therefore, a shorter period of
training program (e.g., 6 week in the present study) might be more feasible, accessible, and efficient for individuals with DS
(Gupta et al., 2011; Wang, Huang, & Wuang, in press).
Appropriate use of commercially available equipment or products make physical training programs more accessible and
fun for individuals with disabilities. Several intervention programs were implemented over the years with some using the
treadmill. These programs achieved improvement in various fields, such as muscle tolerance, physical fitness lower pulse per
minute, and muscle strength in particular (Chanias, Reid, & Hoover, 1998; Merriman, Barnett, & Jarry, 1996). Treadmill has
been used in physical fitness training programs on DS and other ID as well. A short-term daily treadmill exercise conducted
by Lotan, Isakov, Kessel, and Merrick (2004) produced significant improvements in physical fitness and functional ability for
children with ID after 8 weeks. Aged adults with DS can significantly improve muscle strength and balance by adopting
suitable programs of treadmill walking as well (three times a week for 25 consecutive weeks) (Carmeli, Kessel, Coleman, &
Ayalon, 2002). However, due to their cognitive limitations and lower physical fitness, individuals with DS might be more able
to adhere to treadmills exercise protocol with shorter walking time (Carmeli, Bar-Chad, Lotan, Merrick, & Coleman, 2003;
Wang et al., in press).
Clinical practitioners have kept trying to use more appealing therapeutic equipment to address the motivation and
attention limitations identified for individuals with cognitive impairments. Serious studies (Lotan, Yalon-Chamovitz, &
Weiss, 2009; Lotan, Yalon-Chamovitz, & Weiss, 2010; Wuang et al., 2011) incorporated the virtual reality based (VR-based)
activity into the regular exercise programs and also demonstrated improvement in physical fitness (e.g., muscle strength)
and motor functions (agility performance) for individuals with developmental disabilities and ID. The averaged intensity of
these VR-based activities was 45 min per week for 16 weeks. They also found that children playing in VR-based activities felt
safe and were able to practice; playfulness was increased if the child had some control and allowed creativity and persistence
with the VR’s task. Compared to treadmill exercise, VR-based activities focused more on training components essential for
agility performance such as postural control, weight shifting, and dynamic balance.
To date, scant data is available on exercise training programs involving a substantially larger sample of adolescents with
DS. Improvement of muscle strength and agility performance in adolescents might lead to a more productive and active
lifestyle in adulthood with DS. In light of the therapeutic values of both treadmill and VR-based exercise and their combining
effects (Wang et al., in press), this study aimed to conduct a clinical trial to evaluate the effectiveness of a combined program
of strength and agility training by using treadmills and Wii game protocols. We hypothesized that the short-term exercise
program is effective in improving muscle strength and agility in a cohort of adolescents with DS.
2238 H.-C. Lin, Y.-P. Wuang / Research in Developmental Disabilities 33 (2012) 2236–2244

2. Materials and methods

2.1. Participants

The inclusion criteria were (a) age 13–18 years and current high school enrollment; (b) diagnosis of DS by board-certified
physician; (c) able to follow simple instructions; and (d) written consent indicating their agreement to participate in the
study. Subjects with associated cardiovascular conditions, blindness, deafness, or previous neurological impairments were
excluded. Individuals who had received any physical or occupational therapy in the year preceding the study were also
excluded.
Adolescents with DS were recruited from 17 high schools and 4 institutions serving individuals with disabilities in the
Kaohsiung and Pingtung metropolitan area. The researchers first contacted the school nurses, teachers, and directors at each
participating facility to explain the goals and procedures of the study and to ask them to suggest individuals eligible for the
study. Families expressing interest in participating were sent detailed written information about the study. The parents/
caregivers were also informed that their children would be randomly selected to be in the control or exercise group, and they
would not receive the exercise training program if they were chosen for the control group during the study period. However,
the control group would get the same exercise training programs after the study ended. An occupational therapist then met
with one parent of each child to assess whether the child was eligible.
Of the 113 participants assessed, 10 (12.1%) were ineligible, and 11 (18.8%) refused to participate. After signing the
consent document, the participants had the baseline tests of lower muscle strength and agility measured including the
hand-held dynamometer and the Bruininks–Oseretsky Test of Motor Proficiency-Second Edition. The remaining 92
participants were randomly assigned to either the experimental or the control group (n = 46 each) using stratified random
sampling. To ensure the homogeneity of the two groups, stratification was done according to the averaged lower
extremities muscle strength (averaged hip extensor, hip flexor, knee extensor, knee flexors, hip abductors, and ankle
plantarflexors).

2.2. Instruments

2.2.1. Study questionnaire

This study-specific questionnaire included child’s anthropometric variables (weight and height), demographic data (age,
gender), received medications, treatments, and paramedical therapies.

