Research in Developmental Disabilities 33 (2012) 675–681

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Research in Developmental Disabilities

The effect of physical training on static balance in young people with

intellectual disability
A. Jankowicz-Szymanska a,*, E. Mikolajczyk b, W. Wojtanowski a
a
Higher Vocational School in Tarnow, Institute of Health, Section of Physical Education, Zaklad Wychowania Fizycznego, Instytut Ochrony Zdrowia,
Panstwowa Wyzsza Szkola Zawodowa, ul. A. Mickiewicza 8, 33-100 Tarnow, Poland
b
University School of Physical Education in Krakow, Department of Physiotherapy, Section of Kinesitherapy, Zakład Kinezyterapii, Katedra Fizjoterapii,
Wydzial Rehabilitacji Ruchowej, Akademia Wychowania Fizycznego, al. Jana Pawła II 78, 31-571 Krakow, Poland

A R T I C L E I N F O A B S T R A C T

Article history: Intellectual disability affects all spheres of people’s lives who suffer from it. It lowers the
Received 8 November 2011 level of intellectual functioning, often stigmatizes, characteristically changing features,
Received in revised form 22 November 2011 and decreases motor performance. Unfortunately, modern medicine cannot cure
Accepted 23 November 2011 intellectual disability; however, there is a chance to improve the quality of life of people
Available online 18 December 2011 with mental retardation by means of physical exercises and by enhancing coordination,
the quality of gait and efficiency in performing everyday activities. This paper deals with
Keywords: observations of static balance in 40 young females and males with mild Down
Static balance
syndrome, out of which 20 were subjected to a three-month sensorimotor training
Intellectual disability
programme. The participants performed exercises with rehabilitation balls and air
Sensorimotor training
pillows twice a week, and the remaining persons constituted a control group. The
balance platform test conducted at the beginning of the experiment revealed that the
level of static one-legged balance was similar in both groups. A significant difference
was noted in the length of the path of the general centre of gravity (COG) and the time
frame in which the vertical projection of COG remained within the 13 mm radius circle,
between the result of the test conducted under visual control and with the eyes closed,
both in the group of the participants performing exercises and the ones who did not do
them. After the training sessions the results of both tests improved in the group of the
persons subjected to the training programme, however differences between the groups
were not statistically significant, apart from the comparison of the time of keeping COG
within the 13 mm radius circle at the beginning and at the end of the experiment by the
participants who were physically active. Our results lead to a conclusion that exercises
with the use of unstable surfaces improve deep sensibility in people with mild mental
retardation.
ß 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Intellectual disability is a complex dysfunction difficult to define accurately; it considerably hinders the functioning of
people suffering from it in all spheres of their lives, affects their mental sphere and behaviour, disturbing both self-
perception and inter-personal relations, which to a considerable degree decreases the quality of coexistence in society.
Mental retardation negatively affects the life of a disabled person also by lowering their motor development, which is

* Corresponding author. Tel.: +48 504 238 962.

E-mail address: jankowiczszymanska@gmail.com (A. Jankowicz-Szymanska).

0891-4222/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ridd.2011.11.015
676 A. Jankowicz-Szymanska et al. / Research in Developmental Disabilities 33 (2012) 675–681

manifested by poor visual and motor coordination, limited precision of movements, inhibition and difficulties in learning
new forms of activities.
Persons with intellectual disability are worse at performing motor tasks which require combination of two activities
(tossing and catching a ball, performing run-up jumps, tossing a ball up in the air after a leap), they also often have difficulties
in developing praxis skills. Additionally disturbed body sensibility and poor spatial orientation considerably decrease the
level of static and dynamic balances, which is manifested by awkward movements and increases the risk of falls. The above
mentioned results in worsening the performance of everyday self-management activities and decreases chances to
participate in the life of a group of healthy peers or a possibility to find at least simple gainful employment. All these factors
often make persons with intellectual disability alienated from society and experience lack of acceptance, which further
decreases their self-assessment and motivation.

