This article discusses the barriers preventing people with learning disabilities from being more physically active, and how nurses can encourage them to increase their level of activity
Abstract As well as poorer health and lower life expectancy, people with learning disabilities have lower levels of physical activity than their typically developing peers. Taking part in physical activity has been shown to have a number of benefits for both their physical health and psychological wellbeing. This article discusses the barriers preventing people with learning disabilities from being more physically active and how nurses can encourage them to increase their physical exercise.
Citation: McKenzie K et al (2018) Encouraging physical activity in people with learning disabilities. Nursing Times [online]; 114: 8, 18-21.
Authors: Karen McKenzie is chartered clinical psychologist and professor of psychology, Northumbria University and NHS Lothian; Kara Murray is mental health nurse, NHS Lothian; George Murray is chartered clinical psychologist and professor of psychology, Northumbria University and NHS Lothian.
- This article has been double-blind peer reviewed
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Engaging in physical activity is a protective factor for health, while being physically inactive is related to serious health problems – such as cancer, obesity and cardiovascular disease – as well as reduced lifespan (Martin et al, 2011). Despite this, only 9% of people with learning disabilities included in a recent systematic review had levels of physical activity that met the minimum recommended by guidelines (Dairo et al, 2016). This article explores what prevents people with learning disabilities from being more physically active and what nurses can do to remedy this.
People with learning disabilities face significant inequalities in their physical and psychological health. These inequalities have been highlighted in a series of reports and policy documents over the past decades (Department of Health, 1995) and are at odds with the principles that underpin good healthcare service provision for people with learning disabilities (Wolfensberger, 1972).
People with learning disabilities continue to have poorer health, an increased risk of specific serious health threats – such as particular types of cancer – and a lower life expectancy than their typically developing peers (Emerson and Baines, 2012). They are also three times more likely to die from an avoidable cause.
In 2013, the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD) highlighted a number of deficiencies in service provision for this group (Heslop et al, 2013). Developed in response to the CIPOLD findings, the Learning Disabilities Mortality Review Programme supports the reporting and reviewing of deaths of people with learning disabilities with the aim of reducing the number of premature deaths.
One of the barriers to good healthcare identified by the CIPOLD was poor communication and coordination between different care providers. It also high-lighted that staff had limited know-ledge of people with learning disabilities and their healthcare needs, and that proactive approaches, such as health screening, were being used inconsistently (Heslop et al, 2013).
Two further barriers are that people with learning disabilities may not be able to communicate their symptoms and may find it difficult to understand health-related materials that have not been adapted to suit their abilities (Turnbull et al, 2005).
Benefits of physical activity
The term ‘physical activity’ covers all activities involving “any force exerted by skeletal muscles that results in energy expenditure above resting level” (World Health Organization, 2006). This includes structured and unstructured exercise programmes and sport.
The benefits of participating in structured exercise programmes may vary according to the type of exercise (Calders et al, 2011), but these programmes have generally been found to improve the health of adults with learning disabilities. Kastanias et al (2015) found that a 12-week aerobic exercise programme resulted in significant improvements in a range of health indicators, including body mass index (BMI) and blood pressure. Hakim et al (2017) found that participation in an eight-week aquatic exercise programme improved balance and endurance.
Research has also demonstrated that exercise has health benefits for younger people with learning disabilities – including improved endurance, aerobic capacity and muscular strength (Collins and Staples, 2017). A recent systematic review of 18 studies and subsequent
meta-analysis of 14 studies found that, in adolescents with learning disabilities, exercise resulted in improvements in agility, power, reaction time and speed (Jeng et al, 2017).
People with learning disabilities are at particular risk from being overweight or obese (Jenkins and McKenzie, 2011) and exercise can benefit these groups. Wu et al (2017) reported that overweight or obese adolescents with learning disabilities who took part in a 12-week exercise programme – comprised of cross-circuit activities for 50 minutes five days a week – achieved reductions in weight, BMI and fat mass, as well as improvements in cardiorespiratory performance, balance, strength and endurance. The benefits of exercise in terms of reduced fat mass have also been found in older women with learning disabilities who were obese or overweight (Merrick et al, 2013).
In addition to the benefits to physical health, exercise improves the psychological wellbeing of people with learning disabilities, with benefits such as reduced anxiety (Carraro and Gobbi, 2012), increased self-esteem and improved mood (Vogt et al, 2012). There is an association between higher reported levels of physical activity and increased quality of life, as indicated by levels of community participation (Blick et al, 2015).
Encouraging physical activity
Despite the significant associated health benefits, both adults and children with learning disabilities have lower levels of physical activity than their typically developing peers (Robertson et al, 2018). Reasons for this are discussed below, along with ways nurses can encourage this group to engage in physical exercise.
Increasing sense of control
A number of practical barriers experienced by many people with learning disabilities have been highlighted, including cost, transport, difficulties accessing organised activities, lack of suitable activities, and lack of promotion of activities when available (Shields and Synnot, 2016). As well as presenting challenges in themselves, these practical barriers may also have an indirect negative effect by reducing individuals’ sense of control over their ability to engage in physical activity.