2.2.2. Wechsler Intelligence Scale for Children-Third Edition (WISC-III; Wechsler, 1991)
The WISC-III was used to measure the intelligent quotient (IQ) of the participants in this study. The test is designed for
ages 6 years 0 months to 16 years 11 months and consisted of 13 subtests split into two scales: verbal and performance. Full
scale IQ (FSIQ) is a scaled score representing overall ability in both verbal (VIQ) and performance (PIQ) subtest measures. The
WISC-III also yields four index scores, including verbal comprehension (VCI), perceptual organization (POI), freedom from
distractibility (FDI), and processing speed (PSI). The WISC-III generates three IQ and four index scores which have a mean of
100 and a standard deviation of 15. Psychometric properties of the WISC-III have been well established. The Chinese version
was used in the study (Chen, 1997).

2.2.3. Hand-held dynamometer

A hand-held dynamometer was used to measure the strength (in pounds, lb) of hip extensor, hip flexor, knee extensor,
knee flexors, hip abductors, and ankle plantarflexors according to the instrument manual. This was proven to be reliable in
measuring the isometric muscle strength in children with DS with intraclass coefficients ranging from 0.89 to 0.95 (Mercer &
Lewis, 2001). After explaining and demonstrating the test procedure, four test trials with a 30-s rest in between were
performed for each lower extremity muscle group (Mercer & Lewis, 2001). The average of the best performance of both lower
extremities was used for data analysis.

2.2.4. Bruininks–Oseretsky Test of Motor Proficiency-Second Edition (BOT-2) (Bruininks & Bruininks, 2005)
The BOT-2 assesses proficiency in four motor-area composites for individuals aged 4 through 21. Fine manual
control composite measures the motor skills involved in tasks requiring precise control of finger and hand movements.
Manual coordination composite evaluates speed, dexterity, and coordination of upper extremities. Body coordination
composite taps the balance and motor skills required for successful participation in sports, while strength and
agility composite assesses large muscle strength, running speed, and postural control during walking and running. The
four composite scores are combined to yield a total motor composite score. For the composites, internal consistency
reliability coefficients ranged from 0.78 to 0.97, test–retest coefficients over an interval of 7–42 days ranged from 0.52 to
0.95, and inter-rater reliability coefficients exceeded 0.92 (Bruininks & Bruininks, 2005). The BOT-2 had good reliabilities
(internal consistency, test–retest reliability, responsiveness) and construct validity in children with ID (Wuang, Lin, & Su,
2009; Wuang & Su, 2009). The strength and agility composite (SAC) used in the present study included five subtests:
standing long jump, push-ups, sit-ups, wall sit, and V-up. The average age-adjusted standard scores for composites are
100 (SD = 15).
 H.-C. Lin, Y.-P. Wuang / Research in Developmental Disabilities 33 (2012) 2236–2244 2239

2.3. Procedures

Informed consent was obtained from the participant and his/her parent or guardian using assent (for the adolescents) and
consent (for parent/guardian) forms approved by the Institutional Review Board of Kaohsiung Medical University Hospital.
All intervention sessions were conducted at a 48 m2 room located at the Department of Occupational therapy of Kaohsiung
Medical University.

2.3.1. Warm-up sessions

Prior to the formal intervention session, participants were given opportunities to practice using a treadmill and Wii
equipment during the warm-up sessions. Each participant spent about 10 min on each piece of equipment. This session was
helpful in teaching the participants the correct procedure to carry out the exercise programs.

2.3.2. Intervention sessions

The research group was enrolled in a 6-week intervention program consisting of three 35-min sessions
per week. The intervention program was conducted on an individual basis in a specially designated space in
the university and facilitated by the caregivers/staff/teachers familiar with the participants. The personnel were
supervised by a senior occupational therapist with expertise in working with DS and who was familiar with the
Wii system. Home programs were not provided to the parents or caretakers to minimize possible confounding due
to practice effects and variations of treatment techniques between therapists and parents. According to similar
protocols that significantly improving the physical fitness in children with DS earlier (Wang et al., in press); the 35-
min exercise program had two major components: 5-min treadmill exercise (Lotan, Isakov, Kessel, et al., 2004; Lotan,
Isakov, & Merrick, 2004) and a 20-min VR-based exercise program with 10-min break in between. This combined
exercise program has been proven to be effective in improving physical fitness in children with DS (Wang et al.,
in press).

2.3.2.1. Treadmill exercise protocol. The Sunpro Treadmill Model 005 was used for treadmill exercises. Three to five
minutes of active stretching exercise were undertaken prior to each walking sessions. The treatment program for each
child (speed and instrument elevation) was determined in advance by the therapist. The trainer was responsible for
placing the children on the exercise machine, performing the predetermined program, and registering the maximal pulse
at the end of the session. The children began walking at an average initial speed of 2.0 kph (with 0% incline) and ended at
an average speed of 3.0 kph (with 58 of elevation degree). Participants were allowed to grab the handrails for walking
balance adjustment.