1.1. Objectives

This paper presents an assessment of the impact of physical exercises with the use of unstable surfaces on the level of
static balance in persons with mild intellectual disability. Two one-legged standing trials with the eyes open and closed
allowed observing changes in using information from the deep sensibility receptors for maintaining a stable position of the
body. Showing whether sensorimotor exercises can improve the quality of deep sensibility in mentally retarded young
people, and whether it would be advantageous to implement them in the general programme of increasing the efficiency of
those people, was the superior objective of the experiment.

2. Methods

2.1. Participants

The experiment comprised a total of 40 participants with mild intellectual disability, students of a Special Education and
Care Centre. The group consisted of 20 females and 20 males, aged 16–18 years (the average 16.8 years). Down syndrome
was the cause of mild retardation of the participants and none of the persons taking part in the study suffered from
dysfunctions of the musculoskeletal system or another accompanying ailment.

2.2. Procedure

The assessment of the level of basic somatic build characteristics, i.e. body weight and height, was conducted and the
body mass index was calculated on its basis. Body weight was assessed on the Tanita scales to an accuracy of 0.1 kg, body
height was measured within 1 mm by means of a calibrated anthropometer, and the quality of static balance was estimated
employing the Emi duo balance. Observations were made during one-legged standing on the extremity chosen by the
participant, first with the eyes open then closed.
The length of the path covered in 30 s by COG of the person standing on the platform was noted and the result was
recorded in millimetres. Moreover, we estimated the percentage of time in which the vertical projection of the
participant’s COG remained within the 13 mm radius circle. The tests describing the level of balance were selected
taking into account their simplicity and accuracy of the variables description; the longer the vertical projection path of
COG, the smaller the stability of the participant. Simultaneously, the time frame expressed in percentages, in which COG
was kept within the circle of a small radius, allowed to state whether a considerable length of the path did not result
from a one-time bigger swaying of the person with an overall good postural balance. The above mentioned tests were
also used by other authors (Carneiro, Santos-Pontelli, Colafêmina, Carneiro, & Ferriolli, 2010; Martinez-Mendez, Sekine,
& Tamura, 2011).
After the first test the whole group was randomly divided into two groups of the same size (20 participants), keeping an
appropriate ratio between the number of females and males. The first group consisted of young people subjected to a training
programme which targeted at improving the quality of balance, and for consecutive 12 weeks they participated twice a week
in a 45-min training session consisting of exercises on rehabilitation balls and air pillows, exercises in balance positions,
standing and walking on surfaces with different structures and degrees of stability. The exercises performed by the subjects
are: prone- and back-lying rocking on a rehabilitation ball, prone-lying in hand support on a rehabilitation ball (lower
extremities straight in knee joints, placed in trunk extension), in kneeling position with hands and knees resting on
rehabilitation pillows, attempts at keeping balance and alternate upper right and left limb raising to horizontal position,
keeping the correct sitting posture on a rehabilitation ball, balancing the pelvis in the sagittal plane while sitting on the ball,
balancing the pelvis in the frontal plane with alternate right and left foot raising above the floor, standing on two-feet on a
rehabilitation pillow, attempt at performing a knee bend while standing on a rehabilitation pillow, walking barefoot on a
spiked gum mat, walking barefoot on a 10 cm thick soft exercise mat, walking along the gym and stepping on rehabilitation
pillows of different thickness.
After completing a 3-month training, the balance test was conducted a new in the way described above and with the use
of the same measurement devices.
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Table 1
The level of the selected somatic build characteristics – descriptive statistics.

