TUGAS FISIOLOGI

Beneficial Effects of Clinical Exercise Rehabilitation for Children and Adolescents with Autism Spectrum Disorder (ASD)

Oleh Nama NPM Kelompo

: ANDITYA MUCHLISIN : 09310035 :3

UNI!"#SITAS MALAHAYATI $ANDA# LAMPUNG %011&%01%

Journal of Exercise Physiologyonline

Volume 1 !umber " April "#1"

Editor$in$Chief Tommy Boone, PhD, MBA Re%iew Board Todd Astorino, PhD Julien Baker, PhD Steve Brock, PhD ance Dalleck, PhD Eric !oulet, PhD "o#ert !otshall, PhD Alexander $utchison, PhD M% &night'Maloney, PhD en &ravit(, PhD James askin, PhD )it Aun im, PhD onnie o*ery, PhD Derek Marks, PhD +ristine Mermier, PhD "o#ert "o#ergs, PhD +hantal ,ella, PhD Dale -agner, PhD .rank -yatt, PhD Ben /hou, PhD 0fficial "esearch Journal of the American Society of Exercise 0fficial "esearch Physiologists Journal of the American Society of Exercise 1SS2 Physiologists 3456'5673

&E'online Beneficial Effects of Clinical Exercise Rehabilitation for Children and Adolescents with Autism Spectrum Disorder (ASD)
Jane E Magnusson3, +aitlin +o#ham8, "achel Mc eod9
3

De:artment of S:ort ; Exercise Science< =niversity of Auckland, Auckland, 2e* /ealand, 8Exercise "eha#ilitation +linic, =niversity of Auckland, 2e* /ealand, 9De:artment of Psychology, =niversity of Auckland, 2e* /ealand

ABS(RAC(
)a*nusson &E+ Cobham C+ )c,eod R% Beneficial Effects of +linical Exercise "eha#ilitation for +hildren and Adolescents *ith Autism S:ectrum Disorder >ASD?% &E'online 8438<37>8?@63'65% Although exercise :rograms have sho*n health and #ehavioral #enefits for individuals *ith Autism S:ectrum Disorder >ASD?, more information is needed a#out the ty:es of exercise used and ho* :rograms are designed to enhance their effectiveness% The :ur:ose of the current study *as to investigate if an individually'tailored, high'intensity exercise :rogram *ould have a :ositive effect on the :hysical fitness and #ehaviors of children and adolescents *ith ASD% Assessments of :hysical fitness and :ositiveAnegative #ehaviors *ere undertaken :re' and :ost'intervention% 1m:rovements across all :hysical fitness and #ehavioral varia#les tested *ere found follo*ing :artici:ation in the exercise :rogram% These findings demonstrate that a high' intensity exercise'#ased :rogram administered *ith an ASD :o:ulation is an effective method to im:rove ASD' s:ecific issues as *ell as health and fitness varia#les in this :o:ulation%

1SS2 3456'5673

-e. /ords@ Autism, As:ergerBs, PPD'20S, Exercise, Physical Activity, Slee:

0!(R1D2C(01! Autistic S:ectral Disorders >ASD? are a range of neuro'develo:mental disorders that include autism, As:erger syndrome, and :ervasive develo:mental disorder not other*ise s:ecified >PPD 20S? >5,3C?% The characteristics of ASD include deficits in cognitive :rocessing, im:aired social interactions, delayed or limited communication skills, and restrictive :atterns of activities or interests >3?% Distur#ed slee: is another sym:tom commonly ex:erienced #y children *ith ASD *ith estimates ranging #et*een DDE and F9E >8,3D?% 1m:airments *ith motor #ehaviors are also seen in those *ith ASD >33?, *hich can im:ede as:ects of daily functioning as *ell as a#ility to undertake such :hysical activities as exercise% As the health risks of a sedentary lifestyle are more common among individuals *ith intellectual and develo:mental disa#ilities such as ASD com:ared to those *ithout the develo:mental disa#ilities >6,5,38?, finding *ays to increase activity levels in this :o:ulation is necessary to reduce the likelihood of negative health conseGuences% Exercise as a (reatment for ASD 1n their revie* of :hysical activity *ith ASD individuals, ang et al% >5? re:ort that all the studies revie*ed sho*ed im:rovements across many domains% These included negative #ehaviors >e%g%, stereoty:y, aggression, and self'inHury?, :ositive #ehaviors >e%g%, a#ility to focus and stay on task and academic :erformance?, :hysical fitness >e%g%, endurance or strength?, and exercise #ehavior >e%g%, more time engaged in exercise?% -ith regard to the ty:e of exercise undertaken, it *as found that vigorous exercise had a more :ronounced effect than milder, less strenuous exercise >5?% Exercise interventions may also #e #eneficial for individuals *ith ASD in relation to slee: distur#ances as they have #een sho*n to reduce slee: onset latency and im:rove slee: Guality in other :o:ulations >7,F,3F?% 1n addition to the health and #ehavioral #enefits of exercise :rograms, for those *orking *ith ASD individuals, one of the #enefits of an antecedent a::roach such as exercise is that the intervention is :reventative as it occurs #efore the #ehavior takes :lace, thus reducing the motivation to :erform the #ehavior >C?% This a::roach is therefore less demanding of an intervenerBs #ehavior management skills >36? and more cost'effective than contingency management :rocedures >9?% !eed for Additional Research As re:orted #y ang et al% >5? most studies on the use of exercise *ith ASD individuals *ere undertaken *ith those diagnosed *ith autism% More studies are needed to investigate the effects of exercise across the s:ectrum of ASD disorders% More information is also needed a#out the :rocedures used to teach and maintain exercise *ith ASD individuals >5?% .or exam:le, more clarity is reGuired in relation to exercise :arameters and ho* :rograms are designed% S:ecific guidelines in relation to the ty:e, dose, intensity, duration, and freGuency of the exercise s:ecified could enhance the #enefits of exercise for ASD individuals%

The :ur:ose of this study *as to determine if an exercise :rogram tailored to ena#le moderate to high'intensity activity *ould #enefit children and adolescents *ith ASD #y having a :ositive effect on their #ehavior, :hysical fitness, and slee:% The a::roach of this study *as uniGue in that to increase the likelihood that the exercise :rograms *ere maximally effective, an Exercise "eha#ilitation S:ecialist familiar *ith ASD designed and monitored the exercise :rograms for each :artici:ant% This feature of the study hel:ed to ensure the a::ro:riateness of the :rograms for each :artici:antBs fitness level and :hysical ca:a#ilities% 1t *as ex:ected that the a::roach of using Guantified measures such as heart rate and exercise intensity, as *ell as o#servational #ehavioral measures, *ould :rovide a greater understanding of ho* exercise affects individuals *ith ASD%

)E(31DS Sub4ects The recruitment of su#Hects through schools, a s:eciali(ed hos:ital youth unit, an autism community grou:, and the =niversityBs Exercise "eha#ilitation +linic and the study :rocedures *ere a::roved #y the =niversityBs $uman Ethics +ommittee% All su#Hects *ere diagnosed *ith ASD >e%g%, autism, As:ergerBs, or PDD 20S? or had disru:tive #ehaviors >e%g%, self'stimulating, disru:ted slee: :atterns?% The su#Hects had sufficient rece:tive language to follo* the instructions of the researchers, and had sufficient motor skills to do the exercises :rescri#ed% The su#Hects had to #e in good general health as determined #y a medical certificate from their !eneral Practitioner >!P?, *hich cleared them to :artici:ate in an exercise :rogram and to exercise u: to a maximal level% 1f a su#Hect dis:layed high levels of aggression, if the motor skills *ere not adeGuate for the exercises, and if the su#HectBs rece:tive language skills *ere not sufficient to follo* instructions, or, then, the su#Hect *as excluded from the study% The su#Hects *ere also excluded if they did not have medical clearance from their !P% As all su#Hects *ere under the age of 3C, consent to take :art in the study *as o#tained from their :arentAguardian% -illingness to take :art in the exercise :rogram *as o#tained ver#ally from :artici:ants at the start of every session% Six su#Hects met the inclusion criteria >D males and 8 females, aged 5 to 37 yrs old?% Their :arent or guardian consented for them to take :art in the study% Diagnoses of :artici:ants included autism >nID?, As:ergerBs >nI3? and ASDAPDD 20S >nI3?% Completion of 5uestionnaires The :arent or guardian com:leted measures on #ehalf of their child% These included a general health assessment, #ehavior screening Guestionnaire, and a section regarding their childBs triggers and motivators% They also ans*ered Guestions regarding the occurrence of negative >e%g%, self'stimulatory #ehaviors, self'harm, :hysical andAor ver#al aggression to*ards others? and :ositive #ehaviors >e%g%, academic :erformance, *illingness to :artici:ate in :hysical activities, and social skills?% The :arents and guardians *ere asked to indicate *hich :ro#lem #ehaviors *ere of most concern to them, ho* freGuently their child engaged in the #ehaviors >4 I not freGuent to 34 I very freGuent?, and ho* much the #ehavior interfered *ith daily living >4 I does not interfere to 34 I interferes a lot?% 6amiliari7ation Session A familiari(ation session *as conducted once all measures *ere com:leted% This session included an intervie* *ith the :arent or guardian and their child to discuss medical history, :ast exercise, severity of ASD and any other clinical diagnoses or health conditions% The familiari(ation session *as conducted *ithin the facilities the su#Hects *ould #e ex:osed to during the study to familiari(e them *ith the eGui:ment and surroundings% (estin* 'rotocol During the first session the su#HectsB height, *eight, and #lood :ressure *ere measured% Then, they undertook a thorough :hysical testing :rotocol that included measures of cardiores:iratory fitness, u::er and lo*er #ody strength, a#dominal strength and endurance, lo*er #ack and hamstring flexi#ility and #alance >see Ta#le 3?%