2.3.2.2. VR-based exercise protocol. Nintendo introduced a novel style of VR by using a wireless controller that interacts
with the player through a motion detection system and its avatar representation in the video. The movements
performed by the individuals could be captured and reproduced on the screen via the infrared light sensor mounted on
TV top. Several distinctive features favored the selection of Wii over other VR systems, including novel and widely
available 3D technology using gaming simulations, affordability, and clinical applicability using simple graphics with
real-time feedback with the intellectual limitations in DS (Saposnik et al., 2010). In the present study, Nintendo Wii
gaming technology provided game-like exercise for the 20-min VR-based exercise program (Wuang et al., 2011). Using a
child-centered approach, the therapist encouraged the participants to choose their preferred activities from 15 pre-
selected Wii Sports items. Since a moderate to high level of physical activity is necessary for the games used in this
study; these 15 Sports items were previously tested on 10 typically developing peers, and 50–65% of the maximal heart
beats/min was reached after using for 20 min. Most virtual game simulations require gross movement of the extremities
and continuous postural shifting to accomplish the task. The games were played in a training or game mode in both
sitting and standing positions. Each game had different demands for muscle strength and agility performance. For
example, golfing required quick position shifting while boxing required weight transfer between the lower extremities.
The five mostly chosen Sports items were boxing, bowling, table tennis, Frisbee, and golfing. The youth participated in
18 sessions over 6 weeks. The first 6 sessions focused on the participants using the systems by themselves. In the 7–
10th session, a therapist or a staff worked with the participant. In the 11th session, the children experienced 2- and 3-
person games.
We assumed the maximal heart rate as 205 (220 minus mean age) (Tanaka, Monahan, & Seals, 2001),
and heart rate was recorded at the end of each exercise session. Another two pediatric occupational therapists,
who were blinded to child group status, administered the measures of muscle strength and agility performance to the
participants at pre-and post-therapy (within a week before and after the intervention) according to standardized
procedures. The inter-rater reliability established before collecting the data were high on both muscle strength and
BOT-2 tests (r = 0.96 and 0.98 respectively). To decrease possible experimenter bias, the examiner did not reacquaint
herself with the participant’s scores from the first assessment when conducting the retest. Subjects in the intervention
groups were tested at the occupational therapy unit, whereas subjects in the no-treatment control group were tested in
a quiet classroom at her/his respective schools or facilities. The testing was conducted on an individual basis in one
session.
2240 H.-C. Lin, Y.-P. Wuang / Research in Developmental Disabilities 33 (2012) 2236–2244

Table 1
Sample demographics.

Demographic Exercise (n = 46) Control (n = 46) p

a
Mean SD Mean SD

Age (years) 15.6 3.6 14.9 3.9 0.12

Intelligence quotient (IQ) 52 11.1 53 12.2 0.95
Height (M) 1.53 .08 1.51 .06 0.77
Body weight (kg) 57.2 10.2 58.8 9.9 0.42
Gender (n, %) 0.45
Female 25 54 24 57
Male 21 46 22 43
a
Or n and percentage when indicated.

2.4. Data analysis

SPSS 15.0 was used to analyze the data. A series of analyses of covariance (ANOVAs) was performed to compare the pre-
and post-intervention differences in muscle strength and agility performance between the control and the exercise group. In
order to quantify the magnitude of the post-intervention difference between intervention and control groups, effect sizes
(ES) were calculated as d = (treatment mean control mean)/SD. As a guide to interpreting these values, Cohen (1988)
labeled an effect size ‘small’ if ES  0.2 < 0.5, ‘moderate’ if ES  0.5 < 0.8, or ‘large’ if ES  0.8. Pearson correlation was used to
investigate the relations between pre-intervention BMI and muscle strength (average muscle strength of six muscle groups)
and agility (SAC of the BOT-2) in all 92 participants.

3. Results

Sample demographics and anthropometric details are presented in Table 1, and all the attributes were evenly distributed
between the two groups. The univariate F-tests were nonsignificant for all the pre-intervention measures on muscle strength
and agility: hip flexors (F1,90 = 0.08, p = 0.78); hip extensors (F1,90 = 1.59, p = 0.21); hip abducors (F1,90 = 0.04, p = 0.084); knee
flexors (F1,90 = 0.28, p = 0.60); knee extensors (F1,90 = 0.17, p = 0.68), ankle plantarflexors (F1,63 = 0.13, p = 0.72), and BOT-2 SAC
(F1,90 = 1.03, p = 0.82). Fig. 1 demonstrates the progress through trial. All participants in the intervention group completed the
exercise protocol successfully. The averaged heart rate after was 125 beats/min, and 60% of the maximal heart rate was

Assessment for eligibility

(N = 113)
Excluded (n = 21)
Not meeting inclusion criteria (n = 10)
Refused to participate ( n = 11)
Included for Study
(n= 92)

Informed Consent Obtained

Baseline Measurement

Randomization

Allocated to intervention (n = 46) Allocated to intervention (n = 46)

Received allocated intervention (n = 46) Received allocated control (n = 46)

Follow-up after 6 weeks (n = 46) Follow-up after 6 weeks (n = 46)

Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Fig. 1. Participant flow chart.