In a study examining whether the Theory of Planned Behaviour was useful in predicting the intentions of 78 Scottish care staff to support people with learning disabilities to engage in physical activity, Martin et al (2011) found that the perceived behavioural control of care staff was the most significant predictor of the reported physical activity levels of their clients. This suggests that increasing staff’s sense of control over their ability to support their clients’ physical activity (for example, by giving them protected time and specifically allocated funds) would be likely to increase their clients’ physical activity levels.
Fostering positive attitudes
Another barrier that prevents people with learning disabilities from participating in physical activity relates to social factors, including attitudes among the general public. Research suggests that people with learning disabilities may be bullied, teased or discouraged when they attend organised activities (Shields and Synnot, 2016).
On the positive side, however, the attitudes of others can also be central in encouraging participation. Whether or not peers have a positive and accepting attitude towards the physical activity of people with learning disabilities is key (Shields and Synnot, 2016).
In one study, support and involvement from typically developing peers encouraged adolescents with learning disabilities to regularly attend an exercise programme over 15 weeks and resulted in improved performance and reduced BMI (Stanish and Temple, 2012).
Adopting a tailored approach
It has been suggested that the motivation and engagement of people with learning disabilities in physical exercise may increase if pathways are created that lead to greater inclusion. For example, they could start learning an activity individually with an instructor or in targeted classes, and as their confidence, fitness and skills grow they could join a mainstream group (Shields and Synnot, 2016).
When people participate in activities on an individual basis, rather than joining a group right from the start, this also allows instructors to tailor activities to their needs and reduce their risk of experiencing stress or anxiety. This can allow, for example, time to show them where the activity takes place, and explain or demonstrate the activity using short, straightforward explanations (Carter and Swank, 2014).
There are often practical constraints that limit the extent to which physical activities can be tailored to individual needs. Shields and Synot (2016), however, highlight the importance of providing as much choice as possible in terms of the types, amount and levels of activity available. This may involve considering factors such as the level of competitiveness of the activity, whether it is segregated or integrated, whether it involves individuals only or is a group or team activity.
Making it enjoyable
Two reasons why people may want to take part in physical activities – regardless of whether or not they have learning disabilities – are that they are enjoyable and sociable. A number of authors have highlighted the importance of maximising these factors by creating a positive atmosphere, planning fun exercises and games, alternating activities to maintain interest, and providing opportunities to work with partners or in groups (Collins and Staples, 2017; Shields and Synnot, 2016; Carter and Swank, 2014).
There is, however, a need to respect individual preferences in terms of what is considered fun and enjoyable. For example, people with both learning disabilities and autism spectrum disorder (between which there is a high overlap) may prefer to avoid social activities, instead choosing to exercise alone. Similarly, while some people with learning disabilities enjoy taking part in competitive sports, others may prefer activities where there is less of a competitive element, such as dancing, swimming or walking (Shields and Synnot, 2016).
Making it manageable
While taking part in physical activities has been shown to have a number of short-term benefits for the health and wellbeing of people with learning disabilities, there has been limited research exploring long-term benefits. Carter and Swank (2014) note the importance of helping the person to develop a ‘habit’ by encouraging daily physical activities, but it may be difficult for people who are accustomed to a very sedentary lifestyle to achieve this level of daily activity quickly.
Research by Elmahgoub et al (2011) suggests that physical activity can be built up gradually. They compared two levels of frequency of the same exercise programme in overweight and obese children with learning disabilities and found that, over a 10-15-week period, participating twice a week had broadly the same health benefits as participating three times a week. A low frequency may be more practical and less demanding when introducing physical activity to someone who is not used to it, with the aim of increasing the level of activity over time.
Making it safe
According to Carter and Swank (2014), a number of safety factors need be taken into account when considering the best type and amount of exercise for people with learning disabilities. Precautions include screening for health conditions, such as cardiovascular and pulmonary disease before individuals start exercising, as well as noting any associated conditions.
Carter and Swank (2014) note that people with Down’s syndrome have lower maximal heart rate and peak aerobic capacity than their typically developing peers. They also have atlanto-axial instability, which means activities such as gymnastics and diving and contact sports such as rugby are not always advisable (Faculty of Sport and Exercise Medicine, 2017).
Implications for practice
While learning disability nurses play a key role in improving the health of people with learning disabilities (Scottish Government, 2012), it has long been recognised that the health of this client group should be a shared responsibility (DH, 1995). All nurses have a role in promoting the physical and psychological health of people with learning disabilities. The studies discussed in this article suggest that there are a number of ways in which nurses can, directly and indirectly, encourage people with learning disabilities to take part in physical activities; some of these are highlighted in Table 1.
- People with learning disabilities have lower levels of physical activity than their typically developing peers
- Physical activity benefits the physical and psychological health of people with learning disabilities
- Ways to encourage people with learning disabilities to exercise include increasing their sense of control and promoting positive attitudes
- Physical activities need to be enjoyable and feel manageable
- Some types of sports or activities are not safe for people with learning disabilities
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