URJHS Volume 8

Athletic Participation Limitations of the Down’s Syndrome Population

Heather L. Orndorff
California University of Pennsylvania

Abstract

The Special Olympics is a sporting event that has been designed for people with intellectual disabilities including Down’s syndrome. Besides having a different body structure, these special population athletes are unable to perform to the capabilities of an individual without an intellectual disability. Thus they are unique athletes and require different management of athletic injuries and athletic participation from athletic trainers. The purpose of this paper was to state behavioral and cognitive capabilities, atlantoaxial and cervical abnormalities, exercise capacities, and cardiac disease of the Down’s syndrome population and how they affect exercise.

Behavioral and Cognitive Capabilities

People with Down’s syndrome have differences in their adaptive behavior that are learned during the developmental period of life (Lavay, Reid, & Cressler-Chaviz, n.d.). In addition to Down’s syndrome, they may be diagnosed with additional behavioral disabilities such as autistic spectrum disorder (ASD) (Einfield et al., 2006, Ghosh, Shah, Dhir, & Merchant, 2008; Kent, Evans, & Sharp, 1999). ASD is a disorder that impairs social skills, communication skills, and behavioral patterns that place a large demand on parents, teachers, and the society (Ghosh et al., 2008; Kent et al., 1999). It was reported that males were more commonly diagnosed with the combination at a 9 percent occurrence rate (Kent et al., 1999). This puts this population at risk for community residential placement, reduced occupational opportunities, and restriction in participation of recreational and educational programs (Einfield et al., 2006).

Due to their diagnosis, many individuals with Down’s syndrome have abnormal behaviors. These behaviors included poor eye contact, no babbling as a toddler, no interaction with other kids, preference for their own company, lack of creativity, and difficulty in making friends (Ghosh et al., 2008; Kent et al., 1999). In more severe cases they were unable to feed themselves, did not like changes in daily routine, did not start walking until three years of age, and started talking at four years of age. It is common to see individuals in this population partake in repetitive behaviors such as rocking back and forth, grinding their teeth, turning in circles, sucking their thumb, and staring at their fingers (Ghosh et al., 2008). These children also put themselves at risk with self-injury behavior including head banging, poking their fingers into their eyes, eating inedible items, and hitting themselves. Self-injury behavior could potentially harm the individual since many people with Down’s syndrome have cervical instabilities.

Atlantoaxial and Cervical Instabilities

Most injuries to this population occur between the junction of the first and second cervical vertebrae (C1 and C2) and involve the laxity of the transverse ligament (Cooke, 1984; Masuda et al., 2003; Au-Yong, Boszczyk, Mehdian, & Kerslake, 2008). The transverse ligament becomes lax due to generalized laxity to all joints or degeneration of the ligament secondary to Down’s syndrome (Masuda et al., 2003; Elliot, Morton, & Whitelaw, 1988). Bony immaturity causes the odontoid process or peg to be unable to grow tall enough to reach the upper edge of the atlas (Masuda et al., 2003; Elliot et al., 1988). The odontoid peg will slip underneath the transverse ligament causing a possible dislocation or instability (Au-yong et al., 2008). At the conclusion of diagnostic imaging, a measurement that exceeds 4 mm between the posterior-inferior aspect of the anterior arch of the atlas and the nearest adjacent surface of the odontoid peg is considered to be significant and abnormal (Elliott et al., 1988). This condition affects 10 – 20 percent of people living with Down’s syndrome (Cooke, 1984; Masuda et al., 2003; Au-Yong et al., 2008; Elliot et al., 1988; Roy, Baxter, & Roy, 1990). Common signs and symptoms include change in gait or trouble walking, changes in bowel or bladder function, neck pain, limited range of motion, overactive reflexes, positive Hoffman and Babinski reflexes, and torticollis (Cooke, 1984, Masuda et al., 2003, Au-Yong et al., 2008, Roy et al., 1990). When participating in the Special Olympics, athletes with Down’s syndrome are unable to participate in sports that could potentially put them at risk for increased stress to the neck or cervical region such as gymnastics, swimming and diving, high jump, soccer, and pentathlon (Lavay et al., n.d.; Cooke, 1984). If a physician has reviewed diagnostic imaging and has found the atlantoaxial joint to be within normal limits, then these athletes have no limitations in sports participation. (Cooke, 1984). However, the amount of oxygen consumed during exercise in people with Down’s syndrome is lower than individuals without Down’s syndrome. This causes them to be unable to participate in lengthy exercise programs.