(able 18 'h.sical Exercise (est for 9outh with ASDs8 Cardiorespirator 2pper Bod. ,ower Abdominal . 6itness Stren*th Bod. Stren*th Stren*th and Endurance
Modified Bruce Protocol >D,34? 3"M Bench PressAMaximal Press'=: Test 3"M eg Press Maximal +url'=: Test

3amstrin* Standin* and Balance ,ower Bac: 6lexibilit.

Sit and "each Test Modified "om#erg Test

Exercise Sessions Sessions *ere run on a one'on'one #asis *ith the researcher and su#Hect% Partici:ants took :art in the exercise :rogram t*ice a *eek for F to 38 *ks to achieve a total num#er of 3C exercise sessions and t*o JtestingB sessions >i%e%, #aseline and follo*'u: data collection?% Each :rogram had cardio and resistance com:onents% .or one session, the su#Hect com:leted the cardio com:onent% .or the second session, the su#Hect com:leted #oth the cardio and the resistance com:onents% Sessions *ere a::roximately 3 hr in duration% -hile :rograms *ere tailored to each su#Hect, all :rograms included a *arm'u:, high'intensity interval training, aero#ic exercises, :lyometric training, resistance training, a *arm'do*n and stretches% The com#ination of activities in the resistance com:onent of the :rogram varied from su#Hect to su#Hect, #ut the same core activities *ere used >e%g%, #ox Hum:s, #ox ste: u: *ith medicine #all thro*, :ress' u:s, and curl'u:s?% The resistance level, length of intervals, and s:eed of running for exercise :rograms *ere #ased on each su#HectBs fitness level and :rogress% As the su#Hects increased their cardiovascular endurance the intervals *ere adHusted for time and s:eed% The amount of calories ex:ended on each machine *as recorded along *ith heart rate to ensure that the su#Hects *ere o#taining the maximum #enefit from the exercise :rogram% 1f it *as not :ossi#le to use a heart rate monitor, heart rate *as o#tained manually% Reward S.stems to 6acilitate Exercise 'articipation To facilitate :artici:ation in the exercise :rogram, a re*ard system individuali(ed to each su#Hect *as used% Some su#Hects used a visual schedule *here#y the sessionBs activities *ere :osted on a #oard in a linear fashion *ith the num#er of :ictures of each activity indicating ho* long it *ould last% 0ther su#Hects used a direct re*ard system >i%e%, at the end of the session they *ere allo*ed to :ick from a Jtreat #oxB something their :arent or guardian indicated they found re*arding?% Some su#Hects did not reGuire a re*ard to fully engage in the exercise sessions% 'ost$0nter%ention (estin* Session At the com:letion of the 3C exercise sessions, the su#Hects *ere re'assessed using the same :rotocol as the initial testing session% Parents or guardians com:leted Guestionnaires regarding their childBs negative and :ositive #ehaviors and rated ho* much their childBs #ehavior had changed since taking :art in the exercise :rogram >4 I not changed to 34 I changed a lot?%

