Abstract:

Objective:

To describe interventions designed to promote physical activity for youth with intellectual disabilities.

Materials and methods:

A systematic review of nine databases until January 31, 2015 identified 213 citations. The inclusion criteria were: a) the study sample consisted of youth with intellectual disabilities, b) the study implemented an intervention to initiate, increase, or maintain physical activity, and c) quantitative or qualitative data were used to report the effectiveness of the intervention. Eleven articles from the 213 citations met this criterion.

Results:

Nine studies reported significant increases in physical activity behavior.

Conclusions:

Conclusions cannot be made regarding intervention components that impacted outcome variables, if the observed effects were specifically due to the intervention or if interventions could be maintained long-term. To advance the knowledge base in this area, a concerted effort should be made to increase rigor in study conceptualization and research design.

Keywords:
physical activity; intellectual disability; youth; children; adolescents; intervention

Resumen:

Objetivo:

Describir las intervenciones diseñadas para promover la actividad física para jóvenes con discapacidad intelectual.

Material y métodos:

Una revisión sistemática de nueve bases de datos hasta el 31 de enero de 2015 identificó 213 citas. Los criterios de inclusión fueron: a) la muestra del estudio consistió en jóvenes con discapacidad intelectual, b) el estudio implementado fue una intervención para iniciar, aumentar o mantener la actividad física y datos c) cuantitativos o cualitativos se utilizaron para informar la efectividad de la intervención. Once artículos de 213 citas cumplen este criterio.

Resultados.

Nueve estudios informaron aumentos significativos en el comportamiento de la actividad física.

Conclusión:

No se pueden establecer conclusiones con respecto a los componentes de intervención variables de resultado, considerando si los efectos observados fueron específicamente debido a la intervención o intervenciones podrían mantenerse a largo plazo. Para avanzar en la base de conocimientos en esta área, se necesita un esfuerzo concertado para aumentar el rigor en el estudio unívoco.

Palabras clave:
actividad física; discapacidad intelectual; jóvenes; niños; adolescentes; intervención

Introduction

There is substantial evidence to support that regular participation in physical activity promotes physical and mental health benefits in children. The World Health Organization (WHO) recommends that children aged 5-17 years accumulate at least 60 minutes of moderate-to-vigorous intensity physical activity each day in order to improve cardiorespiratory and muscular fitness, bone health, and cardiovascular and metabolic health biomarkers.¹1. World Health Organization. Global strategy on diet, physical activity and health. Geneva: WHO,2004. Activities should be predominantly aerobic, but bone- and muscle-strengthening activities as well as vigorous physical activities should also be incorporated at least three times per week. Despite strong evidence to support the physiological and psychological health benefits associated with participation in physical activity, worldwide trends indicate that children fail to meet the recommended levels of physical activity.¹1. World Health Organization. Global strategy on diet, physical activity and health. Geneva: WHO,2004.^,22. Active Healthy Kids Canada. Is Canada in the Running? The 2014 Active Healthy Kids Canada report card on physical activity for children and youth. Toronto: ON, 2014 [accessed on January 1, 2015]. Available at: https://www.participaction.com/sites/default/files/downloads/Participaction-2014FullReportCard-CanadaInTheRunning_0.pdf
https://www.participaction.com/sites/def... This is equally true for children from Latin American; with the latest international ‘Report Card’ on children’s overall physical activity reporting a ‘C+’ for Mexico and a ‘D’ for Columbia.²2. Active Healthy Kids Canada. Is Canada in the Running? The 2014 Active Healthy Kids Canada report card on physical activity for children and youth. Toronto: ON, 2014 [accessed on January 1, 2015]. Available at: https://www.participaction.com/sites/default/files/downloads/Participaction-2014FullReportCard-CanadaInTheRunning_0.pdf
https://www.participaction.com/sites/def...

The physical activity habits of children with intellectual disabilities have been studied far less thoroughly than those of typically developing children (i.e., children without disabilities), although research in this area has increased considerably over the past 5 or 6 years. In 2008, we published a review paper that aimed to summarize and critically analyze the existing literature on physical activity of youth with intellectual disabilities.³3. Frey GC, Stanish HI, Temple VA. Physical activity of youth with intellectual disability: review and research agenda. Adapt Phys Act Quart 2008;25(2):95-117. https://doi.org/10.1123/apaq.25.2.95
https://doi.org/10.1123/apaq.25.2.95... At that time, findings were variable with evidence to support that children with intellectual disabilities were less active, more active, and similarly active than their typically developing peers. We reported that significant methodological limitations and small sample sizes restricted the conclusions that could be drawn about the physical activity behavior of youth with intellectual disabilities. Overall, however, the research demonstrated that there was cause for concern. Empirical studies that have used motion sensors, such as accelerometers, to objectively measure physical activity have increased since that review was published. Consequently, the accuracy of results and the strength of the evidence have grown substantially.

