TDC y Condicion Fisica

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Research in Developmental Disabilities xxx (2014) xxxxxx
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Physical tness in children with Developmental Coordination

Disorder: Measurement matters
Gillian D. Ferguson a,b,*, Wendy F.M. Aertssen c, Eugene A.A. Rameckers c,d,
Jennifer Jelsma a, Bouwien C.M. Smits-Engelsman b
a
University of Cape Town, Faculty of Health Sciences, Department of Health and Rehabilitation Sciences, Suite F45: Old Main Building,
Groote Schuur Hospital, Main Road, Observatory 7925, Cape Town 8000, South Africa
Katholieke Universiteit Leuven, Faculty of Kinesiology and Rehabilitation Sciences, Department of Kinesiology, Movement Control and
Neuroplasticity Research Group, Tervuursevest 101, Postbox 1501, B-3001 Heverlee, Belgium
c
Avans + University of Professionals, Department of Physiotherapy, Heerbaan 14-40, Postbox 2087, 4800 CB Breda, The Netherlands
d
Maastricht University Medical Centre, Department of Rehabilitation Medicine & Adelante Center of Expertise in Rehabilitation &
Audiology, P.O. Box 616, 6200 MD Maastricht, The Netherlands
b
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 13 December 2013
Received in revised form 29 January 2014
Accepted 29 January 2014
Available online xxx
Children with Developmental Coordination Disorder (DCD) experience considerable

difculties coordinating and controlling their body movements during functional motor
tasks. Thus, it is not surprising that children with DCD do not perform well on tests of
physical tness. The aim of this study was to determine whether decits in motor
coordination inuence the ability of children with DCD to perform adequately on physical
tness tests. A casecontrol study design was used to compare the performance of children
with DCD (n = 70, 36 boys, mean age = 8y 1mo) and Typically Developing (TD) children
(n = 70, 35 boys, mean age = 7y 9mo) on measures of isometric strength (hand-held
dynamometry), functional strength, i.e. explosive power and muscular endurance
(Functional Strength Measurement), aerobic capacity (20 m Shuttle Run Test) and
anaerobic muscle capacity, i.e. muscle power (Muscle Power Sprint Test). Results show
that children with DCD were able to generate similar isometric forces compared to TD
children in isometric break tests, but were signicantly weaker in three-point grip
strength. Performance on functional strength items requiring more isolated explosive
movement of the upper extremities, showed no signicant difference between groups
while items requiring muscle endurance (repetitions in 30 s) and items requiring whole
body explosive movement were all signicantly different. Aerobic capacity was lower for
children with DCD whereas anaerobic performance during the sprint test was not. Our
ndings suggest that poor physical tness performance in children with DCD may be
partly due to poor timing and coordination of repetitive movements.
2014 Elsevier Ltd. All rights reserved.
Keywords:
Physical tness
Strength
Anaerobic muscle capacity
Muscle power
Aerobic capacity
Developmental Coordination Disorder
South Africa
1. Introduction
The American College of Sports Medicine (ACSM) denes physical tness as a set of measurable health and skill-related
attributes that include body composition, cardiorespiratory tness (CRF), muscular tness, exibility, and neuromotor
* Corresponding author at: University of Cape Town, Department of Health and Rehabilitation Sciences, Suite F45: Old Main Building, Groote Schuur
Hospital, Main Road, Observatory 7925, Cape Town 8000, South Africa. Tel.: +27 21 406 6045; mobile: +27 82 9743924.
E-mail addresses: gillian.ferguson@uct.ac.za (G.D. Ferguson), wendyverhoef@live.nl (Wendy F.M. Aertssen), eaa.rameckers@hetnet.nl
(Eugene A.A. Rameckers), jennifer.jelsma@uct.ac.za (J. Jelsma), bouwiensmits@hotmail.com (Bouwien C.M. Smits-Engelsman).
http://dx.doi.org/10.1016/j.ridd.2014.01.031
0891-4222/ 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ferguson, G. D., et al. Physical tness in children with Developmental Coordination
Disorder: Measurement matters. Research in Developmental Disabilities (2014), http://dx.doi.org/10.1016/
j.ridd.2014.01.031
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G.D. Ferguson et al. / Research in Developmental Disabilities xxx (2014) xxxxxx
tness (Garber et al., 2011). In the last decade, physical tness in children with Developmental Coordination Disorder (DCD)
has gained recognition as an important factor inuencing performance in daily activities and as a mediator of health and
wellbeing (Wahi et al., 2011). Children with DCD are reported to have reduced levels of physical tness (Nascimento et al.,
2013; Rivilis et al., 2011; van der Hoek et al., 2012) and are considered to be at increased risk for cardiovascular problems
later in life (Cairney, Hay, Veldhuizen, & Faught, 2011).
