Effectiveness of Yoga Training on the Health-related Physical Fitness and Balance in Children with Autism Spectrum Disorder

doi:10.21203/rs.3.rs-3236097/v1

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Effectiveness of Yoga Training on the Health-related Physical Fitness and Balance in Children with Autism Spectrum Disorder

https://doi.org/10.21203/rs.3.rs-3236097/v1

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Background: Children diagnosed with Autism Spectrum Disorder (ASD) experience motor difficulties that result in reduced chances for engaging in physical activities and lower levels of fitness. The unique characteristics of yoga can play a substantial role in yielding positive outcomes in terms of physical fitness.

Aim: The present study aims to evaluate the effectiveness of yoga training on the health-related physical fitness and balance of children with ASD.

Methods: Twenty-five children with ASD (mean age 10 ± 0.8 years) were included in the study and randomly assigned to two groups: yoga and control. The yoga sessions were conducted three times per week for eight weeks.

Results: The findings indicated a significant improvement in upper body muscle strength and endurance (P < 0.01), lower body strength and endurance (P < 0.001), core strength and endurance (P < 0.001), flexibility (P < 0.01), static balance (P < 0.001), and dynamic balance (P < 0.05) following yoga training. However, yoga training did not have a significant effect on body fat and cardiorespiratory endurance.

Conclusions: Based on these findings, it is suggested that integrating yoga into the therapeutic approach for children with ASD can improve musculoskeletal fitness and balance, which may have positive effects on their overall physical health and motor development.

Physical fitness

Exercise

Muscular strength

ASD

Autism spectrum disorder (ASD), a neurodevelopmental disability primarily diagnosed in childhood, affects around 1 in 100 children globally [1]. The disorder significantly impacts essential brain functions, resulting in social and behavioral deficits [2]. Remarkably, motor impairment is also acknowledged as a diagnostic criterion for ASD [3]. A substantial proportion, approximately 86.9%, of children with ASD encounter potential motor impairments, including challenges with fine and gross motor skills [2]. Muscle strength, endurance, balance, and coordination are crucial for the development of gross motor movements [4]. Studies investigating motor impairments in children with ASD have identified deficiencies in musculoskeletal fitness, reduced aerobic capacity, and difficulties with balance and coordination [5, 6]. Consequently, these challenges hinder their engagement in activities like running, jumping, catching, or throwing, pivotal for physical fitness development. These limitations also influence their ability to perform daily tasks and participate in group activities, affecting social communication skills, cognition, and overall quality of life [2]. Furthermore, children with motor impairments face an increased risk of adopting sedentary lifestyles [7, 8]. Childhood is a pivotal phase for physical activities, and the motor difficulties experienced by children with ASD result in fewer opportunities for exercise and lower fitness levels [2, 9]. Nevertheless, initiatives to enhance the physical fitness of these children can yield positive outcomes for motor development, social communication skills, and engagement in physical activities.[10]

Physical exercise significantly impacts the physical fitness of children with ASD, particularly in neuromuscular and motor development. Physical fitness includes cardiorespiratory, musculoskeletal, and motor components [11]. Recent reviews and meta-analyses emphasize the positive effects of exercise interventions for children with ASD. These interventions show moderate to large improvements in motor and muscular fitness, communication and social skills, motor abilities, and executive functions [12–17]. Notably, targeted interventions effectively enhance balance, a crucial fitness skill [18]. However, children with ASD are at a heightened risk of obesity, with prevalence ranging from 7.9–31.8%, due to factors like sleep, diet, inactivity, and medication [19]. Childhood obesity is linked to adult obesity and cardiovascular diseases. Nonetheless, lifestyle interventions hold promise in improving body composition in ASD youth [20]. Activities like water exercises, horseback riding, and mind-body practices also offer benefits [21].

