Adapted Physical Activity Quarterly, 2011, 28, 326-341

2011 Human Kinetics, Inc.

The Effects of Swim Training on

Respiratory Aspects of Speech Production
in Adolescents With Down Syndrome
Amanda Faith Casey
St. Francis Xavier University

Claudia Emes
University of Calgary

Reduced respiratory muscle strength in individuals with Down syndrome (DS) may
affect speech respiratory variables such as maximum phonation duration (MPD),
initiation volume, and expired mean airflow. Researchers randomly assigned
adolescents with DS (N = 28) to either 12 weeks of swim training (DS-ST) or a
control group (DS-NT). Repeated measures MANOVA demonstrated a significant
increase in MPD for DS-ST participants from pretest to posttest, t(11) = 3.44, p =
0.006, that was not maintained at follow-up, t(11) = 6.680, p < .001. No significant
change was observed for DS-NT participants across time, F(2, 11) = 4.20, p =
0.044. The lack of long-term change in DS-ST participants may be related to the
relatively short training period.

Few published speech interventions feature individuals with Down syndrome

(DS; Roberts, Price, & Malkin, 2007) despite suggestions that individuals with DS
possess lower respiratory muscle strength than individuals without DS (Da Silva
et al., 2010). Decreased respiratory muscle strength has been shown to influence
speech production in different populations (Chiara, Martin, & Sapienza, 2007; Jones
et al., 2006; Sapienza, 2008), and it is possible that the respiratory support needed
for speech might be compromised among individuals with DS as well (Dodd &
Thompson, 2001; Miller & Leddy, 1998).
Different factors have been advanced to explain why individuals with DS may
experience reduced respiratory muscle strength (Da Silva et al., 2010). Increased
obesity (Rubin, Rimmer, Chicoine, Braddock, & McGuire, 1998) and an inactive
lifestyle (Shields, Dodd, & Abblitt, 2009) might both play a role while muscle
hypotonia has also been found to varying degrees in this population (Gauld, Boyn-
ton, Betts, & Johnston, 2005; Miller, Leddy, & Leavitt, 1999; Ronchi, Antunes,
& Fioretto, 2008). It is plausible that any lack of muscle tone and reduced ability

Amanda Faith Casey is an assistant professor at St. Francis Xavier University in Antigonish, Nova
Scotia, Canada. This research was conducted at the University of Calgary. Claudia Emes is with the
Faculty of Kinesiology at the University of Calgary in Alberta, Canada.

326
 Effects of Swim Training 327

to control muscle stiffness may affect the phonation, resonation, articulation, and/
or prosody of speech (Miller et al., 1999). Indeed, the harshness, hoarseness, and
gruffness of voice observed in individuals with DS (Groves & Gray, 1985; Van
Riper & Erickson, 1996) could originate from the muscular fatigue caused by the
excessive effort required to activate hypotonic laryngeal muscles (Pryce, 1994).

Respiratory Muscle Training

Respiratory muscle training (RMT) targets improvement in the efficiency of the
respiratory system by strengthening the inspiratory and/or expiratory muscles (Celli,
1998; Kim & Sapienza, 2005; Weiner, Magadle, Beckerman, & Beray-Yanay, 2003).
As such, RMT has been used to rehabilitate speech and voice disorders in diverse
populations (Chiara et al., 2007; Sapienza, 2008). Jones et al. (2006) examined
the effects of expiratory muscle training on a single participant diagnosed with
dysarthria due to Lance Adams syndrome because they believed their participants
perceptually deviant speech signs owed to deficits in respiratory laryngaenial speech
subsystems. Results indicated an increase in maximum phonation duration (MPD)
for the vowel /a/ immediately after treatment finished although this increase was not
sustained at follow-up. It remains undetermined whether individuals with DS, who
may also have dysarthric speech profiles (Hamilton, 1993; Kumin, 2006; Miller &
Leddy, 1998; Roberts et al., 2007) and deficits in respiratory laryngaenial speech
subsystems (Venail et al., 2004) stand to benefit from RMT aimed at influencing
respiratory aspects of speech production (Sapienza, 2008).

Sports Training
Regular participation in certain endurance sports could provide a means to train
the respiratory muscles (Voliantis et al., 2001; Wylegala, Pendergast, Gosselin,
Warkander, & Lundren, 2007) while simultaneously combating obesity and physical
inactivity (Ordonez, Rosety, & Rosety-Rodriguez, 2006). Limited sports training
interventions, meeting recommended guidelines for health benefits, have been
conducted on individuals with DS (Dodd & Shields, 2005). Aquatic exercise offers
benefits for people with various disabilities (Yilmaz et al., 2009), and recent work
on competitive athletes suggests that participation in swim training (ST) may also
promote increased respiratory muscle strength (Wells, Plyley, Thomas, Goodman,
& Duffin, 2005). ST allows for both variable loading and quantifiable intensity,
which may achieve the same outcomes as the pressure threshold trainer devices
currently used for RMT (Mickleborough et al., 2008). Whereas RMT devices often
focus solely on either inspiration or expiration, ST offers near flow independent
resistance to both inspiration and expiration and can be used for both endurance
and strength paradigms (Lomax & McConnell, 2003).
Research has yet to examine the effects of ST on respiratory aspects of speech
production among populations with voice and speech disorders. As with speech,
swimming breathing patterns require phases of rapid inspirations and prolonged
expirations (Hixon & Hoit, 2005). A swimmers immersion in the water during
front-crawl forces her or him to coordinate breathing with stroke mechanics because
physiological necessity often dictates when the former occurs, especially among
inexperienced swimmers (Lomax & McConnell, 2003). It is possible, however, to
328 Casey and Emes