Exercise Capacities

When testing physical fitness, maximal oxygen uptake (VO 2 max) and heart rate have the most important impact on aerobic fitness (Armstrong & Welsman, 1994; Rimmer, Heller, Wang, & Valerio, 2004). VO 2 max is the highest rate during exercise in which an individual can consume oxygen (Armstrong & Welsman, 1994; Andreson & Godfrey, 1971). The mean maximal oxygen uptake was 50.0 ml/kg/min plus or minus 11.7 ml/kg/min in individuals without a form of cognitive disability (Myers, Walsh, Buchanan, & Froelicher, 1989). Males generally have a 12 percent increase in VO 2 max compared to females at the age of 10 and increases to a 37 percent increase at the age of 16 (Armstrong & Welsman, 1994). An average heart rate for adults not effected with Down’s syndrome during exercise would be around 191 beats per minute (Astrand & Saltin, 1961). When consuming the same amount of oxygen, all females, effected and non effected, have the tendency to have a higher heart rate than males and have a decrease in heart rate as height increases (Andreson & Godfrey, 1971).

People with Down’s syndrome consume about 24.6 ml ×kg -1 ×min -1 of oxygen which is about half of what an individual without Down’s syndrome consumes (Fernhall et al., 1996). Men with Down’s syndrome calculated at about 27.6 ml ×kg -1 ×min -1 whereas women calculated at about 22.2 ml ×kg -1 ×min -1. It has been stated that adult women with Down’s syndrome have the tendency to have VO 2 levels that relate to women that are twice their age (Rimmer et al., 2004). When standing alone, people with Down’s syndrome have a heart rate of 79 b ×min -1 that increases to about 119 b ×min -1 during exercise (Pitetti, 1992). On average, the peak heart rate is about 8-30 percent lower than age predicted (Fernhall, 1996). Because motivation and lake of effort put forth toward exercise are major factors influencing their target heart rate, not all results are accurate (Lavay et al., n.d.; Rimmer et al., 2004; Fernhall et al., 1996; Pitetti et al., 1992). People with Down’s syndrome are considerably shorter than the human beings without any medical diagnosis or complications as well as other individuals with some form of mental retardation (Lavay et al., n.d.). Due to the prevalence of obesity in this population, there is a concern that individuals will have a higher percent of body fat and less lean body muscle mass that influences their response to exercise (Lavay et al.; Rimmer et al., 2004; Fernhall et al., 1996; Pitetti et al., 1992).

Heart and blood vessel abnormalities, pulmonary hypoplasia, hypotonicity, narrowed aorta, and small nasal and oral cavities are some conditions that limit the capacity of exercise for this population (Lavay et al., n.d.; Rimmer et al., 2004; Fernhall et al., 1996; Pitetti et al., 1992). More commonly and importantly, congenital heart defects (CHD) are seen in a large population of infants born with Down’s syndrome (Freeman et al., 2008). On average, 41 percent of individuals born with Down’s syndrome have one or more major heart defect. Atrioventricular septal defect (AVSD), secundum atrial septal defect (ASDII), ventricular septal defect (VSD), and tetralogy of Fallot (TOF) are the most common and severe defects found in people with Down’s syndrome. Defects can arise from meiotic or mitotic origin and depend on the parent. Ninety-three percent of the defects were maternal meiotic errors, 4 percent were paternal errors, and 3 percent were mitotic. African American infants are twice as likely to be born with AVSD as compared to Caucasian, Hispanics were half as likely and compared to Caucasian and Asian had the smallest occurrence of AVSD. Women of Sub-Saharan Africa have a higher risk of having children with Down’s syndrome and AVSD. However, AVSD is more commonly seen in North America and Europe. Participating in exercise is beneficial if done within appropriate boundaries and does not put the person at risk of greater harm.

Benefits of Exercise

Since people with Down’s syndrome have less motivation to exercise and have lower levels of VO 2 max and heart rate, they are unable to exercise for the recommended time needed for them to maintain their ability to work, recreate, and perform self-care activities (Lavay et al., n.d.; Rimmer et al., 2004; Fernhall et al., 1996; Pitetti et al., 1992). They are also classified as having fitness levels equivalent to sedentary lifestyle, which relates to obesity rates (Fernhall et al., 1996). Because their levels are so much lower, they are considered to be a population at risk, and professionals are targeting this group to increase the participation of physical activity (Rimmer et al., 2004). When a Down’s syndrome person does decide to partake in physical activity, it is important to incorporate strength and cardiovascular conditioning into the regimen. These activities have less physiologic stress but will help them in conducting activities of daily living.