Studies examining body composition report that children with DCD have higher body mass indices (BMI) (Rivilis
et al., 2011), higher body fat percentage (Cairney, Hay, Faught, & Hawes, 2005) and increased waist circumference
(Cairney, Hay, Veldhuizen, Missiuna, et al., 2010; Wahi et al., 2011) compared to their Typically Developing (TD) peers.
Regular participation in moderate to vigorous physical activity has therefore been recommended to reduce the risk of
children developing cardiovascular conditions later in life (Lipnowski & Leblanc, 2012). However, participation in
physical activity is often hampered by the limited motor performance capacity of children with DCD (Fong et al., 2011;
Haga, 2009).
Decreased CRF in DCD has been reported in several studies in which aerobic capacity was measured using eld-based
running tests such as the Leger 20 m shuttle run test (20 mSRT) (Rivilis et al., 2011) or less frequently, in laboratory tests
using cycle ergometry (Cairney, Hay, Veldhuizen, & Faught, 2010) and treadmill protocols (Chia, Reid, Licari, & Guel, 2013).
Laboratory-based measures of CRF (i.e. volume of oxygen consumed at maximal physical exertion/VO2max) are considered
to be the gold standard for assessing aerobic capacity, whereas eld-based measures have been criticized for the
confounding factors associated with measuring maximal effort in the absence of objective indicators of exertion (Cairney,
Hay, Veldhuizen, & Faught, 2010). In DCD specically, the main factors associated with poor performance in eld-based tests
of CRF are thought to be related to lowered perceived self-efcacy (Cairney, Hay, Wade, Faught, & Flouris, 2006), low
motivation and reduced levels of physical activity (Cairney, Hay, Faught, Wade, et al., 2005). Despite this, various authors
agree that eld-based running testing using standardized protocols, such as the Leger 20mSRT, are valid and reliable means
to assess aerobic capacity in children with and without DCD (Cairney, Hay, Veldhuizen, & Faught, 2010).
In contrast to the endurance running tests used to measure aerobic capacity, tests of anaerobic capacity include maximal
running speed tests (e.g. 10 m 5 m, 20m and 50m sprint tests). Importantly, Verschuren, Takken, Ketelaar, Gorter, and
Helders (2007) highlight that the agility requirements within the 10 m 5 m sprint test may confound the interpretation of
anaerobic capacity in children with poor coordination (Verschuren et al., 2007).
Another important attribute of physical tness is exibility. The sit and reach test is the most commonly reported
exibility measure used among children with DCD (Rivilis et al., 2011). Results show that children with DCD have a
heterogeneous exibility prole, with some studies showing poorer exibility (Cantell, Crawford, & Tish Doyle-Baker, 2008;
Hands, Larkin, Parker, Straker, & Perry, 2009) and others reporting no difference in exibility compared to TD children
(Schott, Alof, Hultsch, & Meermann, 2007; Tsiotra, Nevill, Lane, & Koutedakis, 2009).
Concerning muscular tness, three elements are typically evaluated: muscle strength, power and endurance. Findings
from studies using either isometric or isokinetic dynamometry, which are considered the most robust forms of measuring
muscular strength report that muscle strength is decreased in most muscle groups in DCD (Raynor, 2001; van der Hoek et al.,
2012). Muscle power and muscular endurance tests on the other hand, are commonly used to make inferences about
anaerobic muscle capacity. Tests of explosive muscle power examine parameters such as distance covered (e.g. throwing a
heavy ball or performing a standing-long-jump) whereas tests of anaerobic muscle endurance measure the maximal number
of repetitions within a specic time constraint (e.g. number of sit- or push-ups executed in 30 s). While the extent to which
motor coordination decits inuence performance on these tests is acknowledged (Raynor, 2001; Rivilis et al., 2011) few
studies have examined the relationship between muscle tness and task constraints in DCD.
