Clinical Applications

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

Special Considerations for Exercise Testing

and Prescription for the Individual with an
Intellectual Disability
INTRODUCTION

his 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.

BACKGROUND
According to the American Association of
Intellectual and Developmental Disabilities,
a person with an intellectual disability (ID)
is characterized by significant limitations
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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 persons level of
functioning will improve if appropriate support is provided for a sustained period (1).

SPECIAL CONSIDERATIONS FOR

EXERCISE TESTING
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 V
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
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37

Clinical Applications
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.

SPECIAL CONSIDERATIONS FOR

PRESCRIBING EXERCISE
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, agepredicted 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

38

small group exercises or personal training

preferable to large group programs.

INNOVATIVE PROGRAMMING FOR

INDIVIDUALS WITH ID
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.

CONCLUSIONS
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.

References
1. American Association of Intellectual and
Developmental Disabilities Web site [Internet];
[cited 2013 Oct 7]. Available from: http://
aaidd.org/intellectual-disability/definition.
2. ACSM. ACSMs Guidelines for Exercise Testing
and Prescription. 9th ed. Baltimore (MD):
Lippincott Williams & Wilkins; 2013. p. 301Y305.
3. Durstine JL, Moore GE, Painter PL, Roberts SO.
ACSMs Exercise Management for Persons With
Chronic Diseases and Disabilities. 3rd ed.
Champaign: Human Kinetics; 2009. p. 359Y366.
4. Frey GC, Chow B. Relationship between BMI,
physical fitness, and motor skills in youth with mild
intellectual disabilities. Int J Obes. 2006;30:861Y7.

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):1854Y62.
6. Temple V, Frey GC, Stanish HI. Physical
activity of adults with mental retardation.
Am J Health Promot. 2006;21(1):2Y12.
7. Yamaki K. Body weight status among adults
with intellectual disability in the community.
Ment Retard. 2005;43:1Y10.

Disclosure: The authors declare no

conflicts of interest and do not have any
financial disclosures.
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
SM
Specialist certified, and a fellow of ACSM.

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