 H.-C. Lin, Y.-P. Wuang / Research in Developmental Disabilities 33 (2012) 2236–2244 2241

Table 2
Muscle strength of lower extremities measures by experimental and pre-posttest condition.

Pretest Posttest

Exercise group Control group Exercise group Control group p*

Mean SD Mean SD Mean SD Mean SD

Hip flexors 16.39 1.71 16.28 2.00 17.33 2.15 16.20 1.97 0.010
Hip extensors 13.43 1.97 12.89 2.15 14.07 1.24 13.02 2.04 0.018
Hip abductors 12.89 2.15 13.24 1.99 14.46 1.73 13.37 1.82 0.004
Knee flexors 14.67 1.56 14.85 1.58 16.27 1.81 15.02 1.45 0.029
Knee extensors 14.33 1.65 14.46 1.39 15.75 1.94 14.65 1.23 0.031
Ankle plantarflexor 12.87 1.77 13.00 1.74 14.04 1.28 13.30 1.46 0.011

Note: muscle strength is measure in pounds (lb). p* level indicates significance between groups on post-intervention scores.

reached. Body weight in the exercise group decreased after intervention comparing to the controls (p = 0.04). BMI was
positive correlated to averaged muscle strength (r = 0.66, p = 0.02), but not with agility performance (r = 0.11, p = 0.78).

3.1. Muscle strength

Table 2 presents mean and standard deviations (SD) for the pre- and post-exercise outcomes by designated group along
with the F tests for each outcome measure. Analysis between the groups revealed a significant group difference in terms of
strength in all muscle groups following the 6-week intervention. Significant group differences were observed for the
following muscle groups: hip flexors (F1,90 = 6.90, p = 0.01, d = 0.57); hip extensors (F1,90 = 5.80, p = 0.02, d = 0.51); hip
abducors (F1,90 = 8.61, p = 0.004, d = 0.59); knee flexors (F1,90 = 4.92, p = 0.03, d = 0.86); knee extensors (F1,90 = 4.78, p = 0.03,
d = 0.89), and ankle plantarflexors (F1,63 = 6.67, p = 0.01, d = 0.51). Moderate to large effect sizes (d) were obtained for all
muscle groups as well (0.51–0.89) (Table 3).

3.2. Agility performance

The initial mean total agility score was 11 for both groups. Following the intervention, these scores increased to 16 for the
exercise group and decreased to 10 for the control group respectively. A significant difference (F1,90 = 14.03, p = 0.02, d = 0.80)
was found when comparing the pre–post measurements on the BOT-2 SAC for the whole research group (Table 2).

4. Discussion

Our main finding of this study was that lower-extremity muscle strength and agility performance in adolescents with DS
improved significantly after a 6-week exercise training program comparing to the controls. The observed effect sizes were in

Table 3
Strength and agility measures by experimental and pre-posttest condition.

Pretest Posttest

Exercise group Control group Exercise group Control group p*

Mean SD Mean SD Mean SD Mean SD

Agility
Shuttle run 5.0 1.2 5.0 1.3 7.0 1.8 4.0 1.5 0.01
Stepping sideways 3.0 1.0 3.0 1.1 3.0 1.1 3.0 1.3 0.02
One-legged stationary jump 4.0 1.3 4.0 1.0 6.0 1.5 4.0 1.6 0.03
One-legged side hop 4.0 1.4 4.0 0.9 5.0 1.5 3.0 1.2 0.01
Two-legged side hop 3.0 0.8 3.0 0.8 4.0 1.0 3.0 1.2 0.02
Total agility score 11.0 6.3 11.0 5.9 16.0 6.6 10.0 6.8 0.01
Body strength
Standing long jump 5.0 1.2 5.0 1.3 7.0 1.8 4.0 1.5 0.01
Push-ups 3.0 1.0 3.0 1.1 3.0 1.1 3.0 1.3 0.04
Sit-ups 4.0 1.3 4.0 1.0 6.0 1.5 4.0 1.6 0.04
Wall sit 4.0 1.4 4.0 0.9 5.0 1.5 3.0 1.2 0.05
V-up 3.0 0.8 3.0 0.8 4.0 1.0 3.0 1.2 0.02
Total strength score 11.0 6.3 11.0 5.9 16.0 6.6 10.0 6.8 0.02
Strength and Agility score 33.1 7.9 34.2 6.5 40.4 10.2 33.9 8.1 0.01
Body composition
Body weight 52.2 7.2 50.8 5.9 49.8 6.6 51.3 6.0 0.05
BMI 29.5 8.8 30.2 7.6 27.2 4.5 30.8 4.7 0.77

p* level indicates significance between groups on post-intervention scores.