International evidence suggests that children and youth with intellectual disabilities are less active than their peers without intellectual disabilities. A recently published study from Finland compared accelerometer-measured physical activity levels of children with intellectual disabilities and typically developing children aged 6-16 years.⁴4. Einarsson IO, Ólafsson A, Hinriksdóttir G, Jóhannsson E, Daly D, Arngrímsson SA. Differences in physical activity among youth with and without intellectual disability. Med Sci Sports Exerc 2015;47(2):411-418. https://doi.org/10.1249/MSS.0000000000000412
https://doi.org/10.1249/MSS.000000000000... Children with intellectual disabilities were found to be 40% less active than their peers, and none of the children with intellectual disabilities met the recommended guidelines for physical activity compared to 40% of typically developing children who did. A significantly lower proportion of children with intellectual disabilities used active commuting to school and fewer participated in organized sports. In the United States, Stanish and colleagues also found that physical activity levels measured by accelerometer were significantly lower in adolescents with intellectual disabilities than typically developing adolescents.⁵5. Stanish HI, Must A, Phillips S, Curtin C, Maslin M, Bandini LG. Comparison of moderate and vigorous physical activity levels among adolescents with and without intellectual disabilities. Orlando, Florida: American College of Sports Medicine, 2014. Only 6% of those with intellectual disabilities met the recommended time for moderate-to-vigorous intensity physical activity (MVPA) compared to 29% of their typically developing counterparts. Foley and colleagues compared the physical activity levels of young children with and without intellectual disabilities during the elementary school day and during out-of-school time. Accelerometer-measured physical activity levels were lower for children with intellectual disabilities compared to typically developing children during physical education class, recess, after school, and on weekends.⁶6. Foley JT, Bryan RR, McCubbin JA. Daily physical activity levels of elementary school-aged children with and without mental retardation. J Dev Phys Disabil 2008;20(4):365-378. https://doi.org/10.1007/s10882-008-9103-y
https://doi.org/10.1007/s10882-008-9103-... These results are corroborated by a study conducted in England that reported no children with intellectual disabilities met the physical activity recommendations, and participation in vigorous physical activity was essentially non-existent.⁷7. Phillips AC, Holland AJ. Assessment of objectively measured physical activity levels in individuals with intellectual disabilities with and without Down’s syndrome. PLoS ONE 2011;6(12):e28618. https://doi.org/10.1371/journal.pone.0028618
https://doi.org/10.1371/journal.pone.002... Further, compared to published data on the general pediatric population in England, children with intellectual disabilities engaged in considerably more sedentary behavior. Shields and colleagues in Australia examined the physical activity levels of children with Down syndrome, a chromosomal abnormality involving intellectual disabilities, using accelerometers.⁸8. Shields N, Dodd KJ, Abblitt C. Do children with down syndrome perform sufficient physical activity to maintain good health? A pilot study. Adapt Phys Act Quart 2009;26(4):307-320. https://doi.org/10.1123/apaq.26.4.307
https://doi.org/10.1123/apaq.26.4.307... It was found that 42% of children with Down syndrome performed 60 minutes of MVPA each day which is lower than published reports of typically developing Australian children. Also, older children with Down syndrome accumulated significantly less physical activity compared to younger children. Though not without methodological shortcomings, these accelerometer studies demonstrate that overall youth with intellectual disabilities do not engage in sufficient physical activity to achieve health benefits.⁹9. McGarty AM, Penpraze V, Melville CA. Accelerometer use during field-based physical activity research in children and adolescents with intellectual disabilities: A systematic review. Res Dev Disabil 2014;35:973-981. https://doi.org/10.1016/j.ridd.2014.02.009
https://doi.org/10.1016/j.ridd.2014.02.0...

Some efforts have been undertaken to explain the low physical activity levels among children with intellectual disabilities. Given the intellectual, behavioral, social, and motor impairments that are often associated with an intellectual disability, it cannot be assumed that the factors that influence physical activity participation for these youth are the same as the general pediatric population. As such, studies of physical activity correlates among youth with intellectual disabilities have emerged. Research to date indicates that child and caregiver preferences for physical activity and caregiver educational level are positively related to physical activity participation among children with intellectual disabilities.¹⁰10. Barr M, Shields N. Identifying the barriers and facilitators to participation in physical activity for children with Down syndrome. J Intellect Disabil Res 2011;55(11):1020-1033. https://doi.org/10.1111/j.1365-2788.2011.01425.x
https://doi.org/10.1111/j.1365-2788.2011... ^,1111. Lin JD, Lin PY, Lin LP, Chang YY, Wu SR, Wu JL. Physical activity and its determinants among adolescents with intellectual disabilities. Res Dev Disabil 2010;31:263-269. https://doi.org/10.1016/j.ridd.2009.09.015
https://doi.org/10.1016/j.ridd.2009.09.0... ^,1212. Minear KS. Parents’ perceptions of health and physical activity needs of children with Down syndrome. Down Syndrome: Res Pract 2007;12:60-68.^,1313. Yazdani S, Yee CT, Chung PJ. Factors predicting physical activity among children with special needs. Prev Chronic Dis 2013;10:E119. https://doi.org/10.5888/pcd10.120283
https://doi.org/10.5888/pcd10.120283... Barriers to participation have included lack of accessible programs, child’s lack of interest, physical/motor challenges, behavioral difficulties, insufficient time, no location at which to participate, and transportation challenges. In addition, limitations in cognitive and adaptive functioning may warrant structure and supports in order for children with intellectual disabilities to participate successfully in activities. It is for these reasons that we must think uniquely when planning and implementing physical activity interventions for youth with intellectual disabilities.

The low levels of physical activity among children with intellectual disabilities coupled with their unique functional limitations and specialized needs, have created a significant need to develop and test interventions. The intervention research is growing and an evaluation of this work is fundamental to identifying effective strategies for increasing physical activity and health outcomes among children with intellectual disabilities. As such, the purpose of this review is to describe what characterizes interventions designed to promote physical activity for children with intellectual disabilities; and the effects of the interventions on overall physical activity levels and on health outcomes.

Materials and methods

Literature search strategy

A systematic search for physical activity intervention research in children and youth with intellectual disabilities was conducted as follows: a) EBSCOHost with selected databases: Academic Search Complete, CINAHL, Health Source: Nursing/Academic Edition, MEDLINE, PsychARTICLES, PsychINFO and SPORTDiscus and b) Scopus, a database that includes approximately 22 000 peer-reviewed journals from over 5 000 publishers until February 28, 2015. Since the terms physical activity, exercise, and fitness are often used interchangeably, albeit in error, all three were included for the outcome of interest and combined with population search terms (intellectual disability, mental retardation, Down syndrome, developmental disability, Prader-Willi syndrome) and (children, youth, adolescents). Reference lists of selected papers were also reviewed for relevant articles.

Study selection and data extraction

The following search criteria were established a-priori: a) the study sample was comprised of youth with intellectual disabilities aged 0-18 years, b) an intervention was used, c) physical activity was specified as dependent variable, and d) quantitative or qualitative data were used to analyse the efficacy of the intervention.