Yoga, a mind-body exercise involving stretching, focus, and controlled breathing, has demonstrated benefits for physical and mental health, including in healthy individuals [22, 23]. Research indicates positive effects of yoga interventions on factors like cardiorespiratory endurance, flexibility, muscular endurance, and balance in children [24]. Yoga-based approaches also hold promise for enhancing motor and cognitive skills in those with ASD [25, 26]. However, more investigation is required to grasp yoga's impact on fitness indicators, particularly musculoskeletal and aerobic fitness, in children with ASD. Studies on yoga's effect on body composition in this population yield mixed results and are limited. With its accessibility and engaging nature, yoga presents potential to improve health and fitness in those with ASD [27].

Yoga enhances balance by impacting sensory-motor systems and sensory integration [28]. Common in ASD, balance impairment improves with yoga, particularly in adolescents [29]. Bodyweight poses strengthen skeletal muscles, increasing hand grip and leg strength in ASD youth [29, 31]. The rhythmic yoga movements also benefit cardiorespiratory fitness and body composition [32].

Yoga poses impact various body systems, enhancing overall health. Existing literature emphasizes behavioral and social skills, lacking physical fitness research in ASD children. Yoga holds potential for musculoskeletal and aerobic improvement, especially addressing balance issues. This study explores an 8-week yoga program's effects on balance and health-related fitness in ASD children. The hypothesis suggests enhanced body composition, strength, flexibility, cardiorespiratory endurance, and static/dynamic balance through this intervention.

Participants

The study involved twenty-five preadolescent boys, aged 9 to 11 years, diagnosed with ASD. The sample size was determined using G*Power software v3.1.9.7, based on effect sizes from a similar study (80% power, significance level of 0.05, effect size of 0.56 for balance and coordination) [27]. Participants were selected from special needs schools and evaluated using the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2) [33] to determine ASD traits. Additionally, their intelligence levels were assessed using the Stanford-Binet Intelligence Scales, Fifth Edition [34]. The study included individuals with ASD severity levels ranging from 5 to 10 and an intelligence level above 70.

Procedures

Eligible volunteers were randomly assigned to either the yoga group (n = 12) or the control group (n = 13) by an independent researcher unaware of participant identification. The study comprised three pre-test sessions, an 8-week intervention period, and three post-test sessions. Muscle strength and endurance tests were conducted on the first day, followed by cardiorespiratory endurance evaluation on the subsequent day. The third session assessed body fat, flexibility, and balance. All measurements and yoga training occurred in a school's sports hall, supervised by a certified yoga instructor and a physical therapist. The exercise environment followed evidence-based therapeutic approaches for children with ASD, using visual supports, standard verbal encouragement, clear instructions, and a structured schedule [35]. The control group received no intervention.

Training Protocol

The intervention consisted of 24 sessions over eight weeks, with three sessions per week lasting 45–60 minutes each. The yoga training protocol was designed based on existing reports and recommendations for children with and without ASD [24, 35, 36]. Each session included a warm-up (e.g., slow jog and arm swings), loosening exercises (e.g., neck exercises and waist bending), specific yoga poses aimed at improving physical fitness (listed in Table 2), breathing practices (preparatory blowing exercises), and cool down, all conducted in a group setting. Considering motor impairments in children with ASD, modifications were made to the activities, such as using support tools like chairs and walls during initial sessions. The yoga poses changed every two weeks, progressing from simple to more complex exercises.

Table 1

General characteristics of participants
Characteristic	Yoga Group (12 boys)	Control Group (13 boys)	Sig ^*
Characteristic	Mean ± SD	Mean ± SD	Sig ^*
Age (y)	9.92 ± 1.60	10.35 ± 1.54	0.61
Height (cm)	136.00 ± 11.80	131.78 ± 11.74	0.31
Weight (kg)	43.69 ± 4.75	40.78 ± 7.18	0.69
ADOS-2 ^a	7.58 ± 1.37	7.46 ± 1.61	0.84
Stanford-Binet Intelligence Scales	83.33 ± 7.24	81.92 ± 6.78	0.62
* Significance level is P ≤ 0.05
^a Autism Diagnostic Observation Schedule