Variable Group Average Minimum Maximum Range Variance Standard deviation

Body weight Training 63.69 48.0 79.0 31.0 63.67 7.97

No training 61.43 42.0 90.0 48.0 111.39 10.6
Body height Training 1.7 1.58 1.83 0.25 0.06 0.004
No training 1.68 1.57 1.78 0.21 0.055 0.003
BMI Training 21.82 18.28 27.33 9.04 2.02 4.11
No training 21.65 1.03 28.4 11.36 2.72 7.44

2.3. Analysis

The following statistical methods were employed to analyse the material collected: Shapiro–Wilk test (a = 0.05) for
examination of normal distribution, f-test (a = 0.05) for assessment of variance homogeneity, t-test for dependent trials
(a = 0.05), t-test for independent trials (a = 0.05), Wilcoxon test (a = 0.05), Mann–Whitney U-test (a = 0.05).

3. Results

3.1. The level of basic somatic build characteristics

The assessment of basic somatic build characteristics, i.e. body weight and height, was made during the first test and on
the basis of the above BMI was calculated. Table 1 presents descriptive statistics concerning the variables for the group of the
participants who took part in the training sessions and the ones who did not train.
Participants from the group who did not perform efficiency improving exercises boasted a slightly smaller body weight
and height, and BMI (Table 1). The greatest homogeneity was observed in relation to the body height variable, and the
smallest one within BMI in both groups of the participants. There were no statistical significances between the participants
taking part in training sessions and the ones who did not perform exercises (Table 2).

3.2. The length of the path of the general COG

Static balance in one-legged standing on the dominant limb on a balance platform was assessed for all participants. The
test was first carried out with the participants’ eyes open and then without visual control, at the beginning and at the end of a
12-week exercise programme. The length of the path covered by the participants’ general centre of gravity in 30 s (Table 3).
The analysis of the material collected showed that before commencing the efficiency improving exercises the higher level
of static balance expressed by a smaller value of the length of the path of COG of the body was characteristic of the persons
from the group not participating in training sessions, both in the tests conducted under visual control and with the eyes
closed. In the control test, after implementing rehabilitation exercises, better results of the one-legged balance expressed
both by the mean value and medians were achieved by the persons from the group participating in training sessions.
The intergroup comparison of the length of the path in the trial with the eyes open and closed showed significantly better
results in the test conducted under visual control in both groups, before and after the period of training sessions (Table 4).

Table 2
The comparison of somatic build characteristics of the subjects who took part in training sessions and the ones who did not train (t-test for independent
trials, a = 0.05).

Variable t df p-Value

Body weight 0.721 38 0.478

Body height 1.325 38 0.193
BMI 0.153 38 0.878

Table 3
The examination of the length of the path of COG – descriptive statistics.

Variable Group Test time Average Median Minimum Maximum Range Variance Standard deviation

Eyes open Training Before 2083.26 1736.7 1052.13 6088.34 5036.21 1,490,595 1220.8
After 1615.62 1419.7 844.7 4182.58 3337.8 482,593.3 694.6
No training Before 1858.15 1644.1 792.0 3532.5 2740.41 599,451.1 774.24
After 1871.19 1540.6 949.65 7026.65 6077.0 234,658.0 1531.8
Eyes closed Training Before 3440.04 3488.8 1453.09 6267.0 4813.9 1,710,897 1308.01
After 2591.46 2592.3 491.34 4895.46 4404.1 1,361,141.0 1166.6
No training Before 3169.9 3028.1 641.7 6896.78 6255.01 1,826,047 1351.3
After 3107.5 3300.0 1100.0 9281.1 8181.1 4,910,760.0 2216.0
678 A. Jankowicz-Szymanska et al. / Research in Developmental Disabilities 33 (2012) 675–681

Table 4
Differences in the length of the path in exercises with the eyes open and closed before and after training sessions (t-test for dependent trials, a = 0.05).

Eyes open vs. eyes closed Test time t df p-Value

Training Before 5.226 23 0.00002*

No training Before 3.315 15 0.0047*
Training After 33.0 3.193 0.0014*
No training After 40.0 3.309 0.00093*
*
Significant differences.

Table 5
Intergroup comparisons of the length of the path before and after the period of training sessions (Mann–Whitney U-test, a = 0.05).

