An exploratory study of physical activity levels in children and adolescents with visual impairments

Abstract

This study investigated activity patterns in nineteen students attending a state school for the
blind. Factors such as residential status, gender, body mass index, and level of vision were unrelated
to one another and did not predict physical activity behavior in study participants. Further, these
data demonstrate that participants studied accumulated 7.31 bouts of moderate-to-vigorous
physical activity per day, lower than estimates reported for peers without disabilities. Further, age-
related analysis demonstrated an inverse relationship where physical activity was inversely
correlated to age (rs = -.74) in these children and adolescents with visual impairments. Key Words:
Visual Impairment, Physical Activity Although it is stated in the most recent Physical Activity and
Health: A Report of the Surgeon General (21) that inactivity is a major health concern and that
individuals with disabilities are at a heightened risk for developing sedentary lifestyle patterns,
limited research exists that quantifies inactivity in persons with disabilities (12). In one of the few
studies of individuals with disabilities, researchers concluded that individuals with visual
impairments were susceptible to inactivity. This coupled with the increased energy requirements for
movement make physical activity an important variable for continued study in individuals with visual
impairments (5).

The current study expands on research by replacing traditional self-report questionnaires

with recent advances in motion sensor technology allowing for more accurate estimates of physical
activity (15). To date, no study in the published literature has used activity monitors to study physical
activity in individuals with visual impairments. Inactivity in special populations. Inactivity is believed
to be pervasive in individuals with visual impairments consistent with disability groups (12). Recent
studies on individuals with disabilities utilizing activity monitors show results for individuals with
mental retardation that document inactivity and a pattern of age-related decline consistent with
nondis abled peers (7). Variability is also supported where individuals with mental retardation
ranged between 6 and 12 bouts of moderate to vigorous physical activity per day (7). A bout of
moderate to vigorous physical activity refers to at least one minute where an individual is physically
at a level equal to or greater than 4.5 metabolic equivalents (METs). Many of the individuals with
disabilities previously studied were below peers without disabilities in activity counts using bouts of
moderate-to-vigorous physical activity (MVPA) as the unit of measure (4, 7). Inactivity in children
and adults with disabilities has many root causes making it imperative that researchers continue to
use the most sensitive technology possible to accurately quantify inactivity as well as find
determinants to assist in interventions aimed at increasing activity patterns in all persons.

Specific to individuals with visual impairments, convincing evidence exists from a prior study
that habitual inactivity is a concern with results estimating as high as one-third of participants with
visual impairments lead sedentary lives (12). Furthermore, research demonstrates that up to 80% of
children with visual impairments failed to reach criterion levels of health-related physical fitness
(10). These findings put individuals with visual impairments at risk for health related illnesses
attributed to inactivity and low fitness, as well as, functional limitations in daily living skills. This is
particularly true when it is considered that energy requirements for tasks increase as a function of
vision loss based on less efficient movement in persons with visual impairments compared to peers
without disabilities (5).

Educational placements and activity levels. An important consideration for individuals with
sensory impairments, in general, is quality of educational services and placement options related to
physical education and recreational programming. Contrary to inclusive philosophies, state schools
for the blind still exist and segregated placements are considered appropriate for some children with
disabilities. Segregated placements can vary depending on whether or not an individual lives on
campus fulltime or participates in a day program and returns home at the end of the school day. The
current status of physical activity patterns in children from day and overnight residential placements
is unknown. Further, comparisons between children who are exposed to residential placement
recreation programs versus those who return to community physical activity options has not
occurred. Reported literature has demonstrated that fitness level differences are noted in favor of
students with visual impairments educated in fulltime residential programs in comparison to
students from more inclusive settings (18).

Issues related to safety and appropriate programming make it likely that children with visual
impairments have better movement options in more restrictive environments which are tailored to
learner needs (19). Opportunities exist in residential facilities for children and adolescents to take
part in activity programs supervised by trained staff and at accessible facilities. Those who are
educated in inclusive settings or return home after receiving day educational services at segregated
settings are reliant in many instances on integrated community options for physical activity as
special sport programs suited to the needs of individuals with disabilities do not exist in many locales
(9, 11). However, no published studies have quantified differences in activity levels to determine if
residential after-school programming does result in higher physical activity counts for individuals
with visual impairments. Age-related trends in physical activity.