The term neuromotor tness is a collective noun, introduced by Garber et al. (2011) to describe motor skills such as
balance, coordination, agility, and proprioceptive ability. Neuromotor tness is a skill-related component of physical tness
and considered to be important in injury prevention. Neuromotor skills are by denition, functional skills and the motor
tasks used to evaluate neuromotor tness include running, walking on a line or hopping. Outcome measures designed to
evaluate motor performance in children with DCD include standardized measures such as the Movement Assessment
Battery for Children 2nd Edition (MABC-2) (Henderson, Sugden, Barnett, & Smits Engelsman, 2010), the BruininksOseretsky
Test of Motor Prociency 2nd edition (BOT-2) (Bruininks & Bruininks, 2005) and the McCarron Assessment of
Neuromuscular Development (MAND) (McCarron, 1997). On examination of the items in these tests, it is evident that aspects
of neuromotor tness (i.e. balance, agility, coordination) are evaluated in each test.
Importantly, adequate performance in neuromotor tness tests is inuenced by the ability to mitigate the variable
inuence of external forces and environmental constraints affecting movement quality. Evidently, motor prociency plays
an important role since carefully graded and well-timed muscle contractions lead to more economical and efcient ways of
moving. Poor balance and agility in children with DCD (Chia, Licari, Guel, & Reid, 2012) may therefore explain their less
favorable performance on neuromotor tness measures. In DCD, compensatory strategies for motor control decits are likely
to inuence physical tness outcomes. One of the strategies frequently used in early stages of skill learning is co-activation of
muscles, which leads to increased stability but can also potentially hamper force production (Raynor, 2001). Since DCD is a
motor skill-learning decit by denition, it is likely that the ne-tuning (grading) of multi-joint movements used in agility or
dynamic power tests will be harder to optimize. Freezing joints may then be used as a temporary solution for controlling
degrees of freedom or as a kind of mechanical lter to suppress the effects of force variability (Smits-Engelsman & Wilson,
2013).
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The assessment of particular components of physical tness rest on the premise that the limiting factor in test
performance is fatigue following a certain time period or number of repetitions, rather than the level of difculty of the test
(Cairney et al., 2006). Importantly, this may be different for children with coordination problems. For instance, the control of
velocity and force changes that occur during an explosive throwing action and the implicit knowledge of how to use stored
energy during a standing-long-jump (by exploiting the effect of the stretch-shortening cycle) will give an experienced and
coordinated child an advantage in throwing and jumping distance even with the same generated muscle strength. In the
current study, we suggest that, as both co-ordination and tness elements are assessed concurrently.
Isolated forms of isometric or isokinetic muscle contractions, using dynamometry, could improve the validity of
measuring muscular tness in children with poor co-ordination. Hand held dynamometry (HHD) for isometric strength
attempts to isolate muscle action by controlling for joint movement. Although physical (e.g. BMI, ligament, tendon factors)
and other aspects (e.g. motivation, attention, cognitive level) inuence HHD outcomes, validity reports from studies
conducted among children are generally positive with intra-class correlation coefcient values ranging from 0.73 to 0.99
(Beenakker, van der Hoeven, Fock, & Maurits, 2001; Brussock, Haley, Munsat, & Bernhardt, 1992). Inclusion of isometric
measures is thus useful in understanding the contribution of muscle strength to function. However, in real life, actions
seldom involve a pure form of isolated muscle action. Moreover, evidence suggests that the relationship between isometric
strength and the ability to perform a functional task in which strength is required is not linear (Mattar & Sobreira, 2008).
Thus, an evaluation of the functional impact of DCD would need to incorporate both complex and simple muscle actions.
The Functional Strength Measure (FSM) is newly developed instrument, which was designed specically to measure
strength within a standardized functional task (Smits-Engelsman & Verhoef-Aertssen, 2012). The FSM measures two aspects
of muscular tness i.e. muscular endurance and explosive strength, within eight functional tasks. Tasks related to muscular
endurance include lifting a heavy box repeatedly, repetitive sitting to standing, running up and down stairs, and performing
repetitive lateral step ups. Tasks related to explosive muscle power include a standing long jump and performing a chest
pass, over- and under-hand throwing using a heavy beanbag.
In the current study, the aim was to determine whether poor performance on physical tness tests is due to muscle
weakness and poor CRF or decits in using this strength in a functional context. To determine whether coordination is an
important factor in physical tness measures, we used various outcome measures, each containing tasks with different
coordination requirements. Since most of the tests used require a certain amount of agility, we hypothesized large
differences (effect sizes) between TD and DCD groups in tests that require more coordination (e.g. standing long jump;
running up and down stairs) and small differences in simpler tasks such as single joint strength measures. The specic
objectives were to compare TD and children with DCD in terms of aerobic and anaerobic muscle capacity, isometric strength,
muscle endurance and explosive muscle power using a combination of functional and isolated measures.