train swimmers to reach a level where they control their breathing and enter into
what Mickleborough et al. (2008) labeled an obligatory controlled frequency
breathing pattern. Such a trained respiratory pattern involves a more rapid inhala-
tion with greater lung volumes and a relatively prolonged exhalation, which may
lead to improved stroke mechanics and reduced drag by increasing buoyancy and
contributing to an elevated body position in the water. Once a swimmers face rises
above the water, rapid inspiration necessitates inspiratory muscle shortening at a
higher velocity, placing increased demand upon the inspiratory muscles (Lomax
& McConnell, 2003; Rodriguez, 2000).
By providing sufficient ST in terms of frequency, intensity, and duration (Dodd
& Shields, 2005), it may be possible for individuals with DS to improve the capacity
of the respiratory muscles and reach an ability level at which an obligatory controlled
frequency breathing pattern occurs (Mickleborough et al., 2008). By increasing the
endurance of the respiratory muscles, individuals with DS might be able to sustain
their effort for longer without tiring (Wylegala et al., 2007). In terms of speech, this
may translate into a decrease in inspiratory time and consequently a reduction in
the pause time between utterances (Hixon & Hoit, 2005). ST focusing on breathing
techniques may therefore be used not only to improve the performance of athletes
(Mickleborough et al., 2008), but also aid individuals with DS who experience a
compromised respiratory system and difficulty with speech production.

Speech Respiratory Variables (SRV)

Speech respiratory variables (SRV) such as maximum phonation duration (MPD),
initiation volume, and mean expired airflow may be used to assess the impact of
ST on individuals with DS as they provide an indication of respiratory support
for speech (Solomon, Garlitz, & Milbrath, 2000). Voice pathologists stress the
importance of measuring MPD in clinical settings as it is a relatively noninvasive
measurement that provides an overall indication of vocal functioning (Speyer et
al., 2008). MPD is measured as the greatest length of time over which phonation
can be sustained for a vowel sound. Research shows MPD to be correlated with
both expired mean airflow and initiation volume in different populations (Pratha-
nee, Watthanathon, & Ruangjirachuporn, 1994). For a given phonation volume,
different MPD values will be obtained depending on the airflow or time derivative
of volume (Kent, Kent, & Rosenbek, 1987). Previous studies providing normative
data on each of the SRVs have, however, demonstrated differences based on gender
(Colton & Casper, 1990).

Purpose
The purpose of this study was to address (a) how adolescents with DS fare in com-
parison with normative data collected on individuals without DS with regard to
three SRVsMPD (sec), initiation volume (ml), and expired mean airflow (ml/sec);
(b) the effects of a 12 week ST intervention on SRV in adolescents with DS (DS-
ST) compared with a control group (DS-NT); and (c) whether DS-ST participants
could pass the Swim to Survive Standard test based on the guidelines of the Royal
Lifesaving Society of Canada (2009) following participation in the ST intervention.
 Effects of Swim Training 329

Method
Procedures
Researchers recruited 28 participants (Mean Age = 14.6 years, SD = 1.9) through
advertisement in a newsletter distributed to over 200 families of individuals with
DS. Participants were randomly assigned to either a 12-week ST intervention
(DS-ST; six females, eight males) or a control group (DS-NT; six females, eight
males). Although DS-NT participants did not take part in any intervention during
the course of the study, they continued with their usual daily activities. By chance,
at baseline pretest, there was no significant difference in age between the randomly
selected DS-ST (M = 14, SD =1.56) and DS-NT (M = 15, SD =1.98) participants (p
= 0.171). Participants originated from a single Canadian city (White = 26; Asian-
Canadian = 1; First Nation = 1) and diverse socioeconomic strata (SES; low SES
= 2; medium SES = 14; high SES = 12).
Adolescents with DS were excluded from the study if they had any underly-
ing health condition that prevented participation or if they belonged to any other
exercise or speech interventions (Casey, Rasmussen, MacKenzie, & Glenn, 2010).
No attempt was made to include or exclude participants based on prior swimming
ability or on the distinction of mosaicism, translocation, or trisomy 21 while acqui-
sition of participants IQ scores was also beyond the scope of this study. Research-
ers outlined testing procedures, potential benefits, associated risks, and the time
required for the study in an information letter and discussion session prepared for
participants and their parents and/or guardianswho provided signed informed
consent. DS-NT participants were offered free of charge the same 12-week ST
intervention following the completion of the research. The institutional research
ethics board provided approval before the commencement of the study.