2242 H.-C. Lin, Y.-P. Wuang / Research in Developmental Disabilities 33 (2012) 2236–2244

the moderate to large range, especially in the improvement of muscle strength in knee extensors (d = 0.89) and flexors
(d = 0.86). The improvement in muscle strength and agility may be significantly pertinent to adolescents with DS since their
daily activities and work-related skills require lower limbs movement and overall agility. Both muscle strength (health-
related) and agility (skill-related) are subcategories of fitness which are important to general health (Caspersen, Powell, &
Christenson, 1985). Compliance with the program was excellent as expected, with all participants completing all the
treatment sessions. There were also no drop-outs from the study, indicating that the exercise program implemented for this
study was feasible for adolescents with DS.
The study also found that non-trained persons who were supervised by the therapist could provide the youth with DS an
exercise training program, thus reducing the cost of such intervention and enabling the execution of a low-cost high-
frequency program. Such programs can be provided in addition to regular therapy sessions and might enhance the effects of
rehabilitation intervention (Lotan, Isakov, Kessel, et al., 2004; Lotan, Isakov, & Merrick, 2004). Additionally, the implemented
exercise training program seemed to be rather safe since no major adverse events were reported by the participants or
supervising staffs. This finding challenges the viewpoint that individuals with DS should not take part in physical activities
because of their health concerns (Frey, Buchanan, & Sandt, 2005).
The findings of this study agree with other studies showing that subjects with DS significantly improved their muscle
strength after participating in a training program that mainly included strengthening exercise (Carmeli et al., 2002; Rimmer,
Heller, Wang, & Valerio, 2004; Tsimaras & Fotiadou, 2004). Water exercise and swimming have also been proven to be
effective in improving the muscle strength and agility in children with ID (Yilmaz et al., 2009). Additionally, some
commercially available fitness equipment has been applied in individual with ID to improve their physical fitness. Varela,
Sardinha, and Pitetti (2001) proposed a 16-week, 3-day per week training program using a rowing machine for adults with
DS, and this program obtained increases in work performance including time on graded exercise test and work level attained.
By using an appropriate treadmill walking programs, both children and elderly people with DS could significantly improve
muscle strength and physical fitness (Carmeli et al., 2002; Lotan, Isakov, Kessel, et al., 2004; Lotan, Isakov, & Merrick, 2004).
The correlation of results between studies indicates the positive effect that physical activity, through participation in
training programs or use of equipment such as treadmills, has on the muscle strength or agility performance of individuals
with ID, with and without DS. The current program differed from previous treadmill training protocols in its shorter duration
and periods (5 min/session, 3 times a week for 6 weeks), better effects of the present protocol was attained in terms of muscle
strength (effect size were in moderate to large range).
Individuals with DS continue to engage in high rates of sedentary behavior (Hoge & Dattilo, 1995) and have extremely low
levels of physical fitness when they reach adolescence and adulthood (Fernhall & Pitetti, 2001; Wuang & Su, 2012). This
increases the likelihood that persons with DS will have greater difficulty maintaining their abilities in work, recreation, and
performance of self-care activities as they age (Graham & Reid, 2000). Furthermore, many chronic diseases are found to be
associated with low physical activity. However, traditional therapies to improve physical activity in individuals with
disabilities are repetitive and offer very little to keep a young mind occupied (Adamovich, Fluet, & Merians, 2009). Besides,
individuals with DS tend to show difficulty in repeated practice of therapeutic activities because of the nature of their
disabilities (i.e., movement limitation, attention deficit, or cognitive impairments) or a lack of intervention context
variability (Taub, Ramey, DeLuca, & Echols, 2004; Wuang, Wang, Huang, & Su, 2008). As a consequence, individuals with DS
are in need of effective and motivating training programs opposed to the conventional rehabilitation interventions. The
playfulness inherent in the VR-based activities was able to motivate this DS population to engage with VR-based activities.
Besides the shorter duration (20 min/session) of the present VR-based activities comparing to previous studies, the present
program was well planned since we chose 15 Wii sports activities that proved to be able to meet the physical activity
requirement (moderate to high) of physical training program. The current program was also based on child-center
approaches that children could choose their preferred sport items from 15 pre-selected activities. By actively participating in
the goal-directed and enjoyable activities, the therapeutic effects could be maximized (Larin, 2000; Parham & Mailloux,
2010), and the psychosocial needs of the youth were fulfilled as well (Tye & Tye, 1992).
Our study results suggested that muscle strength and BMI are correlated, but agility performance is not associated with
BMI. Measurement of muscle strength may be affected by anthropometric and lifestyle factors in DS as well as in individuals
who are typically developing. In the study conducted by Stemmons and Lewis (2001), body weight and BMI were significant
predictors of peak torque production in children with DS. Unlike the association between muscle strength and body weight,
agility has more intricate relationships with trainable physical qualities such as power and technique, as well as cognitive
components such as visual motor integration and anticipation (Sheppard & Young, 2006).
It usually takes a minimum of 12 weeks of training to build muscle size in typically developing pubescent children that in
turn increase their muscular strength (Wilmore, Costill, & Kenney, 2008). Accordingly, a 12-week strengthening protocol
was usually adopted. Nevertheless, previous research findings suggested that DS youth acquire their muscle strength
primarily by neural recruit that requires only 4–8 weeks training (Cioni et al., 1994; Horvat et al., 1997; Mercer & Lewis,
2001). As a consequence, a rather short-term training program (such as the 6-week training program proposed in this study)
might be sufficient for DS youth to gain their muscle strength. In addition, the VR-based exercises that enhance the
motivation and playfulness might be helpful in increasing the workout in a short period. The findings of significant gains in
muscle strength and agility performance are noteworthy given the relatively short-period of the intervention (6 weeks).
Future study is warranted to investigate whether a longer intervention might result in greater gains in muscle strength and
agility for DS.
 H.-C. Lin, Y.-P. Wuang / Research in Developmental Disabilities 33 (2012) 2236–2244 2243