All study designs were included to better capture the scope of the interventions being used in the field. Only original research papers published in indexed journals and that targeted youth with intellectual disabilities, not care givers, were included. Uncertainties about article inclusion were resolved through discussion and agreement between authors.

The systematic search process resulted in 951 citations. Of these, 738 were excluded as duplicates or because they did not meet the inclusion criteria based on abstracts or titles. Abstracts of the remaining 213 papers were examined and another 202 were excluded, with a final total of 11 papers included in the review (figure 1). Information on participant characteristics, study aims and design, study setting, intervention description, outcome measures and measurement time points, and physical activity results were extracted.

Results

Table I provides an overview of the few intervention studies focused on youth with intellectual disabilities that have included physical activity as a dependent variable. The scale of interventions ranged greatly from single subject/case study designs to randomized control trials. The number of randomized control trials was surprising since this type of research design is not common in exercise/physical activity research among people with disabilities.¹⁴14. Rimmer JH, Chen MD, McCubbin JA, Drum C, Peterson J. Exercise intervention research on persons with disabilities: what we know and where we need to go. Am J Phys Med Rehab 2010;89(3):249-263. https://doi.org/10.1097/PHM.0b013e3181c9fa9d
https://doi.org/10.1097/PHM.0b013e3181c9... Since the purpose of this review was to include studies using all types of research designs, randomized control trials were not assessed for quality using an objective tool such as the CONSORT checklist.¹⁵15. Boutron I, Moher D, Altman D, Schulz K, Ravaud P. CONSORT group. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Int Med 2008;148:295-309. https://doi.org/10.7326/0003-4819-148-4-200802190-00008
https://doi.org/10.7326/0003-4819-148-4-... However, of the randomized control studies included in the current review, only one reported the random allocation process and who generated the allocation sequences.¹⁶16. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... O’Connor and colleagues ¹⁷17. O’Connor TM, Jago R, Baranowski T. Engaging parents to increase youth physical activity a systematic review. Am J Prev Med 2009;37(2):141-149. https://doi.org/10.1016/j.amepre.2009.04.020
https://doi.org/10.1016/j.amepre.2009.04... found that the quality of reporting for randomized control trial studies on engaging parents to increase activity in youth without disabilities was consistently poor and few met the CONSORT criteria. A tool such as the CONSORT checklist provides both a framework for reporting and process evaluation of randomized control trials, which improves the veracity and usefulness of the data. Five studies used accelerometry as an objective physical activity measure either alone or paired with a subjective measure (e.g. parent diaries). Youth physical activity is more intermittent and less predictable than adult physical activity, thus multiple measures may provide a more comprehensive picture of youth activity than single measures.¹⁸18. Welk GJ, Corbin CB, Dale D. Measurement issues in the assessment of physical activity in children. Res Quart Exerc Sport 2000;71(suppl 2):S59-S73. https://doi.org/10.1080/02701367.2000.11082788
https://doi.org/10.1080/02701367.2000.11... Two studies using accelerometry were conducted in infants with Down syndrome, but methodological research supporting the use of this instrumentation to assess physical activity in infants is lacking and requires further study.¹⁹19. Cliff DP, Reilly JJ, Okely AD. Methodological considerations in using accelerometers to assess habitual physical activity in children aged 0-5 years. J Sci Med Sport 2009;12(5):557-567. https://doi.org/10.1016/j.jsams.2008.10.00
https://doi.org/10.1016/j.jsams.2008.10.... There are also concerns that motion sensors may not capture movement differences in youth with intellectual disabilities and there are no intensity thresholds (i.e. cut-points) validated for this population segment.²⁰20. Hinckson EA, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: A systematic review. Res Dev Disabil 2013;34(1):72-86. https://doi.org/10.1016/j.ridd.2012.07.022
https://doi.org/10.1016/j.ridd.2012.07.0... Two accelerometry studies in this review used cut-points to assess physical activity intensity.²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2222. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... Ptomey and associates ²²22. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... reported using cut-points from the National Health and Nutrition Survey and referenced Troiano and colleagues.²³23. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc 2008;40(1):181-188. https://doi.org/10.1249/mss.0b013e31815a51b3
https://doi.org/10.1249/mss.0b013e31815a... However, Troiano and colleagues ²³23. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc 2008;40(1):181-188. https://doi.org/10.1249/mss.0b013e31815a51b3
https://doi.org/10.1249/mss.0b013e31815a... used two different sets of cut-points for adults and children and the cut-points for children were adopted from research by Trost and colleagues.²⁴24. Trost SG, Pate RR, Sallis JF, Freedson PS, Taylor WC, Dowda M, et al. Age and gender differences in objectively measured physical activity in youth. Med Sci Sports Exerc 2002;34(2):350-355. https://doi.org/10.1097/00005768-200202000-00025
https://doi.org/10.1097/00005768-2002020... Ptomey and associates²²22. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... did not reference the Trost and colleagues ²⁴24. Trost SG, Pate RR, Sallis JF, Freedson PS, Taylor WC, Dowda M, et al. Age and gender differences in objectively measured physical activity in youth. Med Sci Sports Exerc 2002;34(2):350-355. https://doi.org/10.1097/00005768-200202000-00025
https://doi.org/10.1097/00005768-2002020... paper, thus it is unclear if the correct cut-points were used to distinguish between intensity levels. Unfortunately, the authors only reported p-values which limited the ability to interpret the data and findings. In contrast, Ulrich and associates ²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... used the Actical accelerometer and cut-points developed for both the specific motion sensor model and children.²⁵25. Puyau M, Adolph A, Vohra F, Butte N. Validation and calibration of physical activity monitors in children. Obes Res 2002;10:150-157. https://doi.org/10.1038/oby.2002.24
https://doi.org/10.1038/oby.2002.24... Ulrich and colleagues ²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... also reported both p-values and mean±SD of physical activity variables, and this allowed the reader to better understand the data and findings. Poor consistency in reporting intervention methods and outcomes has also been observed in physical activity studies on youth without disabilities.¹⁷17. O’Connor TM, Jago R, Baranowski T. Engaging parents to increase youth physical activity a systematic review. Am J Prev Med 2009;37(2):141-149. https://doi.org/10.1016/j.amepre.2009.04.020
https://doi.org/10.1016/j.amepre.2009.04... ^,2626. Van Sluijs E, Kriemler S, McMinn A. The effect of community and family interventions on young people’s physical activity levels: a review of reviews and upated systematic review. British J Sports Med 2011;45:914-922. https://doi.org/10.1136/bjsports-2011-090187
https://doi.org/10.1136/bjsports-2011-09...