Measurements
Sustained Vowel /a/ Prolongation Test. All participants underwent the same
measurement procedures for SRV at pretest, posttest, and 12 weeks following
the completion of the ST intervention. The sustained vowel /a/ prolongation test
assesses respiratory aspects of speech production including each participants
MPD (sec), initiation volume (ml), and expired mean airflow (ml/sec) using a
phonetic unit segment. For testing, each participant sat upright in a chair and was
asked to perform relaxation, isovolume, and vital capacity maneuvers for calibra-
tion, according to standard kinematic method (Hixon et al., 1973). Participants
were shown their respiratory response on a computer screen and instructed to
sustain the vowel /a/ for as long as possible (Koike & Hirano, 1968) at a com-
fortable pitch and loudness into a facemask attached to a speech pneumotach
(Parvo Medics TrueMax 2400), which had been calibrated with a 3-L syringe
(5 repetitions) before testing. The pressure transducer transmitted data to the
metabolic cart and measurement software. To ensure reliable measurement, each
participant repeated the task three times (Speyer et al., 2008) with the longest
MPD and its inspiration and expired mean airflow values used for further analysis
(Iwata, Von Leden, & Williams, 1972; Prathanee et al., 1994; Terasawa, Hibi, &
Hirano, 1987). The same technicians performed measurements for both groups
330 Casey and Emes

and did not have a preestablished relationship with any participant or knowledge
of group composition.
Swim to Survive Standard. The swimming ability level of all DS-ST participants
was assessed at the beginning and end of the intervention based on the guidelines
of the Royal Lifesaving Society of Canada (2009), which required participants
to complete the following skills unassisted: roll into deep water, tread water for
one minute, and also swim for 50 m. These standards were used to assess the
effectiveness of ST, although the intervention began for all DS-ST participants
regardless of whether they passed the pretest Swim to Survive Standard or prior
swim experience.

Swim Training Intervention

DS-ST participants attended three one-hour sessions per week over a period of 12
weeks. Each ST session occurred in a competitive-size, indoor 25 m pool (78 F)
in the presence of certified lifeguards, three swim coaches who had all been certi-
fied by the Canadian national coaching certificate program (NCCP Level 1), and
also three adolescent peer instructors with DS. To ensure maximum participation,
nationally certified coaches implemented motivational strategies including verbal
reinforcement (e.g., cheering and positive feedback) and physical praise (e.g., high-
fives). Participants also trained in the same pool in swim lanes alongside members
of a local competitive swim team to provide a visual image of an on-going sports
training environment (Casey et al., 2010).
The intervention followed the competitive swim model adapted (Crowley,
2005; Maglischo, 2003). Coaches taught participants only one-stroke, front-crawl,
and focused on breathing by emphasizing 1-2-3 Breathe techniques to increase
sustained expiration and short inspiration by training respiratory muscles. Flutter-
boards were provided for assistance. As recommended by Hixon and Hoit (2005)
in the domain of speech, the load of RMT involved in learning to breathe was
raised incrementally as the study progressed by gradually increasing the volume of
training (Ordonez et al., 2006). Participants initially swam as little as 50 m or less
per session assisted, but by the end of the intervention, completed approximately
1000 m per session. See Figure 1 for complete intervention plan.

Data Analysis
To assess the effects of the intervention on selected SRV, data were analyzed by a
repeated measure multivariate analysis of variance (MANOVA) using SPSS statisti-
cal software (Statistical Package for Social Sciences 15.0, SPSS Inc., Chicago, IL)
and R-project (R-project, R Development Core Team, Version 2.12.0). A repeated
measure MANOVA allows us to analyze SRV as dependent variables as well as
identifying patterns for three time points (pretest, posttest, and follow-up tests)
simultaneously. MANOVA was used to examine the effects of time (pretest, post-
test, follow-up), intervention (DS-ST, DS-NT), and gender (female, male) on SRV
(MPD, initiation volume and expired mean airflow). A multivariate approach was
preferred over a univariate approach (ANOVA) because the sphericity assumption
was violated in our data. When the sphericity assumption is violated in a univariate
analysis, it markedly affects the true Type I error rates and power. A MANOVA
Figure 1 Complete 12-week swim training intervention plan.

331
332 Casey and Emes

does not assume sphericity (Maxwell & Delaney, 2004; OBrien & Kaiser, 1985).
Using \a\ as the number of levels for repeated measures, the recommended sample
size was 12 (a + 10; a = 2; 2 + 10 = 12), indicating that with a final sample of 26
(DS-ST = 12; DS-NT = 14), we had a moderately large sample size to conduct
MANOVA (Cohen, 1977; Stevens, 1990). ANOVA follow-up tests (planned com-
parisons) were later conducted to analyze findings further using the Bonferroni
adjustment to maintain the Type I error rate at the 0.05 level.

Results
Normative Data
Table 1 shows the comparison between normative data collected on both sexes
without DS (Finnegan, 1985; Peppard, Bless, & Milenkovic, 1988; Wilson & Starr,
1985; Yanagihara & Koike, 1967) and participants with DS at baseline pretest
(nonage/gender matched). There were significant differences for both females and
males in terms of MPD and initiation volume, but no significant differences for
expired mean airflow. No significant differences were found between DS-ST and
DS-NT participants in terms of MPD (p = 0.165), initiation volume (p = 0.327),
or expired mean airflow (p = 0.642) at pretest.