RES2,(S Measures of $ealth and Physical Activity All su#Hects exhi#ited overall im:rovement in the measures of :hysical fitness *ith statistically significant changes in cardiores:iratory fitness >( I '8%843, PK4%47? >see Ta#le 8? and a#dominal strength >( I '8%846, PK4%47? >see Ta#le 9?% 1m:rovement on the measure of hamstring and lo*er #ack flexi#ility a::roached significance >PI4%4CC?% All su#Hects im:roved their u::er and lo*er #ody strength, #ut the changes did not reach statistical significance% "esults on the tests of standing #alance *ere varia#le, #ut failed to sho* statistically significant im:rovements% (able "8 )ean Scores for Cardiorespirator. 6itness 're$ and 'ost$ Exercise 0nter%ention8 're 'ost +ardiores:iratory .itness >m Lkg Lmin ? 3%6C 8%9D (able ;8 )ean Scores for )easures of 'h.sical Acti%it. 're$ and 'ost$ Exercise 0nter%ention8
'3 '3

)easure of 'h.sical Acti%it. Mean curl u:s Mean sit and reach Mean :ress'u:s >nID? Mean #ench :ress >kg? >nI8? Mean leg :ress >kg? Mean standing #alance > ? Mean standing #alance >"?

're 37%74 '3D%94 C%67 3C%74 74%44 84%94 89%84

'ost 94%64 '5%44 39%67 35%74 C3%64 89%34 87%64

)easures of 'ositi%e and !e*ati%e Beha%iours All :ositive #ehaviors im:roved *ith statistically significant im:rovements #eing found for Jattention to taskB >( I '8%846, PK4%47?, J:ositive #ehaviors to*ards exerciseB >( I '8%498, PK4%47?, Jvoluntary :artici:ation in :hysical activity >unstructured?B >( I '8%498, PK4%47? and J:ositive :artici:ation in :hysical activityB >( I '8%498, PK4%47? >see Ta#le D?% 1m:rovements in :ositive #ehaviors related to Jacademic :erformanceB and Jsocial skillsB a::roached significance >PI4%4CF and 4%4C9, res:ectively?% Although negative #ehaviors *ere reduced at :ost'intervention testing, the im:rovements did not reach statistical significance >see Ta#le 7?% Statistically significant im:rovements *ere found for the freGuency of :ro#lematic #ehaviors identified #y :arents and guardians >( I '8%78, PK4%47? and ho* much these #ehaviors *ere interfering *ith daily life >( I '8%7D, PK4%47? >see Ta#le C?% At the :ost intervention assessment, all :arents and guardians re:orted their childBs #ehavior had im:roved follo*ing :artici:ation in the exercise :rogram >see Ta#le 6?%

(able <8 )ean Scores for 'ositi%e Beha%iours 're$ and 'ost$Exercise 0nter%ention8 )ean 're )ean 'ost

Academic performance Attention to tas: Social s:ills 'ositi%e beha%ior towards exercise Voluntar. participation in ph.sical acti%it. 'ositi%e participation in ph.sical acti%it.

7%99 D%74 D%74 C%36 D%F9 9%C6

6%36 6%36 C%74 F%C6 6%36 C%36

(able 8 )ean Scores for !e*ati%e Beha%iors 're$ and 'ost$Exercise 0nter%ention8 Self$stimulator. beha%iors Self$harm 'h.sical a**ression Verbal a**ression )ean 're 7%44 9%44 8%99 9%44 )ean 'ost 9%74 8%44 3%99 3%F9

(able =8 'arent>?uardian Ratin*s of 'roblematic Beha%iors and 3ow )uch (he. 0nterfere with Dail. ,i%in*8 'articipant (.pe of 'roblem 6re@uenc. of 0nterferin* with Dail. ,ife Beha%ior 'roblem Beha%ior 're 'ost 're 'ost 1 1bsessi%e 34 C%7 34 5 1 Sleep F 9 F C " Stimmin* 34 8 F 9 " Sleep 5 8 34 9 ; Verbal abuse 6 C F F ; Sleep F nAa F nAa < Verbal abuse 6 7 F C < A**ressi%e 6 3 F C Stimmin* F C 5 D Sleep C nAa 6 nAa = Stimmin* 6 6 C 8

(able A8 'arent>?uardian Ratin* of 1%erall Beha%iour Chan*e at 'ost$ 0nter%ention Assessment8 'articipant 1%erall Ratin* of Beha%ior Chan*e

3 8 9 D 7 C

34 5 6 5 5 7

D0SC2SS01! 1t is *ell kno*n that issues such as *eight and :hysical fitness need to #e managed in childhood and adolescence to avoid the multitude of health risks associated *ith