The present study has some other clinical implications. First, hand-held dynamometers can be used as a relatively simple,
inexpensive and portable instrument to identify impairments and monitor changes in muscle force in DS population. Second,
findings from this study and those on strengthening exercises (e.g., treadmill walking program) and VR-based activities
suggest that to achieve better muscle strength and agility performance, a combination program of treadmill and VR-based
activities might be even more effective. While VR-based exercises might enhance the motivation and playfulness, treadmills
exercise emphasized more on specific muscle strengthening (Hesse et al., 2004). Also, to enrich the therapeutic programs
content, combining the use of various exercise programs has been used broadly in physical exercise programs (Sherrington
et al., 2008). Third, the unique medical needs and physical features (e.g., lax ligament, joint looseness) of DS affect exercise
programming and implementing (Dunn, 1997). However, the program was adapted to the interest and attention level of the
subjects; it is possible that significant gains will be made by DS individuals in overall muscle strength and agility
performance. Finally, since adolescents with DS are at higher risk of chronic disease that is worsened by obesity and
sedentary lifestyle, physical activity needs to become part of their lifestyle.
This study has several limitations. First, most of the participants were in the moderate ID range classified by the DSM-IV
criteria (mean WISC-IV score was 51.2). Therefore, generalizing results to groups with severe and profound ID should be
cautiously made. Second, we did not monitor if participants took part in any related physical exercise or VR-based activities
in addition to the intervention program. Future study should advise the primary caregivers to maintain a diary of the youth’s
activity.