Speech Respiratory Variables (SRV)

Two DS-ST male participants completed the 12-week ST intervention and also
the Swim to Survive Standard tests but did not attend post or follow up testing
so were not included in the data set for SRV analysis. Table 2 presents the mean
and standard deviation for MPD, initiation volume, and expired mean airflow for
DS-ST and DS-NT participants at pretest, posttest, and follow-up for the sustained
phonation /a/ test. A moderate correlation existed between SRV at each time point.
Therefore, we conducted repeated measures MANOVA to evaluate the effects of
ST on three SRV simultaneously. Results showed that the ST intervention did not
have a significant effect on SRV, F(1, 22) = 1.83, p = 0.19. However, gender did
have significant effect on SRV, F(1, 22) = 11.77, p = 0.0024, and the interaction
effect of the ST intervention and gender was also significant, F(1, 22) = 5.75, p =
0.025, suggesting that the ST intervention affected the gender difference. There-
fore, we examined further each dependent variable individually through repeated
measures MANOVA.

Maximum Phonation Duration (MPD)

Repeated measures MANOVA demonstrated that the main effect of gender was not
significant for MPD, F(2, 21) = 0.93, p = 0.088. The main effect of time was signifi-
cant, F(2, 21) = 27.79, p < .001, as well as the interaction for time intervention,
F(2, 21) = 13.25, p < .001, 2 = 0.56. Further analysis revealed a significant effect
of time for DS-ST, F(2, 9) = 22.71, p < .001, but no effect of time for DS-NT, F(2,
11) = 4.20, p = 0.044. Paired t tests between each time factor for DS-ST revealed a
significant 1-tailed result between pre and posttests, t(11) = 3.44, p = 0.006. There
was also a significant result between posttest and follow-up, t(11) = 6.680, p < .001.
 Table 1 Normative Means and Standard Deviations for Speech Respiratory Variables During Sustained
Phonation /a/ at a Comfortable Pitch and Loudness Compared With Participants With Down Syndrome
Norm Females DS Females DS Males
Mean (n = 12) Mean Significance Norm Males (n = 14) Significance
Variable Source(s) (SD) (SD) Females Mean (SD) Mean (SD) Males
Maximum Finnegan 19(4.84) 12(1.16) p < 0.001 22(6.22) 15(4.68) p < 0.001
Phonation (1985)
Duration (sec)
Initiation Yanaghara & 2146(345) 720(164) p < 0.001 3256(602) 877(209) p < 0.001
Volume (ml) Koike (1967)
Expired Mean Peppard, 116(26) 131(23) p = 0.171 N/A N/A N/A
Airflow (ml/sec) Bless, & N/A N/A N/A 183(54) 172(78) p = 0.642
Milenkovic,
(1988); Wilson
& Star (1985)
Note. DS, Down syndrome; N/A, Not applicable; Finnegan (1985) examined females aged 1217 years (n = 60) and males aged 1217 years (n = 60); Yanaghari and
Koike (1967) examined females aged 2140 (n = 11) and males aged 3043 (n = 11); Peppard, Bless, and Milenkovic (1988) examined females aged 1630 (n = 10);
Wilson and Starr (1985) examined males aged 1926 (n = 25).

333
334
Table 2 Mean, Standard Deviations, and Paired t Test Results for Speech Respiratory Variables During
Sustained Phonation /a/ at Pretest, Posttest, and Follow Up
Group and Pretest Mean Posttest Follow Up Pretest vs. Posttest Pretest vs. Follow-up Posttest vs. Follow-up
Variable (SD) Mean (SD) Mean (SD) Paired t (p-value) Paired t (p-value) Paired t (p-value)
DS-ST
MPD 12 (1.48) 15 (2.99) 12 (1.68) 3.4418 (0.006) NS 6.6797 (3.47E-05)
IV 749 (188) 805 (136) 684 (295) NS NS NS
EMA 122 (27) 152 (30) 156 (48) 2.8468 (0.015) 2.578 (0.025) NS
DS-NT
MPD 14 (4.97) 13 (5.34) 13.6(5.06) NS NS NS
IV 853 (332) 808 (228) 857 (245) NS NS NS
EMA 166 (131) 158 (47) 166 (77) NS NS NS
Note. DS-ST, Swim training group; DS-NT, Control group; MPD, Maximum phonation duration; IV, Initiation volume; EMA, Expired mean airflow; NS, No significance.
 Effects of Swim Training 335

No significance was found between pretest and follow-up test in MPD for DS-ST,
t(11) = 1.97, p = 0.075. Therefore, MPD increased at posttest but returned to baseline
at follow-up for the DS-ST group.

Initiation Volume
Using repeated measures MANOVA, the only main effect found to be significant
was with regards to gender, F(1, 22) = 10.02, p = 0.004. The two-way interaction
group gender was also significant, F(1, 22) = 4.34, p = 0.049. Further analysis
on the main effect of gender revealed no significant effect of gender for the DS-ST
group, F(1, 10) = 0.569, p = 0.468, but a significant effect of gender for the DS-NT
group, F(1, 12) = 11.33, p = 0.006. The mean scores also indicated initiation volumes
were lower for females (M =720, SD =165) than for males (M = 877, SD = 209).

Expired Mean Airflow

Results indicated no significant findings for time, group, and/or gender.

Swim to Survive Standard

At pretest baseline only two DS-ST participants attained the Swim to Survive
Standard. By the end of the study, however, all DS-ST swimmers passed the same
test and swam 500 m with a flutter board by either eight or twelve weeks. Six
participants also completed an additional 200 m front-crawl breathing every three
strokes without the flutter board during the final week of the intervention.