#eing over*eight or o#ese, and this risk is increased for individuals *ith ASD as the condition leads to a more sedentary lifestyle than age'matched individuals *ithout ASD >39,37?% Engaging ASD individuals in exercise :rograms re:resents an the o::ortunity to demonstrate that exercise intervention im:roves their health and *ell' #eing% The results of this study indicate that the #enefits of engaging individuals *ith ASD in an individually'tailored, high'intensity exercise :rogram im:roves all :hysical fitness and #ehavioral outcomes for cardiores:iratory fitness and a#dominal strength as *ell as :ositive #ehaviors to*ards exercise, voluntary :artici:ation in :hysical activity >unstructured?, and :ositive :artici:ation in :hysical activity% These im:rovements in :hysical functioning are encouraging as they sho* that *ith the right activities, changes in this :o:ulation can #e achieved *hich have real'*orld relevance% As an exam:le, the im:rovement in a#dominal strength and endurance is im:ortant as core strength is vital in maintaining correct :osture, su::orting #alance, and :reventing lo*er #ack inHuries% Although im:rovements in the other measures of :hysical fitness failed to meet statistical significant, their clinical significance should still #e considered since the su#Hects sho*ed im:rovement across these varia#les% 1n addition to #enefits related to :hysical fitness, taking :art in the exercise :rogram *as #elieved #eneficial in relation to the increase in :ositive #ehaviors and reduced negative #ehaviors% The im:rovements in #ehaviors seen in this study are therefore encouraging as they indicate that an antecedent a::roach >such as exercise? may have #eneficial effects #eyond the exercise session and hence may :ro'actively hel: to enhance :ositive #ehaviors and :revent the occurrence of :ro#lematic #ehaviors% 1n addition to demonstrating the #enefits of an exercise :rogram for ASD su#Hects, the :resent study :rovides guidance *ith regard to the ty:e of exercise :rogram that is #eneficial for this :o:ulation and the com:onents that should #e included% -hen designing an exercise :rogram for ASD su#Hects, it is im:ortant to note that *here :revious studies have used generic exercise :rotocols, the exercise :rograms in the current study *ere designed #y an Exercise "eha#ilitation S:ecialist familiar *ith ASD and individuali(ed to each su#Hect% This a::roach allo*ed for the develo:ment of :rograms that *ere a::ro:riate to each su#HectBs :hysical a#ilities and needs% The current study also used stringent measures to assess the :hysical changes from :re' to :ost'intervention there#y :roviding a guideline for ho* to o:timi(e the #enefits of an exercise :rogram for ASD individuals% 1n addition to using s:ecific measures of :hysical fitness, the :resent study monitored the heart rate of su#Hects, *hich is an essential as:ect of an exercise :rogram as it ensured that the su#Hects *ere *orking *ithin their target heart rate and it ena#led their :rogram to #e increased in intensity relative to their im:roved fitness levels% -hile the individuali(ation of each su#HectBs :rogram could limit the generali(a#ility of the findings to less structured, more generic exercise :rograms, the essential as:ects of the :rograms used common exercise techniGues and can, therefore, #e a::lied across different exercise settings%

C1!C,2S01!S

The current study demonstrated that an individuali(ed, high'intensity exercise :rogram is an effective method for im:roving health and fitness, reducing negative #ehaviors, and in im:roving :ositive #ehaviors of children and adolescents *ith ASD% "esults of the :re' and :ost'intervention ratings #y :arents and guardians indicate that the freGuency of :ro#lematic #ehaviors and ho* the #ehaviors interfere *ith daily life *ere significantly reduced follo*ing :artici:ation in the exercise :rograms% The #enefits of using exercise as an intervention include its cost' effectiveness and :otentially :reventative nature com:ared to other #ehavioral interventions% $o*ever, it should #e noted that to maximi(e the effectiveness and hence the #enefits of an exercise :rogram, it should #e develo:ed in consultation *ith those *ho have sufficient ex:ertise in exercise :hysiology and, in :articular, exercise in s:eciali(ed :o:ulations%

Address for correspondenceB Jane E Magnusson, De:artment of S:ort and Exercise Science, =niversity of Auckland, Private Bag 58435, Auckland, 2e* /ealand, 33D8% E'mail@ H%magnussonMauckland%ac%n(% Email@ H%magnussonMauckland%ac%n( Phone@ NCD59696755 ext% FF86F, .ax@ NCD596964D9

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