THE BENEFITS OF EXERCISE TO A DOWN'S SYNDROME POPULATION
Dan Gordon

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Abstract The benefits of exercise and training for a reference population are well understood and the merits well documented. The aim of this review is to ascertain the benefits of exercise for a Down's Syndrome population. The physiological characteristics of the Down's Syndrome individual exhibit potential limitations and restrictions to both cardiovascular and resistance based exercise, with poor skeletal muscle development and chronotropic incompetence being the primary constraints. The merits to the Down's Syndrome individual are clear with many being classed as obese and showing classic signs of the contraindications to exercise. There is limited data available as to the physiological responses to exercise and training, but those presented highlight both benefits in terms of the physiological responses and inconsistencies in terms of methods applied. The physiological responses in terms of cardiovascular (CV) and bi-motor abilities are explored and examined showing that a key stimulus for adaptation are the ground impact forces (GIF). An overriding factor that affects all of the presented outcomes is the adherence of the individual to the program, with drop out rates greater than 50% in six months being reported. The conclusion would appear to be that a program is developed which is structured, and stimulating and conforms to the needs of the Down's Syndrome individual, taking into account their specific physiological needs.

Introduction
In the population as a whole the benefits of regular exercise have been well researched and established (Astrand and Rohdal 2003). Indeed it has been documented that regular aerobic (cardiovascular) exercise induces physiological responses which are of profound significance to the health of the individual (Blair et al 1999; Fletcher et al 1996; American College of Sports Medicine 1998). Of these adaptations perhaps the most pertinent are an increased functioning and efficiency of the myocardium, decreased cholesterol levels, decreased systolic and diastolic blood pressure at rest and during exercise, decreased adipose tissue stores and the concomitant result in a decreased prevalence of the contraindications to health such as diabetes mellitus and coronary heart disease (Fletcher et al 1996).

Yet despite the widespread interest to the clear benefits of exercise per se on health and lifestyle there is a paucity of suitably applicable information for individuals with intellectual disabilities. This should be considered to be both surprising and concerning, given that individuals with less education, lower incomes, and blue collar employment are more likely to be physically inactive than those with more education, higher incomes and white collar employment (Crespo et al 1999). Individuals with an intellectual disability represent a population group who fit into the low education, low income blue collar worker group (Braddock et al 1999; Fujiura et al 1998), and these individuals have been shown to be less physically active when compared to age matched individuals (Beange et al 1995). Indeed in a recent study Pastore et al (2000) demonstrated that from a cohort of 42 individuals with Down's Syndrome (DS), 43% were classed as obese, 20% had reduced Forced Vital Capacity (FVC) scores, 61% of the group showed low exercise tolerance, which appeared to be associated with 91% of the cohort displaying mild tachycardia. All of these factors indicate poor cardiovascular health and functioning which according to Heller et al (2004) are associated with poor self efficacy and decreased life satisfaction. Therefore the purpose of this paper is to review the literature available on exercise for individuals with intellectual disabilities and propose recommendations for interventions in terms of regimes for developing health and fitness.

Physiological characteristics
Individuals with intellectual disabilities have low levels of work capacity and peak oxygen consumption (VO₂max); Guerra et al (2003) and these levels are further exacerbated in individuals with Down's Syndrome (DS), as presented in table 1.

It is reasonably well established in the population as a whole that peak oxygen consumption (VO₂max) is limited by a combination of both central and peripheral mechanisms; Bassett and Howley (2000). This being the case it is not surprising that Down's Syndrome individuals exhibit low aerobic fitness scores primarily as a result of a reduced red blood cell count Monterio et al (1997) and in many cases chronotropic incompetence Baynard et al (2004); Fernhall et al (2001); Guerra et al (2003). As a result there is a reduced cardiac output and oxygen carrying capacity therefore impairing the ability of the individual to exercise aerobically, with a potential consequent effect on daily functioning Fernhall et al (2001).
Chronotropic incompetence has been attributed to alterations in autonomic cardiac control, and therefore altered autonomic function Fernhall et al (2003); Fernhall et al (2001), the significance of which is that alterations in autonomic cardiac control are associated with increased risk of early mortality and morbidity Pomeranz et al (1985); Huikuri et al (1999). Interestingly it has recently been reported that obesity has been related to altered autonomic function Matsumoto et al (1999), further highlighting the need to develop aerobic functioning and overall fitness in the Down's Syndrome population.