Discussion
The purpose of this study was to (a) compare SRV data in adolescents with DS to
normative data on the general population, (b) examine the impact of a ST interven-
tion on SRV in adolescents with DS, and (c) assess whether adolescents with DS
could pass the Swim to Survive Standard. Findings suggest that (a) adolescents
with DS may have difficulty with initiation volumes and prolonged expiration
for vowel /a/ at a normal expired mean airflow; (b) DS-ST participants improved
MPD significantly compared with DS-NT participants, although this improvement
was not sustained at follow-up; (c) by the end of the study, all DS-ST participants
completed the Swim to Survive Standard test.

Implications of the Study

Findings from the comparison of SRV in adolescents with DS to normative data on
individuals without DS concur with previous research, indicating that individuals
with DS may have a compromised respiratory system for speech (Dodd & Thomp-
son, 2001; Miller & Leddy, 1998; Roberts et al., 2007). Adolescent participants fell
significantly below normative values for both MPD (Finnegan, 1985) and initiation
volume (Yanagihara & Koike, 1967), although this was not the case for expired
mean airflow (Peppard et al., 1988; Wilson & Starr, 1985). These results support
findings suggesting that individuals with DS have significantly reduced respiratory
336 Casey and Emes

muscle strength compared with the norm (Da Silva et al., 2010). This may not impact
attempts to produce short utterances as at normal loudness, a mere 25% of total
lung capacity is sufficient for normal expiration (Lass, 1996). For longer speech,
however, individuals with DS must use muscles actively to inhale more deeply as
the inspiration phase increases with lung volumes ranging from four to five liters
(Bailey & Hoit, 2002). Therefore, compared with people without DS, adolescents
with DS may be more inclined to produce short rather than long utterances. Ado-
lescent boys with DS did have significantly greater initiation volume than girls
with DS, although this may be expected in light of findings that show males tend
to have 2025% more lung capacity than females do (Plowman & Smith, 2007).
The randomized control trial showed that DS-ST participants may increase
MPD following involvement in an ST intervention. Similarly, Jones et al. (2006)
demonstrated that with sufficient training, individuals with dysarthric speech profiles
may learn to sustain the expiration phase needed for improved speech production.
In our study, a clinically significant increase in MPD may suggest that swimmers
with DS learned how to use their abdominal and intercostals muscles to control
the exhalation and force length for both swimming and for sustained phonation
by posttest. Although participants are liable to modify their behavior as a result
of involvement in the study, researchers believe these changes are more likely to
be related to the intervention rather than extraneous factors such as repeated test-
ing, familiarity with testing procedures, experimental setting, or the experimenter
(Ramig et al., 2001). No change was documented for the randomly selected control
group who worked with the same experimenters during measurements even if
DS-NT participants did not have as much experience in the research environment
as DS-ST participants by the end of the intervention.
Findings demonstrated no overall significant change in initiation volume or
expired mean airflow for the DS-ST group following training. The lack of sig-
nificant change in initiation volume for DS-ST participants may be due to lack of
ST experience highlighted by the pretest Swim to Survive Standard results. It is
possible that the 12-week training period was too short for participants to reach a
sufficient ability level for what Mickleborough et al. (2008) deemed an obligatory
controlled frequency breathing pattern to occur.

Limitations of the Study

A primary issue with interpretation of sustained vowel /a/ performance is the
availability of good quality normative data. The lack of aged matched data and
more recent normative values must be taken into consideration when interpreting
results, especially in light of changes in physical activity and obesity levels among
the general population over the past twenty years (Haslam & James, 2005). Conse-
quently, more research may be warranted in this area, especially among adolescents.
Nevertheless, collection procedures and instrumentation in this current study largely
followed methods used to obtain normative data on large samples of individuals
without DS in the past (Kent, Kent, & Rosenbek, 1987). Furthermore, for sustained
vowel /a/ tasks, the basic procedure is the same regardless of the specific software
used to display the waveforms and measure the durations. As such, the normative
data reported is still considered practically useful in the clinical setting (Rvachew,
Hodge, & Ohberg, 2005).
 Effects of Swim Training 337

The criterion for implementing RMT among individuals with voice disorders
has not yet been ascertained experimentally in the area of speech (Sapienza, 2008).
More information on participants speech profiles would allow for a greater under-
standing of the effectiveness of the intervention as findings from strength training
paradigms imply that individuals who commence training programs at a lower level
of function may have a larger capacity for improvement (Powers & Howley, 2000).
This study did not have access to individual speech profiles, and participants were
not selected based on the presence or otherwise of speech impairments or degree
of dysarthria even though researchers knew participants had prior involvement in
speech therapy.
Exercise has been shown to affect cognitive abilities, sleep, and mood in the
pastall of which have been shown to improve the concentration of participants
(Reid et al., 2010). Therefore, changes in these particular variables and not the
measures tested may have contributed to the final outcomes. The ST environment
may have played a role as the indoor pool temperature was lower than is some-
times the case when working with people with disabilities. In addition, research-
ers did not directly measure respiratory muscle strengthening so the absence of
significant long-term change in SRV may have resulted from a lack of change in
DS-ST participants muscle strength. The length of study suggests that change in
MPD following ST may be attributed to enhanced neural recruitment rather than
changes in muscle fiber size (Wilmore & Cstill, 2005). Jones et al. (2006) proffered
an alternative explanation, however, by highlighting how detraining may occur
rapidly in populations with compromised muscle structure and physiology (Baker,
Davenport, & Sapienza, 2005).