Other methods of assessing physical activity included distance walked or snow-shoed ²⁷27. Todd T, Reid G. Increasing physical activity in individuals with autism. Focus on Autism & Other Dev Disabil 2006;21(3):167-176. https://doi.org/10.1177/10883576060210030501
https://doi.org/10.1177/1088357606021003... and parent proxy-reports.²⁸28. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... Distance walked or snow-shoed has not been validated as a measure of physical activity and there is debate as to whether parent-proxy reports are a valid method of assessing youth physical activity.³⁰30. Chaumeton N, Duncan SC, Duncan TE, Strycker LA. A measurement model of youth physical activity using pedometer and self, parent, and peer reports. Int J Behav Med 2011;18(3):209-215. https://doi.org/10.1007/s12529-010-9118-5
https://doi.org/10.1007/s12529-010-9118-... ^,3131. Bender JM, Brownson RC, Elliott MB, Haire-Joshu DL. Children’s physical activity: using accelerometers to validate a parent proxy record. Med Sci Sports Exerc 2005;37(8):1409-1413. https://doi.org/10.1249/01.mss.0000174906.38722.2e
https://doi.org/10.1249/01.mss.000017490... Hinckson and Curtis²⁰20. Hinckson EA, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: A systematic review. Res Dev Disabil 2013;34(1):72-86. https://doi.org/10.1016/j.ridd.2012.07.022
https://doi.org/10.1016/j.ridd.2012.07.0... suggest that parent-proxy reports may be a suitable tool for assessing physical activity in youth with intellectual disabilities because of high parent-child contact during the day, but this conclusion was not based on research comparing child contact time between parents of youth with and without intellectual disabilities. As such, data based on proxy-reports of physical activity in youth with intellectual disabilities must be viewed with caution.

Discussion

None of the studies used direct observation to assess the impact of an intervention on physical activity, which is surprising since this method has frequently been used to assess physical activity levels in youth with intellectual disabilities.²⁰20. Hinckson EA, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: A systematic review. Res Dev Disabil 2013;34(1):72-86. https://doi.org/10.1016/j.ridd.2012.07.022
https://doi.org/10.1016/j.ridd.2012.07.0... Hinckson and Curtis ²⁰20. Hinckson EA, Curtis A. Measuring physical activity in children and youth living with intellectual disabilities: A systematic review. Res Dev Disabil 2013;34(1):72-86. https://doi.org/10.1016/j.ridd.2012.07.022
https://doi.org/10.1016/j.ridd.2012.07.0... recommended that direct observation may be more suitable to assess physical activity in youth with intellectual disabilities than other objective tools because of the ability to capture short bouts of activity and changes in movement patterns. The best approach is to combine multiple measures, preferably at least one objective measure such as accelerometry, to best capture the unique aspects of physical activity in all youth,¹⁸18. Welk GJ, Corbin CB, Dale D. Measurement issues in the assessment of physical activity in children. Res Quart Exerc Sport 2000;71(suppl 2):S59-S73. https://doi.org/10.1080/02701367.2000.11082788
https://doi.org/10.1080/02701367.2000.11... ^,3232. Fox KR, Riddoch C. Charting the physical activity patterns of contemporary children and adolescents. Proceedings of the Nutrition Society 2000;59:497-504. https://doi.org/10.1017/S0029665100000720
https://doi.org/10.1017/S002966510000072... including youth with intellectual disabilities.

There was a large participant age-range and the majority of studies included in the review involved adolescents. Several studies used a cross-section sample with the largest age-range between 7-20 years ²⁹29. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... representing a developmental span from late childhood to young adulthood. Physical activity differs according to developmental level ³³33. National Association of Sport and Physical Education. Active Start: A statement of physical activity guidelines for children birth-age 5. Reston, VA: NASPE, 2009. and none of the studies addressed physical activity from a developmental perspective or determined if participants met age-specific physical activity guidelines. The two studies involving infants were somewhat developmental in relating physical activity to walking onset ³⁴34. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... ^,3535. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39. but no conclusions can be drawn about the impact of interventions on youth and intellectual disabilities meeting physical activity guidelines based on the studies in the current review.

Most interventions were conducted with students at segregated schools and this also reflects the geographical diversity of the studies. All of the studies at segregated schools were conducted outside the US, ²⁷27. Todd T, Reid G. Increasing physical activity in individuals with autism. Focus on Autism & Other Dev Disabil 2006;21(3):167-176. https://doi.org/10.1177/10883576060210030501
https://doi.org/10.1177/1088357606021003... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... ^,3636. Shih CT, Shih CH, Luo CH. Assisting people with disabilities in actively performing physical activities by controlling the preferred environmental stimulation with a gyration air mouse. Res Dev Disabil 2013;34:4328-4333. https://doi.org/10.1016/j.ridd.2013.09.001
https://doi.org/10.1016/j.ridd.2013.09.0... ^,3737. Shih CH, Chiu YC. Assisting obese students with intellectual disabilities to actively perform the activity of walking in place using a dance pad to control their preferred environmental stimulation. R Res Dev Disabil 2014;35(10):2394-2402. https://doi.org/10.1016/j.ridd.2014.06.011
https://doi.org/10.1016/j.ridd.2014.06.0... ^,3838. Chang ML, Shih CH, Lin YC. Encouraging obese students with intellectual disabilities to engage in pedaling an exercise bike by using an air mouse combined with preferred environmental stimulation. Res Dev Disabil 2014;35(12):3292-3298. https://doi.org/10.1016/j.ridd.2014.08.020
https://doi.org/10.1016/j.ridd.2014.08.0... while all but one of those conducted in the home or community were conducted in the US.²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2222. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... ^,2828. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... ^,3434. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... ^,3535. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39. The US has mostly eliminated segregated schools for youth with disabilities in general, and this population segment is typically educated in the public school system.³⁹39. United States Code. Individuals With Disabilities Education. U.S.C. Act, §1400, 2004. Interestingly, no US school-based physical activity interventions for youth with intellectual disabilities were found in the literature search. There have been many multi-site, school-based interventions to address physical activity and health in youth without disabilities, and this approach is recommended to advance the field of physical activity and youth with intellectual disabilities.¹⁴14. Rimmer JH, Chen MD, McCubbin JA, Drum C, Peterson J. Exercise intervention research on persons with disabilities: what we know and where we need to go. Am J Phys Med Rehab 2010;89(3):249-263. https://doi.org/10.1097/PHM.0b013e3181c9fa9d
https://doi.org/10.1097/PHM.0b013e3181c9...