Age-related trends in physical activity are an important concern for physical education
professionals given national standard to promote lifelong learning and moving in all children (14). In
the general population, age-related declines are noted for both males and females between the ages
of 8 and 18 years (20). These same age-related trends are noted in individuals with mental
retardation (7). For individuals with visual impairments, estimates using a self-report questionnaire
do not support a marked age related decline in habitual physical activ ity (12). However, the nature
of this earlier study and questions related to validity of self-report questionnaires in light of new
computer technology that records motion could explain a lack of age- related decline. Researchers
have concluded that many self-report questionnaires tend to result in overestimates of actual
movement in both the general population and for persons with disabilities (3, 15).

Measuring physical activity in special populations. The issue of inaccurate measuring of

activity patterns in persons with disabilities centers around two factors. First, some investigators
question if self-reports provide the most accurate estimates of physical activity for adults with
disabilities or children in light of new computerized monitors (3, 22). Second, even if motion sensor
technology is used, some individuals may have unique movement patterns or inactive lifestyles that
may impact on the validity of motion sensors and lead to inaccuracies in detecting general physical
activity in persons with disabilities (2). In the latter point, researchers have consistently found
encouraging estimates of validity for motion sensors with respect to quantifying movement over
other types of self reports, heart rate monitors, and observational systems (2, 17). Given their
relatively small size and potential for quantifying different types of movements, the suitability of
exercise monitors are supported in the literature on studies of individuals with and without
disabilities from various age groups (2, 7, 22). Specifically, studies show that triaxial accelerometry is
a suitable means to measure long- term (over a period of days) physical activity in children and
provide a model to study physical activity scores in terms of bouts of moderate to vigorous physical
activity (4, 7).

In light of research showing the potential for sedentary lifestyles (12) and low fitness (10) in
individuals with visual impairments, more accurate study using accelerometer technology is
warranted. The first purpose of this study is to utilize RT3TM activity monitors to study potential
determinants of physical activity such as residential status, gender, vision level, and body
composition in a sample of children with visual impairments. Second, an initial exploration and
description of the incidence of bouts of MVPA in children and adolescents enrolled in a Midwestern
school for the blind were studied to compare to earlier studies on children without disabilities (4)
and to determine when children with visual impairments educated in a state school for the blind are
most active. Finally, age-related trends in physical activity for this cross section of children and
adolescents with visual impairments were analyzed to determine if declines in this select sample
were consistent with the larger population.

METHOD Participants.

Nineteen school age children and adolescents from a Midwestern school for the blind
between the ages of 6 and 18 were assessed during the study (M = 12.58, SD = 3.25). For each
participant, signed informed consent documentation was secured from parents or legal guardians
prior to data collection. Demographic information for these participants is found in Table 1 and
includes residential status referring to students who attend school during the day and return home
(Part Time Day), and those who live on campus throughout the school year and took part in after
school programming during the time of data collection (Full Time Residential). Other information is
found in Table 1 including gender, vision level, height, and weight. School administration assisted in
providing vision level information on each participant; however, no specific visual acuity scores were
provided to the researchers. Further, no participant had any known physical disabilities at the time
of the study.

Procedures. Participants were asked to wear activity monitors for one week. Data from two
week days and two weekend days were used for analyses. Monitors were placed on participants’
iliac crest (right hip) during school hours, and school staff were asked to check students during the
morning hours to make sure each participant was wearing the monitor and/or that it was
functioning properly. Part Time Day students’ parents were recruited to remind their child to wear
monitors and check to make sure monitors were functioning properly. An additional safeguard is
built into the monitor in that if a child fails to wear the monitor, vector magnitude values register
zero indicating no movement for extended periods of time. Accelerometer data were checked prior
to data analysis to make sure each day had vector magnitude values during the times of interest for
the study. Based on residential staff check sheets and activity counts recorded, data were collected
for 17 study participants including a Thursday, Friday, Saturday, and Sunday. Two Part Time Day
status participants (011 and 006) were noted to have forgotten their monitors during target
weekdays and to account for missing data, activity counts from a Monday and a Tuesday were used
to replace missing data, resulting in 19 usable data sets for analyses.

Physical activity assessment. To assess physical activity during the study, RT3TM activity
monitors were used. These triaxial accelerometers have been successfully used in a similar study on
children and adolescents with mental retardation and children without disabilities (4, 7, 16). Prior to
data collection each monitor was tested for reliability and validity during short-term activity bouts
on children with visual impairments. Reliability (r = .90) and validity estimates (r = .89) from this
earlier pilot work were encouraging (8).