Recommendations for Future Research

Training for a longer duration could have possibly increased the number of adap-
tations to the expiratory muscles among DS-ST participants. Therefore, ST may
warrant further exploration as an alternative therapy for training the respiratory
system for the purposes of speech production in place of measures already recom-
mended in this population (Kumin, 1994; Rosin & Swift, 1999). A competitive
ST program may prove cheaper and more readily available than current handheld
RMT devices (Sapienza, 2008). Individuals with disabilities may also garner addi-
tional benefits from ST that extend beyond certain respiratory aspects of speech
production (Yilmaz et al., 2009). It is plausible that ST may have provided further
health benefits including decreased obesity (Ordonez et al., 2006). To explore
the potential of ST further in this population, researchers recommend additional
investigation into appropriate methods for teaching people with various disabilities
how to swim. This study focused on one-stroke only at an early stage of athlete
development to promote consistency and repetition among swimmers with DS.
It differed from traditional swim programs such as the Red Cross Learn to Swim
model (Reid & ONeill, 1989) or the YMCA Learn-to-Swim program (Burpee &
McCuiag, 1993), which favor the acquisition of many skills first or learning many
strokes simultaneously.
Although no long-term significant changes in SRV followed the intervention,
all participants with DS attained the Swim to Survive Standard test. At the end
of this study, all participants, including members of the DS-NT group, who were
338 Casey and Emes

offered the same program after the completion of the initial study, wanted to con-
tinue their success in a sports training environment as all had passed the Swim to
Survive Standard (n = 26). This resulted in the formation of the Calgary Dolphins
competitive swim club that has since been recognized as a nonprofit parent run
body under the national governing organization of sport, Swim Canada. Further
research may examine whether a sustainable program of this nature offers long-
term benefits for individuals with DS and other disabilities.

Conclusion
This study suggests adolescents with DS may have difficulty with certain respira-
tory aspects of speech production compared with individuals without DS. The ST
intervention did not result in any significant long-term change in SRV according to
results from the randomized control trial. However, DS-ST participants increased
their MPD significantly between pre and posttest, although this was not sustained
at twelve weeks follow-up. The lack of long-term change may be explained by the
relatively short duration of the intervention especially in light of the participants
lack of ST experience. Future studies may consider training periods of longer
duration to counter possible detraining effects and the likelihood of participants
reaching an ability level where an obligatory breathing pattern occurs.

References
Bailey, F., & Hoit, J.D. (2002). Speaking and breathing in high respiratory drive. Journal
of Speech, Language, and Hearing Research: JSLHR, 45, 89100.
Baker, S., Davenport, P., & Sapienza, C. (2005). Examination of strength training and
detraining effects in expiratory muscles. Journal of Speech, Language, and Hearing
Research: JSLHR, 48, 13251333.
Burpee, A.D., & McCuiag, D.S. (Eds.). (1993). YMCA advanced swimming instructors
guide. Toronto: YMCA Canada.
Casey, A.F., Rasmussen, R., MacKenzie, S.J., & Glenn, J. (2010). Dual-energy X-ray
absorptiometry to measure the influence of a 16-week community-based swim training
program on body fat in children and adolescents with intellectual disabilities. Archives
of Physical Medicine and Rehabilitation, 91, 10541060.
Celli, B.R. (1998). Arm exercises and ventilation. Chest, 93, 673674.
Chiara, T., Martin, D., & Sapienza, C. (2007). Expiratory muscle strength training: Speech
production outcomes in patients with multiple sclerosis. Neurorehabilitation and Neural
Repair, 21(3), 239250.
Cohen, J. (1977). Statistical power analysis for the behavioral sciences. New York: Aca-
demic Press.
Colton, P.H., & Casper, J.K. (1990). Understanding voice problems: A physiological per-
spective for diagnosis and treatment. Baltimore: Williams and Wilkins.
Crowley, S. (2005). Bilateral breathing for young swimmers. Swimming technique. Retrieved
from http://officiatingswimming.com/images/pdf_bilateral_breathing.pdf.
Da Silva, V.Z., Barros, J.F., Azevedo, M., Godoy, J.R.P., Arena, R., & Cipriano, G. (2010).
Bone mineral density and respiratory muscle strength in male individuals with mental
retardation (with and without Down Syndrome). Research in Developmental Dis-
abilities, 31, 15851589.
 Effects of Swim Training 339