References

Adamovich, S. V., Fluet, G. G., & Merians, A. S. (2009). Sensorimotor training in virtual reality: A review. Neurorehabilitation, 25, 29–44.
Bertoti, D. B. (2008). Mental retardation: Focus on Down syndrome. In J. S. Tecklin (Ed.), Pediatric physical therapy (4th ed., pp. 283–285). London: Lippincott
Williams & Wilkins.
Bruininks, R. H., & Bruininks, B. D. (2005). Bruininks–Oseretsky Test of Motor Proficiency (2nd ed.). Minneapolis, MN: Pearson Assessment.
Carmeli, E., Bar-Chad, S., Lotan, M., Merrick, J., & Coleman, R. (2003). Five clinical tests to assess balance following ball exercises and treadmill training in adult
persons with intellectual disability. Journal of Gerontology, 58A, 767–772.
Carmeli, E., Kessel, S., Coleman, R., & Ayalon, M. (2002). Effects of a treadmill walking program on muscle strength and balance in elderly people with Down
syndrome. Journal of Gerontology: Medical Science, 57, M106–M110.
Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985). Physical activity, exercise and physical fitness: Definition and distinction for health-related research.
Public Health Report, 100, 126–131.
Chanias, A. K., Reid, G., & Hoover, M. L. (1998). Exercise effects on health-related physical fitness of individuals with an intellectual disability: A meta-analysis.
Adapted Physical Activity Quarterly, 15, 119–140.
Chen, R. H. (1997). Wechsler Intelligence Scale for Children-Chinese Version (3rd ed.). Taipei: Chinese Behavioral Science Corporation.
Cioni, M., Cocilovo, A., & Di Pasquale, F. (1994). Strength deficit of knee extensor muscles of individuals with Down syndrome from childhood to adolescence.
American Journal on Mental Retardation, 99, 169–174.
Cohen, J. (1988). Statistical power analysis for behavioral science (2nd ed.). Hillsdale, NJ: Erlbaum.
Dunn, J. M. (1997). Special education: Adapted, individualized, developmental (7th ed.). St. Louis, MO WCB/McGraw-Hill. p. 329.
Fernhall, B., & Pitetti, K. H. (2001). Limitations to physical work capacity in individuals with mental retardation. Clinical Exercise Physiology, 3, 176–185.
Fidler, D. J., Hepburn, S. L., Mankin, G., & Rogers, S. J. (2005). Praxis skills in young children with Down syndrome, other developmental disability, and typically
developing children. American Journal of Occupational Therapy, 59, 129–137.
Frey, G. C., Buchanan, A. M., & Sandt, D. D. (2005). ‘‘I’d rather watch TV’’: An examination of physical activity in adults with mental retardation. Mental Retardation,
43, 241–254.
Graham, A., & Reid, A. (2000). Physical fitness of adults with an intellectual disability: A 13 year follow-up study. Research Quarterly for Exercise and Sport, 7, 152–
161.
Gupta, S., Rao, B. K., & SD, K. (2011). Effect of strength and balance training in children with Down’s syndrome: A randomized controlled trial. Clinical Rehabilitation,
25, 425–432.
Hesse, S., Werner, C., Seibel, H., von Frankenberg, S., Kappel, E.-M., Kirker, S., et al. (2004). Treadmill training with partial body-weight support after total hip
arthroplasty: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 84, 1467–1473.
Hoge, G., & Dattilo, J. (1995). Recreation participation of adults with and without mental retardation. Education and Training in Mental Retardation and
Developmental Disabilities, 30, 283–298.
Horvat, M., Pitetti, K. H., & Croce, R. (1997). Isokinetic torque, average power, and flexion/extension ratios in nondisabled adults and adults with mental
retardation. Journal of Orthopaedic and Sports Physical Therapy, 25, 395–399.
Larin, H. M. (2000). Motor learning: Theory and strategies for the practitioner. In S. K. Campbell, R. J. Palisano, & D. W. Vander Linden (Eds.), Physical therapy for
children (pp. 170–197). Philadelphia, PA: W.B. Saunders.
Lewis, C. L., & Fragala-Pinkham, M. A. (2005). Effects of aerobic conditioning and strength training on a child with Down syndrome: A case study. Pediatric Physical
Therapy, 17, 30–36.
Lotan, M., Isakov, E., Kessel, S., & Merrick, J. (2004). Physical fitness and functional ability of children with intellectual disability: Effects of a short-term daily
treadmill intervention. The Scientific World Journal, 4, 449–457.
Lotan, M., Isakov, E., & Merrick, J. (2004). Improving functional skills and physical fitness in children with Rett syndrome. Journal of Intellectual Disability Research,
48, 730–735.
Lotan, M., Yalon-Chamovitz, S., & Weiss, P. L. (2009). Improving physical fitness of individuals with intellectual and developmental disability through a virtual
reality intervention program. Research in Developmental Disabilities, 30, 229–239.
Lotan, M., Yalon-Chamovitz, S., & Weiss, P. L. (2010). Virtual reality as means to improve physical fitness of individuals at a severe level of intellectual and
developmental disability. Research in Developmental Disabilities, 31, 869–874.
Menkes, J. H., & Falk, R. E. (2005). Chromosomal anomalies and continuous-gene syndromes. In J. H. Menkes, H. B. Sarnat, & B. L. Maria (Eds.), Child neurology (7th
ed., pp. 227–257). Philadelphia: Lippincott Williams and Wilkins.
Mercer, V. S., & Lewis, C. L. (2001). Hip abductor and knee extensor muscle strength of children with and without Down syndrome. Pediatric Physical Therapy, 13,
18–26.
Merriman, W. J., Barnett, B. E., & Jarry, E. S. (1996). Improving fitness of dually diagnosed adults. Perceptual and Motor Skills, 83, 999–1004.
Palisano, R. J., Walter, S. D., Russell, D. J., Rosenbaum, P. L., Gémus, M., Galuppi, B. E., et al. (2001). Gross motor function of children with Down syndrome: Creation
of motor growth curves. Archives of Physical Medicine and Rehabilitation, 82, 494–500.
Parham, L. D., & Mailloux, Z. (2010). Sensory integration. In J. Case-Smith & J. C. O’Brien (Eds.), Occupational therapy for children (6th ed., pp. 325–372). Maryland
Heights, MO: Mosby.
2244 H.-C. Lin, Y.-P. Wuang / Research in Developmental Disabilities 33 (2012) 2236–2244