Physical activity scores were calculated for participants by totaling bouts of MVPA. The
criterion of 4.5 METs was used as the value based on similar studies of children and adolescents with
and without disabilities (4, 7, 15). A MET value represents the rate of energy expenditure of an
individual at rest. Calculations for MET values that represent MVPA included converting a
participant’s body weight from pounds to kilograms and multiplying by a gender factor (male factor
= 1; female factor = 0.9). This value represents calories needed during one hour at rest (1). To
accommodate the minute-by-minute values collected by the RT3TM, this hourly value was divided
by 60 and multiplied by 4.5 and resulted in the target value for each minute interval studied. A bout
of MVPA resulted when one or more minutes of physical activity occurred that was at the target 4.5
MET or greater. To separate continuous bouts, the criteria of five minutes between intervals at or
greater this target value was used (4).

Body mass index (BMI). Height and weight values for each participant were provided by
school personnel. These values were used in conjunction with the Brockport Physical Fitness Test
(23) to determine BMI (as an indicator of obesity) for each participant (Table 1). Participants were
then divided into two groups including those who were in the healthy zone and those who were
above the ideal values based on established fitness standards (23).

Data analyses. Independent t-tests were used to determine group (male vs. female, and
criterion level BMI vs. out of healthy zone) differences for total bouts of MVPA and residential status
differences (Part Time Day vs. Full Time Resident) for bouts of MVPA after school and weekends, and
to determine if differences existed in participants compared to estimates from other researchers
who studied children without disabilities (4). Frequency counts were converted into percentages of
bouts of MVPA during the time periods of interest (9 am to 3 pm – school hours, 3:01 to 9 pm – after
school, and the corresponding weekend). Finally, Spearman rank-order correlations were used to
determine if relationships existed between bouts of MVPA and demographic variables (level of
vision and age).

RESULTS Table 1 provides participant information for key study variables. Group differences
based on gender (t17 = -.15, p = .88) and BMI (t17 = .29, p = .78), did not result in significant
differences in total bouts of MVPA. Further, differences in bouts of MVPA after school and during
weekend hours were not found in Full Time Residential vs. Part Time Day students (t17 = 1.41, p =
.17). Vision level did not significantly correlate with MVPA for these participants during the four days
studied (rs = .21, p = .19).

Over the four days participants had a mean value of 29.26 bouts of MVPA or 7.31 bouts (SD
= 4.07) per day lasting on average of 3.77 (SD = 2.26) minutes. Bouts per day values were
significantly different from the 12.20 values (SD = 4.24) reported in a similar study of peers without
disabilities (t18 = - 5.10, p < .05), using RT3TM monitors (4). Since a portion of participants found in
Table 1 are different in age from the Kalankanis et al. study (4), a second analysis was run on the
nine 8-12-year-old participants resulting in significantly higher bouts of MVPA for nondisabled peers
from this earlier study (M = 9.1, SD = 3.39; t8 = -2.58, p < .05). Frequencies of bouts of MVPAs during
three time periods from the four days resulted in 48% of the bouts occurring in the sample during
the two school days studied, 24% occurring after-school hours on these same school days, and 28%
occurring during the weekend days studied.

Age- related trends for the sample are found in Figure 1. This figure includes labels that
depict level of vision classification as provided by the setting where participants were recruited. Age-
related trends show an inverse relationship (r=-.75) between age and total bouts of MVPA in the
sample.

DISCUSSION
Factors thought to be determinants for MVPA in children with visual impairments were not found to
be related to MVPA in this study. Residential status in particular did not support the notion that
children with visual impairments are more likely to be inactive at home than their Full Time
Residential counterparts who were afforded structured program choices as part of the residential
school’s leisure curriculum. Further, activity levels were not dependent on BMI, indicating that those
who scored above the healthy range were no less active than peers who met criterion levels. The
rival hypothesis that vision level affected these results was ruled out by determining that BMI was
also independent of vision level (as determined by the descriptors used at this school: high vision,
low vision, and totally blind).

An interesting note related to BMI is that Full Time Residential students from the current
sample were similar to Part Time Day students. This is not supportive of earlier findings of higher
BMI in children place in full time institutional settings (18). However, the current sample did not
replicate earlier studies as both groups were educated in a segregated institutional setting vs. the
more integrated placements used for the prior comparison (18). The current comparison was
between children educated at the institutional setting who return home at the end of the day vs.
those who are residential students living at the institution during the time of data collection.