Training vs. no training Test time U Z p-Value

Eyes open Before 189.0 0.082 0.933

Eyes closed Before 173.0 0.524 0.599
Eyes open After 175.0 0.256 0.797
Eyes closed After 183.0 0.028 0.977

Table 6
The comparison of the length of the path before and after the period of training sessions (Wilcoxon test, a = 0.05).

The path length before vs. after efficiency improving sessions Group T Z p-Value

Eyes open Training 82.0 1.703 0.089

No training 58.0 0.517 0.605
Eyes closed Training 76.0 1.885 0.059
No training 61.0 0.361 0.717

Differences of the variables under study followed Gaussian distribution (Shapiro–Wilk test, a = 0.05), therefore the t-test for
dependent trials was employed to assess the significance of differences.
At the beginning of the experiment in both groups of the participants the length of the path of COG of the body in the test
with the eyes open and closed differed statistically significant. A similar situation was noticed after the completion of the
cycle of exercises. The next analysis showed lack of significant differences in the level of the discussed variable in the test
with the eyes open and closed between the group taking part in training sessions and the one not performing exercises. The
results of those tests are presented in Table 5. No statistically significant differences – either in the group of the participants
performing exercises or the one not doing them – both in the test with the eyes open and closed, were noticed during the
analysis of the length of COG before and after 12 weeks of efficiency improving exercises (Table 6).
We also assessed the time in which during the 30 s one-legged standing test the vertical projection of the subjects’ COG
was kept within the 13 mm radius circle. The results were given in percentages. The descriptive statistical data showing the
level of the discussed variable are presented in Table 7. In the test conducted at the beginning of the experiment, both in the
trial with the eyes open and closed, a better result expressed by longer keeping the centre of gravity of the body in 13 mm
radius circle was noted in the participants from the group who did not perform exercises. After a 12-week training session
the persons performing efficiency improving exercises showed a higher level of static balance expressed by a longer time of
keeping COG of the body in 13 mm radius circle as compared to the group, which did not perform exercises. Those
observations referred to the one-legged standing trial with the eyes open and with the eyes closed. The statistical analysis
showed the presence of significant differences in intergroup comparisons concerning the level of the discussed variable with
the eyes open and with the eyes closed (Table 8).
On the other hand, at the beginning of the rehabilitation period no statistically significant differences were noticed in the
level of the discussed variable in comparison between the group performing exercises and the one not performing them,
either with the participants’ eyes open or closed. Despite differences in the values of the mean and median, the comparison of

Table 7
Keeping the general centre of gravity within 13 mm radius circle before and after the period of training sessions – descriptive statistical data.

Variable Group Test time Average Median Minimum Maximum Range Variance Standard deviation

Eyes open Training Before 55.91 56.76 19.5 92.67 73.17 615.91 24.81
After 68.02 70.1 45.33 99.67 54.34 240.47 15.5
No training Before 58.25 56.76 4.83 97.0 92.17 556.39 23.58
After 60.01 62.25 4.81 92.33 87.52 565.87 23.78
Eyes closed Training Before 28.87 21.83 5.5 83.5 78.0 444.33 21.07
After 44.02 40.48 19.5 87.5 68.0 407.7 20.19
No training Before 30.59 28.5 1.17 86.5 85.33 412.89 20.31
after 40.7 33.33 9.12 100.0 90.88 488.49 22.1
 A. Jankowicz-Szymanska et al. / Research in Developmental Disabilities 33 (2012) 675–681 679

Table 8
Time differences in keeping COG in the 13 mm radius circle in the test with the eyes open and closed, before and after the period of training sessions
(Wilcoxon test, a = 0.05).

Eyes open vs. eyes closed Test time T Z p

Training Before 19.0 2.721 0.0064*

No training Before 26.0 3.406 0.0006*
Training After 16.0 2.863 0.0041*
No training After 45.0 2.645 0.008*
*
Significant differences.