In a reference population (Rpop) it has been established that there is a relationship between aerobic fitness and bone mineral density Kronhead et al (1998), with the association suggesting that in those individuals who undertake regular exercise there are higher bone mineral density (BMD) scores and a decrease in the value is associated with decreased levels of loading on the musculoskeletal system Heinonen et al (1999). Further it has recently been suggested that in both recreational runners/joggers and elite athletes where there are increased levels of ground impact forces (GIF) and hence loadings on the lower limbs when compared to sedentary individuals there is an attenuated decline in bone mineral density with age Noakes (1991).

In the Down's Syndrome population there is good evidence to show that there are both reduced bone mineral density and lower limb strength scores when compared to both age matched able bodied and individuals with an intellectual disability without Down's Syndrome (NDS) Angelopoulou et al (2000). Indeed Angelopoulou et al (2000) demonstrated that bone mineral density was 26% lower in Down's Syndrome compared to their matched able bodied counterparts. They also demonstrated significantly reduced muscular strength across a range of angles 300º - 60º in the quadriceps and hamstring groups when compared to both a reference population (Rpop) and individuals without Down's Syndrome (p< 0.05). These findings are supported by both Horvat et al (1997) and Croce et al (1994) who showed that in Down's Syndrome individuals there were reduced peak torque and average power scores when compared to individuals without Down's Syndrome (NDS) and the reference population (Rpop). There are clear implications from these findings for health and fitness within a Down's Syndrome population. As has already been highlighted individuals with intellectual disabilities are less likely to exercise and hence are potentially exacerbate the already low bone mineral density scores, the implications of which are early onset of osteoporosis and brittle bones Kronhead et al (1998).

Poor muscular strength especially in the lower limbs has been associated with increased neuromuscular recruitment of synergistic muscles Hakkinen et al (1985). The subsequent effect during exercise would be an increased oxygen cost per muscle contraction resulting in premature onset of fatigue. As such the implications for an exercise regime in Down's Syndrome individuals would appear to be established both from a physiological and social context.

Physiological responses to exercise
As has already been highlighted there is a paucity of available data on the physiological characteristics let alone on the responses to training to Down's Syndrome and individuals without Down's Syndrome (NDS). The data available is presented in tables 2 and 3 showing the cardiovascular and neuromuscular responses to training in both Down's Syndrome and non-Down Syndrome individuals. Rimmer et al (2004), Tsimaras et al (2003) and Peran et al (1997) demonstrated increases in cardiovascular function (P< 0.05), where as the other studies cited show no change in this and associated factors.

Although limited in terms of scope a number of conclusions/inferences can be drawn from these studies. Data from the reference population (Rpop) suggested that in order to develop, aerobic/cardiovascular adaptations take in the region of 12 weeks Kubukeli et al (2002), with minimum responses occurring in around eight weeks Jones and Carter (2000). Interestingly both Rimmer et al (2004), Tsimaras et al (2003) demonstrate significant increases in cardiovascular function following a twelve week period of sustained exercise. Yet Verela et al (2000) demonstrated no change in cardiovascular function following a 16 week period of exercise. This disparity could be addressed by examining the exercise modality in use. Both Rimmer and Tsimaras used weight bearing exercise such as jogging, walking and stepping, while Verela used rowing on an indoor rowing ergometer. There are clearly different physiological responses to these forms of exercise, with rowing being associated with more rest per action than either jogging or walking. Indeed (Astrand et al 2000) demonstrated that during rowing the rest to work ratio is in the region of 2:1, where as for running it is 1:1. The implications of this would be that the individual would encounter less fatigue during the rowing than walking and hence would elicit lower physiological responses and less cardiovascular adaptation.

The benefits of weight bearing exercise have been well documented with a principle peripheral stimulus to cardiovascular exercise being the number of impact forces registered by the musculoskeletal system Kubukeli et al (2002). Indeed Ulrich et al (2001) demonstrated that in a group of infants 307.4±58.9 days, where treadmill walking was actively encouraged there was a significant difference in the onset of independent walking when compared to controls (73.8 and 101 days respectively). The implication of this is that the initiation of independent walking is dependent upon the development of specific movement patterns and the consequent improvement and integration of functional motor responses Badke et al (1990). These findings have significance to the wider issue of exercise and health as the development of motor function and co-ordination have been associated with enhanced oxygen consumption and muscular efficiency Jones and Carter (2000).