Effects on physical activity

Table II outlines the intervention delivery methods and outcomes on physical activity. Overall, 9 of the 11 studies (82%) studies reviewed reported that the intervention led to an increase in physical activity in the target population.¹⁶16. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... ^,2121. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2727. Todd T, Reid G. Increasing physical activity in individuals with autism. Focus on Autism & Other Dev Disabil 2006;21(3):167-176. https://doi.org/10.1177/10883576060210030501
https://doi.org/10.1177/1088357606021003...

28. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... ^-2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... ^,3434. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... ^,3535. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39.^,3636. Shih CT, Shih CH, Luo CH. Assisting people with disabilities in actively performing physical activities by controlling the preferred environmental stimulation with a gyration air mouse. Res Dev Disabil 2013;34:4328-4333. https://doi.org/10.1016/j.ridd.2013.09.001
https://doi.org/10.1016/j.ridd.2013.09.0... ^,3737. Shih CH, Chiu YC. Assisting obese students with intellectual disabilities to actively perform the activity of walking in place using a dance pad to control their preferred environmental stimulation. R Res Dev Disabil 2014;35(10):2394-2402. https://doi.org/10.1016/j.ridd.2014.06.011
https://doi.org/10.1016/j.ridd.2014.06.0... ^,3838. Chang ML, Shih CH, Lin YC. Encouraging obese students with intellectual disabilities to engage in pedaling an exercise bike by using an air mouse combined with preferred environmental stimulation. Res Dev Disabil 2014;35(12):3292-3298. https://doi.org/10.1016/j.ridd.2014.08.020
https://doi.org/10.1016/j.ridd.2014.08.0... Ptomey and colleagues ²²22. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... did not observe an increase in physical activity, but there was a decrease in sedentary behavior and this could not be attributed to the intervention since there were no experimental and control group differences. Three studies came from the same laboratory and motivated youth with intellectual disabilities to increase physical activity by receiving a preferred stimulus.³⁶36. Shih CT, Shih CH, Luo CH. Assisting people with disabilities in actively performing physical activities by controlling the preferred environmental stimulation with a gyration air mouse. Res Dev Disabil 2013;34:4328-4333. https://doi.org/10.1016/j.ridd.2013.09.001
https://doi.org/10.1016/j.ridd.2013.09.0... ^,3737. Shih CH, Chiu YC. Assisting obese students with intellectual disabilities to actively perform the activity of walking in place using a dance pad to control their preferred environmental stimulation. R Res Dev Disabil 2014;35(10):2394-2402. https://doi.org/10.1016/j.ridd.2014.06.011
https://doi.org/10.1016/j.ridd.2014.06.0... ^,3838. Chang ML, Shih CH, Lin YC. Encouraging obese students with intellectual disabilities to engage in pedaling an exercise bike by using an air mouse combined with preferred environmental stimulation. Res Dev Disabil 2014;35(12):3292-3298. https://doi.org/10.1016/j.ridd.2014.08.020
https://doi.org/10.1016/j.ridd.2014.08.0... Different electronic configurations and modalities were used, but the most promising was a wireless gyration air mouse system.³⁶36. Shih CT, Shih CH, Luo CH. Assisting people with disabilities in actively performing physical activities by controlling the preferred environmental stimulation with a gyration air mouse. Res Dev Disabil 2013;34:4328-4333. https://doi.org/10.1016/j.ridd.2013.09.001
https://doi.org/10.1016/j.ridd.2013.09.0... The air mouse is a hand-held computer pointing device embedded with a micro-electro mechanical systems gyro sensor that allows control of a computer with hand movements. Using adapted software technology ⁴⁰40. Shih CH, Chang ML. A wireless object location detector enabling people with developmental disabilities to control environmental stimulation through simple occupational activities with Nintendo Wii Balance Boards. Res Dev Disabil 2010;32:818-823. https://doi.org/10.1016/j.ridd.2010.10.016
https://doi.org/10.1016/j.ridd.2010.10.0... the mouse could both detect precise limb movement and control a preferred stimulus (i.e. video projected on a flat screen TV). The air mouse was placed in a pants pocket and participants had to simply move at a certain intensity level in order to receive the stimulus. By controlling the stimulus through movement, participants were 80% more active than at baseline, although for a very short duration.³⁶36. Shih CT, Shih CH, Luo CH. Assisting people with disabilities in actively performing physical activities by controlling the preferred environmental stimulation with a gyration air mouse. Res Dev Disabil 2013;34:4328-4333. https://doi.org/10.1016/j.ridd.2013.09.001
https://doi.org/10.1016/j.ridd.2013.09.0...