Table 9
The intergroup comparison of the time of keeping COG in the 13 mm radius circle before and after the period of training sessions (t-test for independent
trials, a = 0.05).

Training vs. no training Test time t df p-Value

Eyes open Before 0.302 38 0.763

Eyes closed Before 0.26 38 0.795
Eyes open After 1.202 37 0.236
Eyes closed After 0.483 37 0.631

the level of the discussed variable after the completion of rehabilitation also showed no presence of significant differences
between the group participating in training sessions and the one not doing exercises (Table 9).
Table 10 presents the results of statistical tests measuring the significance of differences in the time of keeping COG
in 13 mm radius circle, in the trials with the eyes open and closed in the group of the persons participating in training
sessions and the one not doing exercises, at the beginning and at the end of the efficiency improving rehabilitation
period. Considerable differences were noted in the group participating in training sessions in the test with the eyes
closed.

4. Discussion

In our study we show that training on unstable surfaces improve static balance of people with Down syndrome. Keeping
ones balance in changeable conditions of external environment is possible thanks to coordinated cooperation of the organ of
sight, the inner ear, deep sensibility and the central nervous system. This is a dynamic process steered subconsciously. Most
authors agree with the opinion that the capability of keeping a stable posture of the body in people with mental handicap is
smaller than in the population of healthy people (Dellavia, Pallavera, Orlando, & Sforza, 2009; Vuijk, Hartman, Scherder, &
Visscher, 2010). It is connected with gait disturbances and increased risk of falls (Agiovlasitis, McCubbin, Yun, Mpitsos, &
Pavol, 2009). The reason for smaller stability of the body posture of the people suffering from intellectual disability has not
been unambiguously identified yet. Some authors show to decreased postural control resulting from slowing down
equivalent reactions (Cimolin et al., 2011; Galli et al., 2008), disturbing the functioning of the vestibular system (Cabeza-Ruiz
et al., 2011) or auditory or visual impairment accompanying intellectual disability (Hale, Bray, & Littmann, 2007;
Hale, Miller, Barach, Skinner, & Gray, 2009). However, one should pay attention to the research which found out lack of
significant dependencies between the loss of hearing (Wierzbicka-Damska et al., 2005), or sight (Rutkowska, Bednarczuk, &
Skowronski, 2010) and capability of keeping a stable posture in people not suffering from additional disability. Gomes and
Barela (2007) showed in their experiments that people with mental retardation, despite generally decreased capability of
keeping balance, use their sight and touch to a similar degree as healthy people to reduce sways of COG of the body in a
standing position. No differences in the level of sensorimotor integration between the Down syndrome participants and the
control group were noticed in the experiment under discussion.
Disturbances in the process of controlling the stability of the body in static and dynamic positions, irrespective of the
cause, affect not only the motor but also mental sphere of functioning of the disabled. The feeling of uncertainty of posture
and gait, as well as the fear of falling and getting hurt, make persons with mental handicap have greater tendency to
sedentary way of life than healthy people (Carmel et al., 2008), which – in turn – can contribute to more frequent occurrence
of overweight and obesity in this population (Lahtinen, Rintala, & Malin, 2007).

Table 10
The comparison of the time of keeping COG in the 13 mm radius circle before and after the period of training sessions (t-test for dependent trials, a = 0.05).