Group differences in after-school and weekend bouts of MVPA also did not yield different numbers
of bouts of MVPA when school values were excluded from the analyses. These data do not support
the contention that residential status, gender, vision loss, or BMI increase the risk of inactivity in
children and adolescents with disabilities. One limitation in the analysis of vision loss is that the
criteria used for categorizing students in this study resulted from procedures used by the state
school for the blind. Actual vision loss as a function of visual acuity and other more precise estimates
of vision may have resulted in findings that support vision level as a predictor of physical activity
counts. The second purpose to explore bouts of MVPA included comparing scores from the current
study to those from research on children without disabilities. The data supports for the notion that
children with visual impairments from residential and day settings were less active than nondisabled
peers in the current study when compared to obese children studied by an earlier research team
using similar procedures (4). Further, obese children have been found to have similar activity
amounts when compared to nonobese peers in accruing about a dozen bouts of MVPA per day (4).
Data from the current sample indicate fewer bouts occurring in individuals with visual impairments.

Data found in Table 1 demonstrated fewer bouts in children and adolescents with visual
impairments that lasted approximately the same length in comparison to a sample studied by earlier
researchers (4). However, the current sample included children and adolescents both younger and
older than those described in this previous report (4). Given the magnitude of age-related decline in
physical activity found in these individuals with visual impairments compared to those noted in all
children (20), more study is needed to determine what impact vision loss has on inactivity in older
adolescents. Data reported in Table 1 showed that eight out of the nine 8-12- year-old children
studied had MVPA counts below the 12.2 bouts per day reported in children without disabilities (4).
Lower mean bouts per day of MVPA from the 8-12-year-old children with visual impairments and
lower mean bouts per day in the overall sample support inactivity in children with visual
impairments in comparison to peers without disabilities. These data support a convincing argument
that individuals with disabilities are inactive, demonstrating that almost half of the bouts of MVPA
occurred during the school day at this segregated school setting. The school day was a time of
inactivity in all children, given the nature of educational programs. Further analysis of Part Time Day
Vs. Full Time Residential students with respect to after-school and weekend differences showed a
comparable pattern of inactivity for Part Time Day participants to the Full Time Residential
participants who receive leisure programming using accessible campus and community facilities. All
participants demonstrated approximately half the number of bouts of MVPA during weekend hours
than those accumulated during school hours and one third the bouts of MVPA on weekends in
comparison to children previously studied (4). The lack of Part Time Day vs. Full Time Residential
student differences indicates that these individuals with visual impairments selected inactive options
to spend leisure time. Residential students had activity choices as parts of their after-school
programming, but based on these data, participants are choosing sedentary options. The options
afforded day students at home were not studied, but imply a lack of opportunity based on studies
that demonstrate a shortage of programs for persons with disabilities (9, 11). The age-related trends
found in these participants are consistent with both studies on children with and without disabilities
(7, 20). Negative relationships found during childhood and adolescent years in the current
participants with visual impairments (Figure 1) demonstrate an even sharper decline than values (r =
-.13, p < .05) noted in earlier work (20). Barriers described by other authors are plausible for the
children and adolescents studied, who return home at the end of the school day and on weekends to
find limited skills and opportunities to take part in physical activity (13). However, in the accessible
state school for the blind with the varied leisure options, the decline in activity is not as easily
explained, as the Full Time Residential setting had programs ranging from extracurricular sports to
recreational swim and outdoor activities. Why these older adolescents are choosing inactivity goes
beyond the scope of this study. Motivational factors are likely and require further study on
adolescents with disabilities (6). These data represent an initial attempt to study physical activity in
persons with visual impairments. However, the convenience sampling and the low sample size limit
the inferences of these findings. The findings showing no differences due to residential status,
reaching criterion level of BMI, and vision loss is also explainable by the high variability found in the
sample with respect to key study variables. Specifically, total MVPA and bouts per day represented
high levels of variability within the sample. This could be an indicator of sample heterogeneity in
variables that may have been omitted and, if accounted for, might uncover statistically significant
differences between groups not found in this study. Future studies utilizing larger samples and
including participants with visual impairments from integrated educational settings might result in
more conclusive findings and a better understanding of inactivity in this target population.
Implications of these findings for practitioners include support for planning related to physical
activity options after formal education has ceased. Transition planning for students with visual
impairments to facilitate active lifestyles particularly as children reach adolescents is warranted (13).
Both Full Time Residential and Part Time Day students require attention as to how to become
physically active adults and a means to include the recommended amounts of movement needed to
remain healthy. The activity patterns found in these participants warrant concern given the times
noted for inactivity as well as overall low amounts of physical activity reported. In conclusion, the
results do not point to specific causes for inactivity in persons with visual impairments such as
residential status, gender, level of vision loss, or BMI. These factors were unrelated to inactivity in
these children and adolescents with visual impairments. Further, the number of bouts of MVPA in
these participants with visual impairments is low in comparison to those recommended for all
children and adolescents (21).