A criterion measure of health is the enhanced ability to consume and utilise oxygen, primarily as a result of specific key physiological adaptations such as increased myocardial functioning Bassett and Howley (1995), increased oxidative enzymes Kubukeli et al (2002), increased slow twitch muscle fibres Jones and Carter (2000) and increased red blood cell count Noakes (1991). The latter is an interesting point given that Monteiro et al (1997) demonstrated a non significant change in red blood cell count (RBC) following a 16 week period of aerobic exercise.

A possible reason for the disparity in the results may be associated with the intensity, frequency and duration of the exercise bouts. The physiological adaptations previously highlighted are dependent on the interplay between these three factors, i.e. how hard an individual trains (intensity), how often they train (frequency) and how long they train for (duration). The combination of these factors is described as training volume Bompa (1999). In most studies exercise intensity is either classed as a percentage of maximal oxygen consumption (VO₂max) or a percentage of maximum heart rate (HRmax). The merits of using these as criterion measures are discussed elsewhere Astrand et al (2003) but their use for Down's Syndrome and non-Down's Syndrome are less well understood.

The limitations to using heart rate as a measure of exercise intensity in a Down's Syndrome population were analysed by Fernhall et al (2001) who suggested that Down's Syndrome individuals exhibit a 20-25% lower maximal heart rate (MHR) when compared to the reference population and that individuals without Down's Syndrome demonstrate an 8-12% reduced maximal heart rate when compared to the reference population. As a result it is perhaps not surprising that the standard method for determining maximal heart rate (220-age) significantly over predicts maximal heart rate (MHR), even though in a reference population this formula provides a conservative estimate. Indeed Robergs (2003) demonstrated that there is no scientific rationale behind the concept of 220-age and as such the use of this method should be viewed with some caution. Therefore it is possible that Millar et al (1999) when using heart rate as a measure of exercise intensity under-predicted the exercise intensity and as a result the participants experienced less fatigue inducing stimulation and hence developed less physiological adaptation (p<0.05). As such Fernhall et al (2001) have proposed the use of a new nomogram/equation for the calculation of maximal heart rate, but still recommend caution when using what is in essence an unreliable variable for determining exercise intensities, especially those in excess of the metabolic threshold Cooper (2001).

The fact that Monterio et al (1997) demonstrated non significant changes (p< 0.05) in aerobic parameters could also be explained by the choice/use of baseline measure from which exercise intensity was determined. Recent reviews Astrand (2000); Bassett and Howley (1995) have suggested that less than 50% of all subjects exhibit a maximal effort during a maximal oxygen consumption (VO₂max) test. Termination of exercise has been associated with both central and peripheral factors including lack of motivation and the onset of pain, thereby producing oxygen consumption (VO₂) values that could not be classified as maximal but rather a peak, thereby indicating that 'more' physiological reserve could have been tapped into. This trend for stoicism during stress testing is magnified in both Down's Syndrome and non-Down's Syndrome individuals primarily as a result of intellectual capacity and reduced motivation for what is a complex task.

Further it is well established that maximal oxygen consumption is dependent on cardiac output (Q) and hence the incidence of chronotropoic incompetence within the Down's Syndrome population would exacerbate the poor maximal oxygen consumption (VO₂max) scores evident in this group. The consequent effects would be evident in the calculation of the exercise intensity (%VO₂max). If the maximal oxygen consumption (VO₂max) score is not truly maximal then the sub-maximal exercise intensities would be misinterpreted and as with the heart rate calculations the subsequent physiological adaptations would be less evident.
Despite the issues surrounding the interpretation of the results from some of the studies there is good reason to support the use of an exercise program for individuals with Down's Syndrome.. Wang (2003; 1997) demonstrated that repeated jumping exercise enhanced bi-motor abilities in both Down's Syndrome and non-Down's Syndrome individuals, when performed over a six week period. The fact that the group only reported bi-motor responses may suggest a limited applicability. However we can, though, make some inferences from these and previous studies.