2. Materials and methods
2.1. Research design and setting
A cross-sectional, casecontrol study design was conducted in three mainstream primary schools situated in a lowincome area in Cape Town, South Africa. The implementation of physical education at these schools was limited by resource
constraints and the accessibility of safe play-areas and opportunities to participate in sports and other physical activities
were limited for all children. Since only one child participated in sports, information regarding participation in physical
activity was not formally assessed.
Ethical approval and permission was granted by the University of Cape Town Human Research Ethics Committee and the
Western Cape Education Department. All parents and their children provided written informed consent and assent to
participate in this study and to publication of the results.
2.2. Participants
Children between the ages of six and ten years old, in grades 14, whose parents had given consent (N = 148) were
recruited using convenience sampling. Exclusion criteria were: (1) failing a grade more than once and (2) a diagnosis of
cerebral palsy or other signicant neurological or medical condition as reported by a parent. Three children were excluded
based on these criteria.
Children were eligible for inclusion in the DCD group if their motor function in daily life was considered to be problematic
according to their teacher and/or parent (Criterion B of the DSM IV diagnostic criteria) and they scored 5th percentile on the
MABC-2 (Criterion A of the DSM IV diagnostic criteria). Inclusion criteria for the TD control group were if their motor function
in daily life was considered to be within normal range for age and gender according to their teacher and/or parent and they
scored above the 16th percentile on the MABC-2.
Seventy children were identied as having DCD (boys = 36, girls = 34) and 75 were classied as TD (girls = 39, boys = 36)
according to our criteria. A ratio of 1:1 was used to randomly select one TD child, matched for age and gender to every child
identied with DCD. Since there were more girls in the TD group, we matched one girl of the same age to a boy with DCD and
the remaining four TD girls were excluded. The nal effective sample thus consisted of 140 children (boys = 71, girls = 69,
mean age: 8.01, SD = 1.35).
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2.3. Outcome measures

2.3.1. Anthropometric measures
Standardized anthropometric measurements were taken. Standing height (in centimeters) was measured without shoes,
heels together using a tape measure xed to a wall. Weight was measured in kilograms (0.1 kg accuracy), using a calibrated
scale and BMI was calculated using the formula (weight/height2). Waist circumference was measured in centimeters, using a
tape measure positioned around the abdomen in line with the top of the iliac crests.
2.3.2. Stand and reach test
The Stand and reach test item, taken from the Beighton Scale of Joint Hypermobility (Beighton, Solomon, & Soskolne,
1973) was used to assess exibility of the lower back and hamstring muscles. Following a brief warm up period, children
were asked to stand with feet together, and then bend forward, with straight arms and knees and place both hands at on the
oor.
2.3.3. The Functional Strength Measure (FSM)
The FSM (Smits-Engelsman & Verhoef-Aertssen, 2012) was used to assess maximal explosive power in one movement
(four items: standing-long-jump, overarm throwing, underarm throwing, and chest pass), and muscle power where weight
(body or object) was moved at maximal speed to generate a maximum number of repetitions within 30 s (four items: sit-tostand, lateral step-up, lifting a box and stair climbing). Each item consists of an instruction and demonstration phase
followed by a practice phase, where participants are encouraged to execute the task. Feedback on how to correct the
movement where necessary is given to those who demonstrate difculty during practice phase. Once testers are satised
that children know what to do (backward demonstration), formal trials may begin.
Three trials were conducted for each task and the results from the best trial were scored. After testing, the highest score
achieved on items in which left and right were tested was designated at the preferred limb for that particular item.
Test reliability is moderate to high (ICC ranging from 0.73 to 0.91) (Smits-Engelsman & Verhoef-Aertssen, 2012).
Concurrent validity of the FSM-items and handheld dynamometer is reported to range between 0.46 and 0.69 for the lower
limb and between 0.52 and 0.74 for upper limb items. This suggests that while constructs related to strength are being
tapped into during the test, it also suggests the presence of additional factors unrelated to one maximal isometric muscle
contraction. Divergent validity assessed against the MABC-2 items yielded correlation values between 0.27 and 0.50. This
suggests that items of the FSM are weakly correlated with coordination ability.