Summary

Physical activity is something that is very important for individuals in this population and needs to be incorporated into their lives. However, they are unable to participate in physical activity like an individual without Down’s syndrome due to their behavior capabilities, cervical instabilities, exercise capabilities, and cardiac disease. This is important because certified athletic trainers are not required to take adapted classes that teach them the management of these athletes. Certified athletic trainers will have difficulty talking and communicating if an injury arises. Many people with Down’s syndrome and a conjunction with ASD have the tendency to stare off into space, have low communication skills, cervical instabilities, and cardiac disease and are unable to participate in athletics for the same length of time as someone without Down’s syndrome. Certified athletic trainers need to be knowledgeable in this area so that cardiac disease and cervical instabilities can be screened in pre-participation exams to prevent further injury or death. Acute care management would also be different due to immobilization of the neck and poor communication skills.

References

Andreson, S. D., & Godfrey, S. (1971). Cardio-respiratory response to treadmill exercise in normal children. Clin Sci., 40, 433-442.

Armstrong, N., & Welsman, J. R. (1994). Assessment and interpretation of aerobic fitness in children and adolescents. Exerc Sport Sci Rev., 22, 435-476.

Astrand, P. O., & Saltin, B. (1961). Maximal oxygen uptake and heart rate in various types of muscular activity. J Apply Physciology, 16, 977-981.

Au-Yong, I., Boszczyk, B., Mehdian, H., & Kerslake, R. (2008). Spontaneous rotatory atlantoaxial dislocation without neurological compromise in a child with Down syndrome: a case report. Eur Spine J., 17 (2), 308-311.

Cooke, R. E. (1984). Atlantoaxial instability in individuals with Down’s syndrome. Adapted Physical Activity Quarterly, 1, 194-196.

Einfield, S. L., Piccinin, A. M., Mackinnon, A., Hofer, S. M., Taffe, J., Gray, K., Bontempo, D. E., Hoffman, L. R., Parmenter, T., & Tonge, B. J. (2006). Psychopathology in young people with intellectual disability. JAMA., 296 (16), 1981-1989.

Elliot, S., Morton, R. E., & Whitelaw, R. A. J. (1988). Atlantoaxial instability and abnormalities of the odontoid in Down’s syndrome. Archives of Disease in Childhood, 63, 1484-1489.

Fernhall, B., Pitetti, K. H., Rimmer, J. H., McCubbin, J. A., Rintala, P., Millar, A. L., Kittredge, J., & Burkett, L. N. (1996). Cardiorespiratory capacity of individuals with mental retardation including Down syndrome. Med Sc Sports Exerc., 28 (3), 366-371.

Freeman, S. B., Bean, L. H., Allen, E. G., Tinker, S. W., Locke, A. D., Druschel, C., Hobbs, C. A., Romitti, P. A., Royle, M. H., Torfs, C. P., Dooley, K. J., & Sherman, S. L. (2008). Ethnicity, sex and the incidence of congenital heart defects: a report from the national Down syndrome project. Genetics in Medicine, 10 (3), 173-180.

Ghosh, M., Shah, A. H., Dhir, K., & Merchant, K. F. (2008). Behavior in children with Down syndrome. Indian J of Ped., 75, 685-689.

Kent, L., Evans, J., Paul, M., & Sharp, M. (1999). Comorbidity of autistic spectrum disorder in children with Down syndrome. Developmental Medicine and Child Neurology, 41, 153-158.

Lavay, B., Reid, G.,& Cressler- Chaviz, M. (n.d.). Measuring the cardiovascular endurance of persons with mental retardation: a critical review. 263-290.

Masuda, K., Iwasaki, M., Seichi, A., Kitagawa, T., Nakajima, S., Kawaguchi, H., Ohnishi, I., & Nakamura, K. (2003). Cervical myelopathy in an adult due to atlantoaxial subluxation associated with Down syndrome: a case study. J of Orthopedic Sci., 8 (2), 227-231.

Myers, J., Walsh, D., Buchanan, N., & Froelicher, V. F. (1992). Can maximal cardiopulmonary capacity be recognized by a plateau in oxygen uptake? CHEST, 96, 1312-1316.

Pitetti, K. H., Climstein, M., Campbell, K. D., Barrett, P. J., & Jackson, J. A. (1992). The cardiovascular capacities of adults with Down syndrome: a comparative study. Med Sc Sports Exerc., 24 (1), 13-19.

Rimmer, J. H., Heller, T., Wang, E., & Valerio, I. (2004). Improvements in physical fitness in adults with Down syndrome. Am J on Mental Retardation, 109 (2), 165-174.

Roy, M., Baxter, M., & Roy, A. (1990). Atlantoaxial instability in down syndrome- guidelines for screening and detection. J of the Royal Society of Med., 83, 433-435.