As has previously been highlighted, most aerobic exercise involves ground impact forces (GIF) and the associated metabolic costs involved with this activity. Therefore it is highly likely that in these two studies, Wang et al would have demonstrated improvements in relation to aerobic parameters in conjunction with the gains in bi-motor abilities. This form of activity clearly meets the needs of an exercise regime in that it would enhance cardiovascular fitness, develop bi-motor abilities and would not be subject to intellectual difficulties associated with more complex tasks.
There are still issues surrounding impact activity on joint stability especially when there is associated muscle instability and skeletal muscle weakness as evidenced in a Down's Syndrome population. Despite these potential limitations the findings of Wang offer considerable benefits to the exercising Down's Syndrome individual. The results indicated increased ability at skilled movements such as a beam walk and floor heel to toe walk. These improvements highlight increased muscle tone and postural control (Wang 2003) which are of pronounced benefit to the individual in terms of health and lifestyle.

Of interest is the time course of adaptations for skeletal muscle to imposed loading (resistance). In a reference population (Rpop) it has been demonstrated that the time course for these adaptations is phased. The initial response, ~6 weeks is an increased strength of the engaged muscles, but without any significant hypertrophy Sale (1988). This paradoxical response has been explained Hakkinen (1985) by an enhanced neural recruitment response. Therefore it appears that the increased strength in this initial phase is a result of an enhanced ability to recruit engaged muscle fibres more rapidly and in greater numbers, rather than from increases in muscle mass Sale (1988).
The development of muscle hypertrophy has been shown to be statistically significant after 12 weeks Sale (1988; Hakkinen (1985). At this point the neural recruitment is slightly diminished but greater than at the onset of the exercise regime. The fact that Wang (2003; 1997) and Almeida (1991) demonstrated enhanced bi-motor abilities after two to six weeks would be evidence of neural adaptations rather than changes in the contractile structures. What is not clear to date is whether these adaptations follow the same time course in the Down's Syndrome individual when compared to the reference population. Again despite this limitation the evidence is good for an enhanced ability following a period of training.

An issue that links all exercise programs and is evident in both the reference population and Down's Syndrome population is adherence to the task. There is compelling evidence Martinsen (1993) that in a reference population 50% of participants will drop out of an exercise program within the first six months. It has been observed that this drop out rate is higher for aerobic based work than those which are less aerobic and that there is little difference between clinical and non clinical populations Robinson and Rogers (1994). What is well understood is that when individuals participate in a structured exercise program the drop out rate can decrease to as little as 10-15% Martin and Dubbert (1985); Robinson and Rogers (1994). In this context what should not be underestimated is that the exercise should be enjoyable and appealing to the individual, indeed this is considered a primary reason for the high drop out rates previously stated Wankel (1993). At present there is very little data highlighting adherence in either the Down's Syndrome or non-Down's Syndrome population although it is perhaps worth noting that both Peran (1997) and Eberhard et al (1997) demonstrated significant cardiovascular and health adaptations following completion of a supervised adapted program.

Conclusions
The consensus is that exercise is of clear benefit to the Down's Syndrome individual both in terms of cardiovascular and neuromuscular responses. The task initiated needs to be simplistic in nature but at the same time sufficient in terms of the imposed demand placed on the body. Wang et al (1997); (2001) demonstrated benefits from performing jumping exercise although there are considerable limitations to a long term exercise program involving a single activity. As such a recommendation would be to introduce a program that offers diversity and interest while at the same time avoiding tasks that are either perceived as being complicated or that are directly associated with being classed as exercise. This form of 'training' can then stimulate social interaction as well as physiological adaptation and avoids many of the pitfalls associated with prescribed exercise programs Millar et al (1993); Monteiro et al (1997); Verela et al (2001).

References
Almeida GL, Corcus DM, Latash ML. (1984) Practice and transfer effects during fast single-joint elbow movements in individuals with Down syndrome. Physical Therapy 74: 1000-1012

American College of Sports Medicine. (1993) Position Stand: Physical Activity, Physical Fitness and Hypertension. Medicine and Sports and Exercise. 25: i

Angelopoulou N, Matziari C, Tsimaras V, Sakadamis A, Souftas V, Mandroukas K. (2000) Bone mineral density and muscle strength in young men with mental retardation (with and without Down syndrome). Calcified Tissue International. 66(3):176-80

Astrand PO, Rohdal K, Dahl HA, Stromme SR. (2003) Textbook of Work Physiology: Physiological basis of exercise. 4th Canada, Human Kinetics

Badke MB, DiFabio RP. (1990) Facilitation: New theoretical perspective and clinical approach. In: Basmajian JV, Wolfe SL eds. (1990) Therapeutic exercise. 5th, Baltimore MD, Williams and Wilkins. 77-91

Bassett DR, Howley ET. (2000) Limiting factors for maximum oxygen uptake and determinants of endurance performance. Medicine and Science in Sports and Exercise. 32: 70-84

Baynard T, Pitetti KH, Guerra M, Fernhall. (2004) Heart rate variability at rest and during exercise in persons with Down syndrome. Archives of Physical and Medical Rehabilitation. 85(8):1285-90.