Similar contingency-based interventions have been successfully used to increase physical activity in youth without intellectual disabilities,⁴¹41. Faith MS, Berman N, Heo M, Pietrobelli A, Gallagher D, Epstein LH, et al. Effects of contingent television on physical activity and television viewing in obese children. Pediatrics 2001;107(5):1043-1048. https://doi.org/10.1542/peds.107.5.1043
https://doi.org/10.1542/peds.107.5.1043... as well the other studies included in this review involving youth intellectual disabilities.³⁷37. Shih CH, Chiu YC. Assisting obese students with intellectual disabilities to actively perform the activity of walking in place using a dance pad to control their preferred environmental stimulation. R Res Dev Disabil 2014;35(10):2394-2402. https://doi.org/10.1016/j.ridd.2014.06.011
https://doi.org/10.1016/j.ridd.2014.06.0... ^,3838. Chang ML, Shih CH, Lin YC. Encouraging obese students with intellectual disabilities to engage in pedaling an exercise bike by using an air mouse combined with preferred environmental stimulation. Res Dev Disabil 2014;35(12):3292-3298. https://doi.org/10.1016/j.ridd.2014.08.020
https://doi.org/10.1016/j.ridd.2014.08.0... These approaches used stationary bicycles ³⁸38. Chang ML, Shih CH, Lin YC. Encouraging obese students with intellectual disabilities to engage in pedaling an exercise bike by using an air mouse combined with preferred environmental stimulation. Res Dev Disabil 2014;35(12):3292-3298. https://doi.org/10.1016/j.ridd.2014.08.020
https://doi.org/10.1016/j.ridd.2014.08.0... ^,4141. Faith MS, Berman N, Heo M, Pietrobelli A, Gallagher D, Epstein LH, et al. Effects of contingent television on physical activity and television viewing in obese children. Pediatrics 2001;107(5):1043-1048. https://doi.org/10.1542/peds.107.5.1043
https://doi.org/10.1542/peds.107.5.1043... or other equipment ³⁷37. Shih CH, Chiu YC. Assisting obese students with intellectual disabilities to actively perform the activity of walking in place using a dance pad to control their preferred environmental stimulation. R Res Dev Disabil 2014;35(10):2394-2402. https://doi.org/10.1016/j.ridd.2014.06.011
https://doi.org/10.1016/j.ridd.2014.06.0... which may not generalize well to a practical setting due to high cost or large size. With the air mouse system participants merely needed to naturally move at a pre-determined intensity threshold to receive the preferred stimulus and this may be an optimal way to encourage physical activity, particularly in the home. These aforementioned studies are limited by small participant numbers and it is important to note that the same two youth participated in all three studies which may have habituated them to the stimuli. Regardless, this is an interesting approach to increasing physical activity in youth with intellectual disabilities that warrants further study.

The delivery of the other interventions varied considerably. Four were based on existing programs ²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2222. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... ^,2828. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... and three cited evidence that the programs had been effectively used in other populations.²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2222. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... One used participating in a bicycle riding training camp,²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... two used infant treadmill training,³⁴34. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... ^,3535. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39. three used different types of exercise-based interventions including strength training,¹⁶16. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... walking and snow-shoeing with specific emphasis on self-monitoring, cuing, and reinforcement,²⁷27. Todd T, Reid G. Increasing physical activity in individuals with autism. Focus on Autism & Other Dev Disabil 2006;21(3):167-176. https://doi.org/10.1177/10883576060210030501
https://doi.org/10.1177/1088357606021003... and a combination of strength/aerobic activities.²⁸28. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... Two interventions targeted both physical activity and nutrition.²⁹29. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... ^,4242. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad Nutr Diet 2015;115(1):112-118. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... Most of the interventions incorporated a level of protocol individualization, even if a program was administered to a group.¹⁶16. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... ^,2121. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2727. Todd T, Reid G. Increasing physical activity in individuals with autism. Focus on Autism & Other Dev Disabil 2006;21(3):167-176. https://doi.org/10.1177/10883576060210030501
https://doi.org/10.1177/1088357606021003... ^,2828. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600...

Several studies included parents by either having them help administer or facilitate the intervention ³⁴34. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... ^,3535. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39.^,4242. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad Nutr Diet 2015;115(1):112-118. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... or by providing them with education materials and/or formal instruction.²⁸28. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... There is an abundance of research on family based physical activity interventions for youth without disabilities, but the findings are generally inconclusive and do not support the efficacy of this approach.¹⁷17. O’Connor TM, Jago R, Baranowski T. Engaging parents to increase youth physical activity a systematic review. Am J Prev Med 2009;37(2):141-149. https://doi.org/10.1016/j.amepre.2009.04.020
https://doi.org/10.1016/j.amepre.2009.04... ^,2626. Van Sluijs E, Kriemler S, McMinn A. The effect of community and family interventions on young people’s physical activity levels: a review of reviews and upated systematic review. British J Sports Med 2011;45:914-922. https://doi.org/10.1136/bjsports-2011-090187
https://doi.org/10.1136/bjsports-2011-09... While it is intuitive that parent contributions would be important to ensure the efficacy of a physical activity intervention for youth with intellectual disabilities, the existing research does not support this supposition. Three studies reported increases in physical activity²⁸28. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... ^,3434. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... ^,3535. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39. and two studies reported no improvements in physical activity.²²22. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... The discrepancy in these findings can be attributed to many factors such as different outcome measures, subject populations, and intervention design. Schreiber and colleagues ²⁸28. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... measured physical activity using a single item question that asked the parent to circle the number of times their child exercised in the past two weeks on a scale of 1-15 and combined these data with qualitative information. The authors erroneously reported positive findings about the effectiveness of the intervention based on the parent’s perception of the child walking “longer and faster” and the single item question. In addition, the other two studies that reported increased physical activity were based on infants with Down syndrome and parents implemented the treadmill intervention at home. Parents had control over the activity, which is a very different approach than parents influencing physical activity in other ways (e.g. verbal prompts, providing opportunities, etc.). As such, the studies reviewed indicate that parents either have no or limited influence on the physical activity of youth with intellectual disabilities.