Table 2

Yoga training protocols over the 8-week
Weeks	Number of exercises	Yoga Poses	Number of repetitions × Time (second)
1,2	5	Swaying Palm Tree Pose, Standing Forward Fold Pose, Rising Standing Cobra Pose, Tree Pose, Palm Tree Pose	2×10–20
3, 4	6	Boat Pose, Half Locust Pose, Snake Pose, Triangle Pose, Dancer Pose, Warrior Pose	1–3×7–20
5, 6	7	Warrior Pose, Standing Forward Fold Pose, Bow Pose, Rabbit Pose, Swaying Palm, Tree Pose, Downward Facing Dog Pose, Chair Pose	2–3×10–20
7, 8	8	Warrior Pose, Pyramid Pose, Rising Standing Cobra Pose, Chair Pose, Standing Forward Fold Pose, Balancing pose, Downward-Facing Dog Pose, Rabbit Pose	2–3×20–40

Measurements

Body fat

Subcutaneous fat was assessed using the skinfold method with a Harpenden skinfold caliper (HaB Direct Ltd., UK). The 3-site skinfold protocol for males (chest, abdominal, and thigh) estimated body fat [37]. Measurements were taken on the right side while subjects stood upright. The caliper was applied to the skin, and readings were recorded in one to two seconds. Each site was re-measured for accuracy. Body fat percentage was calculated using: Body Fat Percentage (%) = (495 / Body Density) – 450, where Body Density = 1.112 – (0.00043499 x sum of skinfolds) + (0.00000055 x square of sum of skinfold sites) – (0.00028826 x age).

Cardiorespiratory endurance

Maximal oxygen consumption (VO2 max) was assessed using the 20-meter shuttle run test [38]. Children followed an audio signal, running between two 20-meter parallel lines. The test ended when they couldn't match the audio or got exhausted. Adjustments like reduced speed and evaluator assistance were made. The VO2 max prediction equation used was: Y = 31.025 + 3.238X1–3.248X2 + 0.1536AX1X2, where Y is VO2peak (mL/kg/min), X1 is maximal shuttle running speed (km/h), and X2 is age (years).

Muscular strength and endurance

The isometric push-up test assessed upper body strength and endurance [39]. Participants extended their arms under their shoulders while testers recorded the time they held a straight line. The sit-to-stand test gauged lower body strength and endurance. Participants sat on a chair, arms crossed, and stood as much as possible in 30 seconds [40]. The plank test evaluated core strength and endurance [41]. Participants held a straight body on forearms and toes, ending if discomfort arose or the position couldn't be maintained.

Flexibility

The sit and reach test assessed lower back and hamstring flexibility [42]. Participants practiced the task using the sit and reach box (DSI, DANESH SALAR Ltd) starting from the zero point on the 26 cm scale. They sat with legs flat on the floor, slowly stretched their arms forward as far as possible, holding that position for 2 seconds. Each subject had three attempts, and a valid measurement was recorded.

Static and dynamic balance

The one-leg stance test measured static balance. Participants stood on one leg with hands on hips and eyes open until they couldn't maintain it. Both legs were tested, and average time in seconds was noted [43]. The Timed Up and Go (TUG) test assessed dynamic balance. Participants completed stages involving getting up from a chair, walking a three-meter path, turning around an obstacle, returning, and sitting down [44]. TUG completion time indicated dynamic balance, with shorter times suggesting better balance.

Statistical analysis

Statistical analyses were conducted using SPSS software (version 25; IBM SPSS, Chicago, IL, USA). The data's normality was assessed using the Kolmogorov-Smirnov test. An independent sample t-test compared pre-test and post-test values between groups. The effect size was calculated using Cohen's d, with d ≥ 0.2 indicating a small effect, d ≥ 0.5 representing a medium effect, and d ≥ 0.8 reflecting a large effect.

The statistical analysis revealed no significant difference in % body fat between the yoga and control groups at baseline [T (23) = 0.78, P = 0.32]. Additionally, there was no significant difference in the post-test values between the groups [T (23) = 0.91, P = 0.37] (Fig. 1). Similarly, no significant change was found in cardiorespiratory endurance between the groups at baseline [T (23) = 0.32, P = 0.74]. Furthermore, no significant changes were found between the groups after the yoga training [T (23) = 0.39, P = 0.70] (Fig. 1).