Keeping COG in the 13 mm radius circle before vs. Group t df p-Value

after efficiency improving exercises

Eyes open Training 1.726 16 0.103

No training 0.192 21 0.846
Eyes closed Training 2.205 16 0.042*
No training 1.324 21 0.199
*
Significant differences.
680 A. Jankowicz-Szymanska et al. / Research in Developmental Disabilities 33 (2012) 675–681

These reasons call precisely for necessary implementation of a special programme of efficiency improving exercises to the
process of rehabilitation of persons with disturbances in intellectual development. In our own research we assessed the
effect of a 3-month sensorimotor training programme on the level of static balance in persons with mild disability. The
examination of one-legged balance was conducted on a balance platform, first with the eyes open and then with the eyes
closed, before and after the efficiency improving period. The control group also consisted of persons of the same age and with
mild retardation, not differing considerably in their body weight, height and BMI.
The assessment of balance conducted before commencing the training programme showed lack of statistically significant
differences both in comparison of the length of the path of COG and the time of keeping the vertical projection of COG in
13 mm radius circle. However, the comparison of the mean values showed that slightly better results were achieved by the
members of the control group. Statistically significant, better results were found in both groups under research in the test
conducted with the eyes open.
Persons performing exercises had considerably better results in the examination of balance after completing the training
programme. The length of the path of COG decreased in them by 22% on average in the test with the eyes open and by 25% in
the test with the eyes closed. In the control group, mean differences did not exceed 2%. During the analysis of the time of
keeping the subjects’ COG in 13 mm radius circle, the control test revealed improvement of results in both groups. Among the
ones performing exercises, the improvement equalled 22% in the test with the eyes open and as much as 52% in the one-
legged standing test without visual control. For comparison, in the group of the participants who did not perform exercises
the result improved respectively by 3% and 33%.
Despite the improvement in the level of balance statistical significance was seen only in the case of comparing the time of
keeping COG of the body within 13 mm radius circle by the one who performed exercises before and after rehabilitation in
the test with the eyes closed. Perhaps a small size of the group of the participants was responsible for the lack of significance
of results in the remaining comparisons. It seems advisable to repeat the experiment with the use of same rehabilitation
programme on a huge number of people. It should be noted that despite the fact that all exercises were performed with the
eyes open, the stability of the participants without visual control significantly improved. The above mentioned allows to
form a conclusion that exercises with the use of unstable surfaces favourably affect deep sensibility in mentally retarded
persons.
Positive influence of physical exercises on the level of balance in people with mild mental retardation was also confirmed
by the research of other authors (Marchewka, 2002; Wang & Ju, 2002). Properly selected physical activity creates favourable
conditions to increase muscle strength, especially isokinetic resistance and improve agility and coordination of intellectually
disabled people (Carmel, Zinger-Vaknin, Morad, & Merrick, 2005; Guidetti, Franciosi, Gallotta, Emerenziani, & Baldari, 2010;
Tsimaras & Fotiadou, 2004). Systematic rehabilitation exercises increase effectiveness of performing self-management
activities and elevate the mood also in children suffering at the same time from intellectual and motor disability
(Puszczalkowska-Lizis, Smigiel, & Zajkiewicz, 2010).
A therapeutic programme can include different activities. For example, there was observed positive influence of
hippotherapy (Champagne & Dugas, 2010), as well as rhythmic gymnastics (Fotiadou et al., 2009), on balance, motor
performance and coordination of people with mental retardation. Implementing many kinds of rehabilitation exercises and
forms of improving efficiency, as well as various experiments in changeable conditions of external environment creates
favourable conditions for learning new skills and encourages to undertake initiative which can make interpersonal relations
easier (Renblad, 2002). During therapeutic sessions it seems important to create situations similar to the natural ones and
improve motor performance in exercises imitating activities of daily life.

5. Conclusions

People with Down syndrome strongly rely on their sense of sight to stabilize their bodies in space. In this study we found
that systematic sensorimotor gymnastics favours improvement of static balance in people with mild retardation. Exercises
on unstable surfaces improved deep sensibility of young people with intellectual disability which was expressed by a better
performance in the test on a balance platform in a trial with the eyes closed. Thus, we suggest that sensorimotor exercises
should supplement a rehabilitation programme of persons with dysfunctions in intellectual development which in turn
would lead to improve their general fitness and the quality of their lives.

Acknowledgments

We would like to thank the participants of our study and their parents. We would also like to thank Technomex for
providing us with the balance platform.

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