Several studies examined the maintenance of intervention impact on physical activity at time points ranging from 3-15 months post intervention.¹⁶16. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... ^,2121. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... ^,3434. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... Of these studies, three reported that participants continued to exhibit elevated levels of physical activity ³3. Frey GC, Stanish HI, Temple VA. Physical activity of youth with intellectual disability: review and research agenda. Adapt Phys Act Quart 2008;25(2):95-117. https://doi.org/10.1123/apaq.25.2.95
https://doi.org/10.1123/apaq.25.2.95... ^,1616. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... 1 534 and 1 221 months post-intervention. Interestingly, Shields and colleagues ¹⁶16. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... observed physical activity differences between experimental and control groups at three months, but not immediately after a progressive strength training intervention. This finding was attributed to the experimental group maintaining and the control group decreasing physical activity levels. Since there were no group differences in physical activity immediately post-intervention, it is incorrect to conclude that the intervention had an impact on physical activity levels in the target population.

Effects on other outcomes

All of the papers reviewed assessed a variety of outcome measures additional to physical activity, including selected anthropometrics (e.g. BMI, waist circumference),¹⁶16. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... ^,2121. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2222. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... eating behavior,²²22. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... technology use,²²22. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... walking onset,³⁴34. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... ^,3535. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39. and other physical fitness ¹⁶16. Shields N, Taylor NF, Wee E, Wollersheim D, O’Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: A randomised controlled trial. Res Dev Disabil 2013;34:4385-4394. https://doi.org/10.1016/j.ridd.2013.09.022
https://doi.org/10.1016/j.ridd.2013.09.0... ^,2121. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2828. Schreiber J, Marchetti G, Crytzer T. The implementation of a fitness program for children with disabilities: A clinical case report. Pediatr Phys Ther 2004;16(3):173-179. https://doi.org/10.1097/01.PEP.0000136007.39269.17
https://doi.org/10.1097/01.PEP.000013600... ^,2929. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... or motor variables.³⁵35. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39. Hinckson and colleagues²⁹29. Hinckson EA, Dickinson A, Water T, Sands M, Penman L. Physical activity, dietary habits and overall health in overweight and obese children and youth with intellectual disability or autism. Res Dev Disabil 2013;34(4):1170-1178. https://doi.org/10.1016/j.ridd.2012.12.006
https://doi.org/10.1016/j.ridd.2012.12.0... examined physical activity, dietary habits, and overall health in youth with intellectual disability or autism. Several different outcome variables were included such as BMI, waist circumference, physical fitness (six-minute walk-test), sedentary behavior (screen time), sport (walking, swimming, active play) and physical activity (physical education). The impact of the intervention on these variables ranged from “unclear” to “very likely negative” and the only “possibly positive” effect was reported for the six-min walk 24-weeks post-intervention. Ptomey and colleagues ²²22. Ptomey LT, Sullivan DK, Lee J, Goetz JR, Gibson C, Donnelly JE. The use of technology for delivering a weight loss program for adolescents with intellectual and developmental disabilities. J Acad NutrDiet 2015(1):112. https://doi.org/10.1016/j.jand.2014.08.031
https://doi.org/10.1016/j.jand.2014.08.0... assessed anthropomorphic variables, several different aspects of energy/macronutrient intake, and diet quality and the intervention had a significant impact on select diet variables, but not anthropomorphic variables or physical activity. Ulrich and colleages ²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... found that participation in a bicycle riding camp significantly improved physical activity, BMI and percent body fat in youth with Down syndrome, but not measures of leg strength and balance.

Inclusion of multiple and potentially correlated variables in an intervention with small subject numbers, is generally an ill-advised approach. Hadley and colleagues⁴³43. Hadley A, Hair E, Dreisbach N. What works for the prevention and treatment of obesity among children: Lessons from experimental evaluations of programs and interventions. Child Trends Fact Sheet, 2010 [accessed on January 1, 2015]. Available at: https://www.childtrends.org/wp-content/uploads/2013/03/Child_Trends_2010_03_25_FS_WWObesity.pdf
https://www.childtrends.org/wp-content/u... reported that child obesity prevention and treatment programs that focused on one outcome (i.e. either nutrition or physical activity or weight loss) were more successful than those that tried to simultaneously focus on multiple outcomes. None of the studies reported power/sample size calculations or analysed dependent variable collinearity, and only one study reported post-analysis effect sizes.²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061...