As shown in Fig. 2, there was no statistically significant difference in baseline upper body strength and endurance values between the yoga and control groups [T (22) = 0.74, P = 0.46]. However, the results indicated significant post-test changes between the groups [T (23) = 23.11, P = 0.002; d = 0.81]. Similarly, the groups at baseline had no significant difference in lower body strength and endurance scores [T (23) = 0.15, P = 0.87]. However, a significant difference in this factor was observed after the intervention [T (23) = 14.89, P = 0.003; d = 0.90]. Regarding core strength and endurance, no significant change was found in the pre-test values between the yoga and control groups [T (23) = 1.11, P = 0.27]. However, the post-test values showed a remarkable difference between the groups [T (23) = 20.69, P = 0.003; d = 0.91]. The study’s results also revealed no significant change in flexibility pre-tests between the yoga and control groups [T (23) = 0.18, P = 0.85]. However, there was a noticeable difference in the post-test scores for flexibility between the two groups [T (22) = 17.72, P = 0.002; d = 0.72].

When comparing the groups, there were no significant differences in static [T (23) = 1.09, P = 0.28] and dynamic [T (23) = 0.49, P = 0.62] balance at the beginning of the study (Fig. 3). However, a significant change was observed in the post-test values for static balance [T (23) = 20.65, P = 0.002; d = 0.91]. Similarly, a significant difference in dynamic balance was found after the intervention [T (23) = -18.05, P = 0.02; d = 0.62].

This study aimed to evaluate the impact of yoga intervention on health-related physical fitness and balance in children with ASD. The main outcome showed that eight weeks of yoga training notably enhanced musculoskeletal fitness and balance. Nonetheless, no significant alterations were seen in body composition and cardiorespiratory endurance. While existing literature supports yoga's positive effects on physical fitness in typically developing (TD) children, limited evidence focuses on its impact on children with ASD. These results align with a recent review, which highlighted the positive effects of yoga-based programs on motor skills in individuals with ASD, demonstrating moderate to large improvements in the measured outcomes [26].

Body composition is essential for health and fitness [45]. Children with ASD engage in less physical activity, which affects their body composition [8]. This study's findings align with a meta-analysis on physical activity interventions for youth with ASD, showing no significant changes [12]. However, aquatic training demonstrated positive effects on body mass index (BMI) and fat percentage [46]. The literature on yoga is limited. A review reported no significant changes in BMI and body fat percentage in the general population [47], but continuous yoga improved BMI in obese adolescents [48]. These conflicting findings may be due to differences in exercise programs. The study didn't measure energy expenditure, and body composition can be influenced by diet. Combined therapies involving diet and exercise may be more effective for individuals with developmental disabilities [15].

Furthermore, there were no significant differences in cardiorespiratory endurance after eight weeks of yoga intervention. In contrast, a more recent review reported improved cardiovascular function in young adults with ASD following exercise-based interventions [20]. Limited information is available on yoga's effects on cardiorespiratory endurance in children with and without ASD. One study observed improvements in aerobic capacity after 12 weeks of yoga training in prepubertal children [24]. The beneficial effects of breathing activities and yoga poses on cardiac output, oxygen delivery capacity, and capillary density may explain these findings [49]. The type, duration, and intensity of physical exercise are important factors in improving the cardiorespiratory system [49]. Significant improvements in cardiorespiratory endurance have been reported with aerobic programs such as water sports or cycling. Additionally, studies focusing on exercises to strengthen respiratory muscles have observed improvements in cardiorespiratory endurance following yoga interventions [50]. Although our study observed a slight increase in cardiorespiratory endurance, the physical weakness of children with ASD limited high-intensity exercises, which may be crucial for increasing aerobic capacity. Future studies could explore longer durations of yoga intervention to assess its potential effects on cardiorespiratory endurance more comprehensively.