Bergh C, Ekblom B, Astrand PO. (2000) Maximal oxygen uptake "classical" versus "contemporary" viewpoints. Medicine and Science in Sports and Exercise. 32: 85-88

Blair SN, Brodney S. (1999) Effects of Physical Activity and Obesity or Morbidity and Mortality: Current evidence and research issues. Medicine and Science in Sports and Exercise. 31: 46-62

Bopma TO. (1999) Periodisation: Theory and Methodology of Training. 4th, Human Kinetics USA

Braddock D. (1999) Aging and developmental disabilities: Demographic and policy issues affecting American families. Mental Retardation. 4: 155-161

Beange H, McElduff A, Baker W. (1995) Medical disorders of adults with mental retardation: A population study. American Journal on Mental Retardation. 99: 595-604

Climstein M, Pitetti KH, Barrett PJ, Campbell KD. (1993) The accuracy of predicting treadmill VO₂max for adults with mental retardation, with and without Down's syndrome, using ACSM gender- and activity-specific regression equations .Journal of Intellectual Disability Research. (6):521-31.

Cooper CB, Storer TW. (2001) Exercise Testing and Interpretation: A practical approach. 1st ed. Cambridge. Cambridge University Press

Crespo CJ, Ainsworth BE, Keteyian J, Heath GW, Smit E (1999) Prevalence of physiological activity and it's relation to social class in U.S. adults: Results from the 3rd National Health and Nutritional Examination Survey 1988-1994. Medicine and Science in Sports and Exercise. 31: 1821-1827

Croce RV, Pitetti KH, Horvat M, Miller J. (1996) Peak torque, average power, and hamstrings/quadriceps ratios in nondisabled adults and adults with mental retardation. Archives of Physical and Medical Rehabilitation. 77(4):369-72.

Eberhard Y, Eterradossi J, Foulon T, Groslambert P. (1993) Changes in plasma lipoproteins in adolescents with trisomy 21 in response to a physical endurance test]. Pathology and Biology (Paris). 41(5):482-6

Fletcher GF, Balady G, Blair SN, Blumenthal J, Caspersem C, Chaitman B, Epstein B, Sivarajan S, Froelicher ES, Froelicher VS, Pina IL, Pollack ML. (1996). Statement on exercise: benefits and recommendations for physical activity programs for all Americans. A statement for health professionals by the Committee on Exercise and Cardiac Rehabilitation of the Council on Clinical Cardiology, American Heart Association. Circulation. 15: 857-862

Fernhall B, McCubbin JA, Pitetti KH, Rintala P, Rimmer JH, Millar AL, De Silva A. (2001) Prediction of maximal heart rate in individuals with mental retardation. Medicine and Science in Sports and Exercise. 33: 1655-60

Fernhall B, Otterstetter M. (2003) Attenuated responses to sympathoexcitation in individuals with Down Syndrome. Journal of Applied Physiology. 94: 2158-2165

Fujiura GT. (1998) Demography of family households. American Journal on Mental Retardation. 103: 225-235

Guerra M, Llorens N, Fernhall B. (2003) Chronotropic incompetence in persons with down syndrome. Archives of Physical and Medical Rehabilitation. 84:1604-8

Hakkinen K, Alen M, Komi PV. (1985) Changes in isometric force-and relaxation time, electromyographic and muscle fibre characteristics of human skeletal muscle during strength training and detraining. Acta Physiologica Scandanavia. 125: 573-585

Heinonen A, Kannus P, Sievnan H, Pasanen M, Oja P, Vuori I. (1999) Good maintenance of high-impact activity-induced bone gain by voluntary, unsupervised exercises: An 8-month follow-up of a randomized controlled trial. Journal of Bone Mineral Research. 14: 25-8

Heller T, Hsieh K, Rimmer JH. (2004) Attitudinal and psychosocial outcomes of a fitness and health education program on adults with down syndrome. American Journal of Mental Retardation. 109(2)175-85