Conclusions

It is well documented that youth with intellectual disabilities are less active than peers without disabilities,³3. Frey GC, Stanish HI, Temple VA. Physical activity of youth with intellectual disability: review and research agenda. Adapt Phys Act Quart 2008;25(2):95-117. https://doi.org/10.1123/apaq.25.2.95
https://doi.org/10.1123/apaq.25.2.95... however there are few published efforts to improve physical activity in this population segment. This review illustrates that both the quantity and quality of physical activity interventions for youth with intellectual disabilities are lacking. Several interventions showed promising results and evidence of some benefits,²¹21. Ulrich DA, Burghardt AR, Lloyd M, Tiernan C, Hornyak JE. Physical activity benefits of learning to ride a two-wheel bicycle for children with down syndrome: A randomized trial. PhysTher 2011;91(10):1463-1477. https://doi.org/10.2522/ptj.20110061
https://doi.org/10.2522/ptj.20110061... ^,2727. Todd T, Reid G. Increasing physical activity in individuals with autism. Focus on Autism & Other Dev Disabil 2006;21(3):167-176. https://doi.org/10.1177/10883576060210030501
https://doi.org/10.1177/1088357606021003... ^,3434. Angulo-Barroso R, Burghardt AR, Lloyd M, Ulrich DA. Physical activity in infants with Down syndrome receiving a treadmill intervention. Infant Behav Dev 2008;31:255-269. https://doi.org/10.1016/j.infbeh.2007.10.003
https://doi.org/10.1016/j.infbeh.2007.10... ^,3535. Lloyd MC, Burghardt A, Ulrich DA, Angulo-Barroso RM. Relationship between early physical activity and motor milestone achievement in infants with Down syndrome. J Sport Exerc Psychol 2007;29:s39-s39.^,3636. Shih CT, Shih CH, Luo CH. Assisting people with disabilities in actively performing physical activities by controlling the preferred environmental stimulation with a gyration air mouse. Res Dev Disabil 2013;34:4328-4333. https://doi.org/10.1016/j.ridd.2013.09.001
https://doi.org/10.1016/j.ridd.2013.09.0... ^,3737. Shih CH, Chiu YC. Assisting obese students with intellectual disabilities to actively perform the activity of walking in place using a dance pad to control their preferred environmental stimulation. R Res Dev Disabil 2014;35(10):2394-2402. https://doi.org/10.1016/j.ridd.2014.06.011
https://doi.org/10.1016/j.ridd.2014.06.0... ^,3838. Chang ML, Shih CH, Lin YC. Encouraging obese students with intellectual disabilities to engage in pedaling an exercise bike by using an air mouse combined with preferred environmental stimulation. Res Dev Disabil 2014;35(12):3292-3298. https://doi.org/10.1016/j.ridd.2014.08.020
https://doi.org/10.1016/j.ridd.2014.08.0... but reporting and design flaws make it difficult to generalize or replicate findings. Four of the single subject design interventions used a withdrawal component to verify intervention effects and were successful in improving physical activity.²⁷27. Todd T, Reid G. Increasing physical activity in individuals with autism. Focus on Autism & Other Dev Disabil 2006;21(3):167-176. https://doi.org/10.1177/10883576060210030501
https://doi.org/10.1177/1088357606021003... ^,3636. Shih CT, Shih CH, Luo CH. Assisting people with disabilities in actively performing physical activities by controlling the preferred environmental stimulation with a gyration air mouse. Res Dev Disabil 2013;34:4328-4333. https://doi.org/10.1016/j.ridd.2013.09.001
https://doi.org/10.1016/j.ridd.2013.09.0... ^,3737. Shih CH, Chiu YC. Assisting obese students with intellectual disabilities to actively perform the activity of walking in place using a dance pad to control their preferred environmental stimulation. R Res Dev Disabil 2014;35(10):2394-2402. https://doi.org/10.1016/j.ridd.2014.06.011
https://doi.org/10.1016/j.ridd.2014.06.0... ^,3838. Chang ML, Shih CH, Lin YC. Encouraging obese students with intellectual disabilities to engage in pedaling an exercise bike by using an air mouse combined with preferred environmental stimulation. Res Dev Disabil 2014;35(12):3292-3298. https://doi.org/10.1016/j.ridd.2014.08.020
https://doi.org/10.1016/j.ridd.2014.08.0... However, none of the intervention approaches were based on behavior change theory or specifically targeted identified physical activity determinants which are important components of successful intervention design.¹⁰10. Barr M, Shields N. Identifying the barriers and facilitators to participation in physical activity for children with Down syndrome. J Intellect Disabil Res 2011;55(11):1020-1033. https://doi.org/10.1111/j.1365-2788.2011.01425.x
https://doi.org/10.1111/j.1365-2788.2011... ^,1111. Lin JD, Lin PY, Lin LP, Chang YY, Wu SR, Wu JL. Physical activity and its determinants among adolescents with intellectual disabilities. Res Dev Disabil 2010;31:263-269. https://doi.org/10.1016/j.ridd.2009.09.015
https://doi.org/10.1016/j.ridd.2009.09.0... ^,1717. O’Connor TM, Jago R, Baranowski T. Engaging parents to increase youth physical activity a systematic review. Am J Prev Med 2009;37(2):141-149. https://doi.org/10.1016/j.amepre.2009.04.020
https://doi.org/10.1016/j.amepre.2009.04... As a result, conclusions cannot be made regarding intervention components that impacted outcome variables, if the observed effects were specifically due to the intervention or if interventions could be maintained long-term.

To advance the knowledge base in this area, there needs to be a concerted effort to increase rigor in study conceptualization and research design. Physical activity intervention research design should be based on established behavior theory, particularly conceptualization of the problem and defining the target behavior that will be modified.¹⁷17. O’Connor TM, Jago R, Baranowski T. Engaging parents to increase youth physical activity a systematic review. Am J Prev Med 2009;37(2):141-149. https://doi.org/10.1016/j.amepre.2009.04.020
https://doi.org/10.1016/j.amepre.2009.04... ^,4444. Keller C, Fleury J, Sidani S, Ainsworth B. Fidelity to theory in PA intervention research. West J Nurs Res 2009;31(3):289-311. https://doi.org/10.1177/0193945908326067
https://doi.org/10.1177/0193945908326067... An increase in the number of randomized control trials is needed,¹⁴14. Rimmer JH, Chen MD, McCubbin JA, Drum C, Peterson J. Exercise intervention research on persons with disabilities: what we know and where we need to go. Am J Phys Med Rehab 2010;89(3):249-263. https://doi.org/10.1097/PHM.0b013e3181c9fa9d
https://doi.org/10.1097/PHM.0b013e3181c9... but studies using this design must address quality control in design and reporting to ensure usability of findings.¹⁵15. Boutron I, Moher D, Altman D, Schulz K, Ravaud P. CONSORT group. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Int Med 2008;148:295-309. https://doi.org/10.7326/0003-4819-148-4-200802190-00008
https://doi.org/10.7326/0003-4819-148-4-... ^,1717. O’Connor TM, Jago R, Baranowski T. Engaging parents to increase youth physical activity a systematic review. Am J Prev Med 2009;37(2):141-149. https://doi.org/10.1016/j.amepre.2009.04.020
https://doi.org/10.1016/j.amepre.2009.04... Finally, there are many challenges to conducting large-scale interventions in youth with intellectual disabilities, so researchers are encouraged to develop multi-site collaborative projects to increase sample size, strengthen research design and improve generalizability of findings.¹⁴14. Rimmer JH, Chen MD, McCubbin JA, Drum C, Peterson J. Exercise intervention research on persons with disabilities: what we know and where we need to go. Am J Phys Med Rehab 2010;89(3):249-263. https://doi.org/10.1097/PHM.0b013e3181c9fa9d
https://doi.org/10.1097/PHM.0b013e3181c9...

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