Musculoskeletal fitness, encompassing strength, endurance, power, and flexibility, is essential for overall health [51]. Youth with ASD typically exhibit lower musculoskeletal fitness compared to their typically developing peers [52]. Movement difficulties like poor balance and coordination in children with ASD can hinder engagement in exercises targeting specific muscle groups and overall fitness. Some may also have low muscle tone, making sustained effort challenging. Cognitive and social challenges may lead to a preference for solitary activities, reducing opportunities for physical activity [53]. In this study, significant improvements were observed in upper, core, and lower body strength and endurance after eight weeks of yoga training. These findings align with meta-analyses demonstrating improvements in muscular strength and endurance following exercise interventions in the ASD population [12, 14, 21]. While yoga has shown effectiveness for muscular fitness in children without ASD [24], results have varied [54]. Studies in children and adolescents with ASD have shown positive effects on hand grip and leg strength [29, 31]. Conflicting results may stem from differences in measurement methods, tailored to the characteristics of ASD [39]. The benefits observed in this study may be attributed to neuromuscular adaptations facilitated by yoga poses involving isometric contractions, enhancing nerve-muscle connections [55]. Childhood is a crucial period for neuromuscular development, and bodyweight exercises during this stage optimize muscular fitness [56]. In terms of flexibility, individuals with ASD tend to exhibit poor scores [53]. However, our study demonstrated improved flexibility after yoga training, consistent with some research [29, 57]. Yoga's static and dynamic stretching activities may increase the length of elastic connective tissue in the limbs, improving motion range [58]. These positive outcomes highlight the potential benefits of yoga interventions for children and adolescents with ASD in enhancing musculoskeletal fitness and flexibility.

Poor balance, difficulties with posture stability, and motor impairments are well-documented in children with ASD [59]. Several studies have focused on balance as a critical component of motor fitness and found beneficial effects of exercise interventions on standing and walking balance in individuals with ASD [12, 16]. Specifically, a recent meta-analysis reported a large, positive effect following interventions aimed at improving balance in children and adolescents with ASD [18]. Furthermore, mounting evidence indicates that yoga has positive effects on this aspect of motor fitness in the ASD population [29, 60]. Similarly, present study revealed significant improvements in static and dynamic balance after yoga training in children with ASD. However, one study reported no change in balance after creative yoga intervention, attributing it to differences in the yoga program and balance subtest used [27]. The positive effects of yoga on balance could be attributed to its impact on the proprioceptive, visual, and vestibular systems, promoting sensory integration [61]. Additionally, increased muscular fitness from yoga likely contributes to better posture control and balance [62]. Attentional focus-based activities during yoga sessions may also strengthen postural control [36]. Overall, yoga training appears to be an effective intervention for improving balance in children with ASD, potentially enhancing their motor fitness and overall physical well-being.

The present study highlights the effectiveness of yoga practice in improving the balance and musculoskeletal fitness of children with ASD. By targeting these specific fitness components, yoga training offers a promising avenue to promote overall physical health and enhance their motor skills in this population.

Autism spectrum disorder ASD

Creative movement therapies CMT

Autism Diagnostic Observation Schedule, Second Edition ADOS-2

Maximal oxygen consumption VO2 max

Timed Up and Go (TUG)

Typically developing (TD)

Body mass index (BMI)

Acknowledgment

We are extremely grateful to all subjects and their parents for participating in this study.

Conflict of Interest

The authors declare that they have no conflict of interest.

Human Rights

This study was approved by the Ethics Committee of Shahid Beheshti University and all procedures during the investigation were in line with the ethical standards of the institutional research committee and in accordance with the Helsinki declaration.

Informed Consent

All participants' parents were informed about the trials of the study and the anonymity of their answers before providing their written consent to participate, in accordance with the Declaration of Helsinki.

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No competing interests reported.

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Effectiveness of Yoga Training on the Health-related Physical Fitness and Balance in Children with Autism Spectrum Disorder

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Abstract

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Introduction

Methods

Participants

Procedures

Training Protocol

Measurements

Body fat

Cardiorespiratory endurance

Muscular strength and endurance

Flexibility

Static and dynamic balance

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1