Rigoldi, C., Galli, M., Mainardi, L., Crivellini, M., & Albertini, G. (2011). Postural control in children, teenagers and adults with Down syndrome. Research in
Developmental Disabilities, 32, 170–175.
Rimmer, J. H., Heller, T., Wang, E., & Valerio, I. (2004). Improvements in physical fitness in adults with Down syndrome. American Journal on Mental Retardation, 2,
165–174.
Roizen, N. (2002). Down syndrome. In M. L. Batshaw (Ed.), Children with disabilities (5th ed.). Baltimore, ML: Paul H. Brookes.
Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlory, W., Cheung, D., et al. (2010). Effectiveness of virtual reality using Wii gaming technology in stroke
rehabilitation: A pilot randomized clinical trail and proof of principle. Stroke, 41, 1477–1484.
Schutzer, K. A., & Graves, B. S. (2004). Barriers and motivations to exercise in older adults. Preventive Medicine, 39, 1056–1061.
Sheppard, J. M., & Young, W. B. (2006). Agility literature review: Classifications, training and testing. Journal of Sports Sciences, 24, 919–932.
Sherrington, C., Whitney, J. C., Lord, S. R., Herbert, R. D., Cumming, R. G., & Close, J. C. T. (2008). Effective exercise for the prevention of falls: A systematic review and
meta-analysis. Journal of the American Geriatrics Society, 56, 2234–2243.
Shields, N., Taylor, N. F., & Dodd, K. J. (2008). Effects of a community-based progressive resistance training program on muscle performance and physical function
in adults with Down syndrome: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89, 1215–1220.
Stemmons, V., & Lewis, C. L. (2001). Hip abductor and knee extensor muscle strength of children with and without Down syndrome. Pediatric Physical Therapy, 13,
18–26.
Tanaka, H., Monahan, K. D., & Seals, D. R. (2001). Age-predicted maximal heart rate revisited. Journal of the American College of Cardiology, 37, 153–156.
Taub, E., Ramey, S., DeLuca, S., & Echols, K. (2004). Efficacy of constraint-induced movement therapy for children with cerebral palsy with asymmetric motor
impairment. Pediatrics, 113, 305–312.
Tsimaras, V. K., & Fotiadou, E. G. (2004). Effect of training on the muscle strength and dynamic balance ability of adults with Down syndrome. Journal of Strength
and Conditioning Research, 18, 343–347.
Turner, S., & Alborz, A. (2003). Academic attainments of children with Down syndrome: A longitudinal study. British Journal of Educational Psychology, 73, 563–583.
Tye, B. B., & Tye, K. A. (1992). Global education: A study of school change. Albany, NY: State University of New York Press.
Varela, A. M., Sardinha, L. B., & Pitetti, K. H. (2001). Effects of an aerobic rowing training regimen in young with Down syndrome. American Journal on Mental
Retardation, 106, 135–144.
Vicari, S. (2006). Motor development and neuropsychological patterns with Down syndrome. Behavior Genetics, 36, 355–364.
Wechsler, D. (1991). Wechsler Intelligence Scale for Children (3rd ed.). San Antonio, TX: The Psychological Corporation.
Welsh, T. N., & Elliott, D. (2001). The processing speed of visual and verbal movement information by adults with and without Down syndrome. Adapted Physical
Activity Quarterly, 18, 156–167.
Wilmore, J. H., Costill, D. L., & Kenney, L. (2008). Adaptations to resistance training Physiology of sport and exercise, (4th ed.). Champaign, IL: Human Kinetics.
Wang, C. C., Huang, M. H., & Wuang, Y. P. Improving physical fitness in children with Down syndrome. Journal of Taiwan Occupational Therapy Association, in press.
Wuang, Y. P., Chiang, C. S., Su, C. Y., & Wang, C. C. (2011). Effectiveness of virtual reality using Wii gaming technology in children with Down syndrome. Research in
Developmental Disabilities, 32, 312–321.
Wuang, Y. P., Lin, Y. H., & Su, C. Y. (2009). Rasch analysis of the Bruininks–Oseretsky Test of Motor Proficiency-Second Edition in intellectual disabilities. Research in
Developmental Disabilities, 30, 1132–1144.
Wuang, Y. P., & Su, C. Y. (2012). Patterns of participation and enjoyment in adolescents with Down syndrome. Research in Developmental Disabilities, 33, 841–848.
Wuang, Y. P., & Su, C. Y. (2009). Reliability and responsiveness of the Bruininks–Oseretsky Test of Motor Proficiency-Second Edition in children with intellectual
disability. Research in Developmental Disabilities, 30, 847–855.
Wuang, Y. P., Wang, C. C., Huang, M. H., & Su, C. Y. (2008). Profiles and cognitive predictors of motor functions among early school-age children with mild
intellectual disabilities. Journal of Intellectual Disability Research, 52, 1048–1060.
Wuang, Y. P., Wang, C. C., Huang, M. H., & Su, C. Y. (2009). Prospective study of the effect of sensory integration, neurodevelopmental treatment and perceptual
motor therapy on the sensorimotor performance in children with mild mental retardation. American Journal of Occupational Therapy, 63, 439–450.
Yilmaz, I., Ergu, N., Konukman, F., Agnuğa, B., Zorba, E., & Cimen, Z. (2009). The effects of water exercises and swimming on physical fitness of children with mental
retardation. Journal of Human Kinetics, 21, 105–111.