Hikuri HV, Jokinen V, Syvanne M, Niemenen MS. (1999) Heart rate variability and progression of coronary atherosclerosis. Arteriosclerosis Thrombosis and Vascular Biology. 19: 1979-1985

Jones AM, Carter H. (2000) The effects of endurance training on parameters of aerobic fitness. Sports Medicine. 29: 373-386

Kronhead AC, Moller M (1998) Effects of physical exercise on bone mass, balance skill and aerobic capacity in women and men with low bone mineral density, after one year of training--a prospective study. Scandanavian Journal of Medicine and Science in Sports. 8: 290-298

Kubukeli ZN, Noakes TD, Dennis SC. (2002) Training techniques to improve endurance exercise performances. Sports Medicine. 32: 489-509

Martin JE, Dubbert PM. (1985) Adherence to Exercise. Exercise and Sports Science Reviews. 13 : 137-164

Martnsen EW (1993) Therapeutic implications of exercise for clinically anxious and depressed patients. International Journal of Sports Psychology. 24: 185-199

Matsumoto T, Miyawaki T, Ue H, Kanda T, Zenji C, Moritani T. (1999) Autonomic responsiveness to acute cold exposure in obese and non obese young women. Int J Obesity Related Metabolic Disorders. 23: 793-800

Millar AL, Fernhall B, Burkett LN. (1993) Effects of aerobic training in adolescents with Down syndrome. Medicine and Science in Sports and Exercise. 25: 270-274

Monteiro CP, Varela A, Pinto M, Neves J, Felisberto GM, Vaz C, Bicho MP, Laires MJ. (1997) Effect of an aerobic training on magnesium, trace elements and antioxidant systems in a Down syndrome population. Magnesium Research. 10: 65-71

Noakes TD. (2001) Lore of running. 5th edition. Human Kinetics USA

Pastore E, Marino B, Calzolari A, Digilio MC, Giannotti A, Turchetta A. (2000) Clinical and cardiorespiratory assessment in children with Down syndrome without congenital heart disease. Archives of Pediatric and Adolescent Medicine. 4:408-410

Peran S, Gil JL, Ruiz F, Fernandez-Pastor V. (1997) Development of physical response after athletics training in adolescents with Down's syndrome.
Scandanavian Journal of Medicine and Science in Sports. 7:283-288

Pomeranz B, MaCauly RJ, Caudill MA. (1985) Assessment of autonomic function in humans by heart rate spectral analysis. Journal of Applied Physiology. 248: 151-153

Rimmer JH, Heller T, Wang E, Valerio I. (2004) Improvements in physical fitness in adults with Down syndrome. American Journal of Mental Retardation. 2: 165-174.

Robinson JL, Rogers MA. (1994) Adherence to exercise programs: Recommendations. Sports Medicine. 17: 39-52

Robergs RA, Landwher R. (2002) The surprising history of the "HRmax = 220-age" equation. Journal of Exercise Physiology. 5: 1-10

Sale DG (1988). Neural adaptations to resistance training. Medicine and Science in Sports and Exercise. 20: 135-145

Stewart KJ, Bacher AC, Hees PS, Tayback M, Ouyang P, Jan de Beur S. (2005) Exercise effects on bone mineral density relationships to changes in fitness and fatness. American Journal of Preventative Medicine. ;28:453-460

Tsimaras V, Giagazoglou P, Fotiadou E, Christoulas K, Angelopoulou N. (2003) Jog-walk training in cardiorespiratory fitness of adults with Down syndrome. Perception and Motor Skills. 96:1239-1251.

Ulrich DA, Ulrich BD, Angulo-Kinzler RM, Yun J. (2001) Treadmill training of infants with Down's Syndrome: Evidence based developmental outcomes. Pediatrics. 108: 1-7

Varela AM, Sardinha LB, Pitetti KH. (2001) Effects of an aerobic rowing training regimen in young adults with Down syndrome. American Journal of Mental Retardation. 106: 135-144

Wankel LM. (1993) The importance of enjoyment to adherence and psychological benefits from physical activity. International Journal of Sports Psychology. 24: 151-169

Wang WY, Chang JJ. (1997) Effects of jumping skill training on walking balance for children with mental retardation and Down's syndrome. Kaohsiung Journal of Medical Science. 13:487-495.

Wang WY, Ju YH. (2003) Promoting balance and jumping skills in children with Down syndrome. Perception and Motor Skills. 94: 443-448

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