Dodd, B., & Thompson, L. (2001). Speech disorder in children with Down syndrome. Journal
of Intellectual Disability Research, 45, 308-316.
Dodd, K.J., & Shields, N. (2005). A systematic review of the outcomes of cardiovascular
exercise programs for people with Down syndrome. Archives of Physical Medicine
and Rehabilitation, 86, 20512058.
Finnegan, D.E. (1985). Maximum phonation time for children with normal voices. Folia
Phoniatrica, 37, 209215.
Gauld, L.M., Boynton, A., Betts, G.A., & Johnston, H. (2005). Spirometry is affected by
intelligence and behavior in Duchenne muscular dystrophy. Pediatric Pulmonology,
40, 408413.
Groves, J., & Gray, R. (1985). A synopsis of otolaryngology. Bristol, UK: John Wright & Sons.
Hamilton, C. (1993). Investigation of the artiuculatory patterns of young adults with Downs
syndrome using electropalatography. Down Syndrome Research and Practice, 1, 1
15-28.
Haslam, D.W., & James, W.P. (2005). Obesity. Lancet, 366, 11971209.
Hixon, T.J., Goldman, M.D., & Mead, J. (1973). Kinematics of the chest wall during speech
production: Volume displacements of the rib cage, abdomen, and lung. Journal of Speech
and Hearing Research, 16, 78115. Retrieved from http://jslhr.asha.org.
Hixon, T.J., & Hoit, J. (2005). Evaluation and management of speech breathing disorders:
Principles and methods. Tucson, AZ: Redington Brown.
Iwata, S., Von Leden, H., & Williams, D. (1972). Air flow measurement during phonation.
Journal of Communication Disorders, 5, 6779.
Jones, H.N., Donovan, N.J., & Sapienza, C.M. Shristastav, R., Fernandez, M.D. & Rosenbek,
J.C. (2006). Expiratory muscle strength training in the treatment of mixed dysarthriain
a patient with Lance-Adams syndrome. Journal of Medical Speech Language Pathol-
ogy, 14(3), 207-217. Retrieved from http://cengagesites.com/academic/?site=3802/
Kent, R.D., Kent, J.F., & Rosenbek, J.C. (1987). Maximum performance tests of speech
production. Journal of Speech and Hearing Disorders, 52, 367-387.
Kim, J., & Sapienza, C.M. (2005). Implications of expiratory muscle strength training in the
elderly. Journal of Rehabilitation Research and Development, 42, 211224.
Kumin, L. (1994). Communication skills in children with Down syndrome. Bethesda, MD:
Woodbine House.
Kumin, L. (2006). Speech intelligibility and childhood verbal apraxia in children with Down
syndrome. Down syndrome Research and Practice, 10(1), 10-22.
Koike, Y., & Hirano, M. (1968). Significance of vocal velocity index. Folia Phoniatrica,
20, 285296.
Lass, N.J. (1996). Experimental Phonetics. St Louis, MO: Mosby.
Lomax, M.E., & McConnell, A.K. (2003). Inspiratory muscle fatigue in swimmers after a
single 200m swim. Journal of Sports Sciences, 21, 659-664).
Maglischo, E.W. (2003). Swimming fastest: The essential reference on technique, training
and program design. Champaign, IL: Human Kinetics.
Maxwell, S.E., & Delaney, H.D. (2004). Designing experiments and analyzing data: A
model comparison perspective (2nd ed.). Mahwah, NJ: Lawrence Erlbaum Associates.
Mickleborough, T.D., Stager, J.M., Chatham, K., Lindley, M.A., & Ionescu, A.A. (2008).
Pulmonary adaptations to swim and respiratory muscle training. European Journal of
Applied Physiology, 103, 635646.
Miller, J.F., & Leddy, M. (1998). Down syndrome: The impact of speech production on
language development. In R. Paul (Ed.), Exploring the speech-language connection
(pp. 163177). Baltimore, MD: Brookes Publishing Co.
Miller, J.F., Leddy, M., & Leavitt, L.A. (Eds.). (1999). Improving the communication of
people with Down syndrome (pp. 41-60). Baltimore, MD: Paul H. Brookes Publishing.
340 Casey and Emes

Morris, A.F., Vaughan, S.E., & Vaccaro, P. (1982). Measurements of neuromuscular tone
and strength in Downs syndrome children. Journal of Intellectual Disability Research,
26, 4146.
OBrien, R.G., & Kaiser, M.K. (1985). MANOVA method for analyzing repeated measures
designs: An extensive primer. Psychological Bulletin, 97, 316333.
Ordonez, F.J., Rosety, M., & Rosety-Rodriguez, M. (2006). Influence of 12-week exercise
training on fat mass percentage in adolescents with Down syndrome. Medical Science
Monitor, 12, 416419. Retrieved from http://www.medscimonit.com/.
Pentz, A.L., & Moran, M.J. (1988). Voice Disorders in Down syndrome. The Journal of
Speech and Hearing Disorders, 12, 109117.
Peppard, R. Bless, D., & Milenkovic, P. (1988). Comparison of young adult singers and
non-singers with vocal nodules. Journal of Voice, 2, 250-260.
Plowman, S.A., & Smith, D. (2007). Exercise physiology for health, fitness and performance.
Philadelphia, PA: Lippincott Williams and Wilkins.
Powers, K.T., & Howley, E.T. (2000). Exercise physiology: Theory and application to fitness
and performance. New York: McGraw-Hill.
Prathanee, B., Watthanathon, J., & Ruangjirachuporn, P. (1994). Phonation time, phona-
tion volume and air flow rate in normal adults. Journal of the Medical Association
of Thailand, 77, 639644. Retrieved from http://www.mat.or.th/journal/current.php.
Pryce, M. (1994). The voice of people with Downs syndrome: An EMG biofeedback study.
Down syndrome. Research and Practice, 2, 106-111.
Ramig, L., Sapir, S., Fox, C., & Countryman, F. (2001). Changes in vocal loudness following
intensive voice treatment in individuals with Parkinsons disease: A comparison with
untreated patients and normal age-matched controls. Movement Disorders, 16, 7983.
Reid, G., & ONeill, K. (1989). Adapted aquatics: Promoting aquatic opportunities for all.
Toronto: ONT: The Canadian Red Cross Society.
Reid, K.J., Glazer Baron, K., Lu, B., Naylor, E., Wolfe, L., & Zee, P.C. (2010). Aerobic
exercise improves self-reported sleep and quality of life in older adults with insomnia.
Sleep Medicine, 11(9), 934940.
Roberts, J.E., Price, J., & Malkin, C. (2007). Language and communication development
in Down syndrome. Mental Retardation and Developmental Disabilities Research,
13, 2635.
Rodriguez, F.A. (2000). Maximal oxygen and cardiorespiratory response to maximal 400m
free swimming, running and cycling tests in competitive swimmers. Journal of Sports,
Medicine, and Physical Fitness, 40, 8795. Retrieved from http://www.minervamedica.
it/en/journals/sports-med-physical-fitness/index.php.
Ronchi, C.F., Antunes, L.C., & Fioretto, J.R. (2008). Respiratory muscular strength decrease
in children with myelomeningocele. Spine, 33, E73E75.
Rosin, P., & Swift, E. (1999). Communication interventions: improving the speech intel-
ligibility of children with Down syndrome. In Miller, J.F., Leddy, & Leavitt (Eds).
Improving communication of people with Down syndrome (pp. 133-154.) Baltimore,
MD: Paul H. Brooks Publishing Co.
Royal Lifesaving Society Canada. (2009). Swim to Survive Standard. Retrieved from http://
www.lifesavingsociety.com/.
Rubin, S.S., Rimmer, J.H., Chicoine, B., Braddock, D., & McGuire, D.E. (1998). Overweight
prevalence in persons with Down syndrome. Mental Retardation, 36, 175181.
Rvachew, S., Hodge, M., & Ohberg, A. (2005). Obtaining and interpreting maximum
performance tasks from children: A tutorial. Canadian. Journal of Speech-Language
Pathology and Audiology, 29, 146158. Retrieved from http://www.caslpa.ca/english/
resources/cjslpa_home.asp.
Sapienza, C. (2008). Respiratory muscle strength training applications. Current Opinion in
Otolaryngology & Head & Neck Surgery, 16, 216220.
 Effects of Swim Training 341

Shields, N., Dodd, K.J., & Abblitt, C. (2009). Do children with Down syndrome perform suf-
ficient physical activity to maintain good health? A pilot study. Adapted Physical Activ-
ity Quarterly, 26, 307320. Retrieved from http://journals.humankinetics.com/apaq.
Solomon, N.P., Garlitz, S.J., & Milbrath, R.L. (2000). Respiratory and laryngeal contribu-
tions to maximum phonation duration. Journal of Voice, 14(3), 331340. Retrieved
from http://www.jvoice.org/.
Speyer, R., Bogaardt, H.C.A., Passos, V.L., Roodenburg, N.P.H.D., Zumach, A., Heijnen,
M.A.M., et al. (2008). Effect of voice therapy: A systematic review. Journal of Voice,
22, 565580.
Stevens, J. (1990). Intermediate statistics: A modern approach. Hillsdale: Lawrence Erlbaum.
Terasawa, R., Hibi, S.R., & Hirano, M. (1987). Mean airflow rates during phonation over a
comfortable duration and maximum sustained phonation. Folia Phoniatrica, 39, 8789.
Van Riper, C., & Erickson, R.L. (1996). Speech correction: An introduction to speech pathol-
ogy an audiology (9th ed.). Boston, MA: A Simon & Schuster Company.
Venail, F., Gardiner, Q., & Mondain, M. (2004). ENT and speech disorders in children with
Downs syndrome: An overview of pathophysiology, clinical features, treatments and
current management. Clinical Pediatrics, 43, 783790.
Voliantis, S., McConnell, A.K., Koutedakis, Y., McNaughton L., Backx, K., & Jones, D.A.
(2001). Inspiratory muscle training improves rowing performance. Medicine and Sci-
ence in Sports and Exercise, 33, 803-809.
Weiner, P., Magadle, R., Beckerman, M., & Beray-Yanay, N. (2003). Specific expiratory
muscle training in COPD. Chest, 124, 468473.
Wells, G.D., Plyley, M., Thomas, S., Goodman, L., & Duffin, D. (2005). Effects of concurrent
inspiratory and expiratory muscle training on respiratory and exercise performance in
competitive swimmers. European Journal of Applied Physiology, 94, 527540.
Wilmore, J.H., & Cstill, D.L. (2005). Physiology of sport and exercise. Champaign, IL:
Human Kinetics.
Wilson, F.B., & Starr, C.D. (1985). Use of the phonation analyzer as a clinical tool. Journal
of Speech and Hearing Disorders, 50, 351-356. Retrieved from http://jshd.asha.org/.
Wylegala, J.A., Pendergast, D.R., Gosselin, L.E., Warkander, D.E., & Lundren, G.E. (2007).
Respiratory muscle training improves swimming endurance in divers. European Journal
of Applied Physiology, 99, 4, 393-404.
Yanaghara, N., & Koike, Y. (1967). The regulation of sustained phonation. Folia Phoniat-
rica, 19, 118.

Ylmaz I., Ergun N., Konukman F, Akbuga B., Zorba E., imen Z. (2009). The effects of water
exercises and swimming on physical fitness of children with mental retardation. Journal
of Human Kinetics, 21, 105- 111. Retrieved from http://www.johk.awf.katowice.pl/.