2.3.4. Hand-held dynamometer (HHD)
The MicroFET-2 (Hogan Health Industries Inc., USA) and the Lafayette Manual Muscle Testing System (Model 01163,
Lafayette Instrument Company, USA) were used to assess isometric muscle strength. The protocol for positioning and testing
children outlined by Beenakker et al. (2001) was adopted. Break tests, where the examiner gradually overcomes the
muscle strength generated by the participant, were used to evaluate elbow exors, elbow extensors and knee extensors. The
make test, dened as exerting maximal strength against the HHD, was used to asses three-point grip strength. Practice
trials were given between each new test item using verbal instruction, demonstration and practice. Participants were
corrected during practice and research assistants made sure that participants understood the requirements of the test. Each
muscle group was tested three times and peak forces, measured in Newton, were recorded for each trial. Research assistants
alternated between testing left and right sides of various muscle groups. The best scores of the three trials were used for
analysis. After testing, the highest score achieved on items in which left and right were tested was designated at the
preferred limb for that particular item.
2.3.5. Muscle Power Sprint Test (MPST)
The MPST is an intermittent sprint test consisting of six, timed 15 m sprints (Verschuren et al., 2007). It was designed to
measure muscle power with good reliability (Douma-van Riet et al., 2012). The time to complete each run is measured in
milliseconds. Power output is calculated using the equations specied by Verschuren et al. (2007). Peak power is dened as
the highest power that is generated of all six sprints and the mean power is the average power output over the six sprints.
Greater mean power indicates the ability to maintain power output over time and is representative of anaerobic running
performance.
The 15 m distance required for the MPST was marked by a painted line on the playground and cones were placed 1 m
beyond the line where children were encouraged to stop. Children were tested in groups of three to six and were instructed
to run as fast as possible and cross the line. Explanations and practice trials were given followed by a brief rest period before
the actual trial. A 30-s rest was allowed between trial runs.
2.3.6. 20 m Shuttle Run Test (20mSRT)
The 20mSRT was used to measure aerobic tness (Leger, Mercier, Gadoury, & Lambert, 1988). A practice trial was given
and a short rest period included before the start of the actual trial. Participants were verbally encouraged to keep running for
as long as possible. For some children, it is difcult to run at the audio signal that determines the running speed. Therefore,
one tester ensured that children understood the principle of the Shuttle Run Test by running with them throughout the test.
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Since it is understood from the literature that BMI may be a confounding factor in performance of children with DCD
(Tsiotra et al., 2009) we used the Matsuzaka formulae (Matsuzaka et al., 2004) to calculate VO2max in this study. This
formula takes into consideration the impact of gender and body mass index (BMI) on VO2max and may yield more valid
estimates of CRF (Barnett, Chan, & BruceIain, 1993; Matsuzaka et al., 2004; Ruiz et al., 2008). The Leger formula was also
calculated for comparison.
2.4. Procedure
Recommendations outlined in the Diagnostic and Statistical Manual of Mental Disorders IV (American Psychiatric
Association, 2000) were used to identify children with DCD. Initially, teacher and parent questionnaires were administered
to determine whether the childs motor coordination ability affected their performance in everyday life (Criterion B of the
DSM IV diagnostic criteria). The questionnaire, developed by the authors, consisted of a description of common functional
problems that children with DCD present with and one closed- and one open-ended question asking parents and teachers to
give their opinion regarding whether they thought the child had a motor coordination problem and why they thought so.
Next, the Movement Assessment Battery for Children 2nd edition (MABC-2) (Henderson, Sugden, & Barnett, 2007) was
used to identify children whose motor performance scores were at or below the 5th percentile (Criterion A of the DSM IV
diagnostic criteria).
All children participated in a standardized warm up phase before testing which including marching across the
playground while swinging arms. This was followed by a brief rest period in which the individual tests were explained. Each
test was conducted a different day over a period of one week. Running tests (MPST and 20mSRT) were performed on a tarred
playground and other tests (FSM and HHD) were conducted in a quiet room on the school premises. All tests were conducted
by physiotherapists and physiotherapy students who received training on the instruments used and were unaware of the
childs group afliation.
2.5. Data analysis
A power calculation was conducted based on the means and standard deviations of results obtained in previous studies
using the 20mSRT (Cairney, Hay, Faught, Flouris, & Klentrou, 2007) and sit-to-stand scores of the FSM (Smits-Engelsman &
Verhoef-Aertssen, 2012). Using an online sample size calculator we determined that sample sizes between 32 and 43
children per group would be sufcient to detect a difference at p = 0.001 level with 80% power (http://www.stat.ubc.ca).
All data were analyzed using SPSS 20.0 (IBM, 2011). Pearsons Chi-square test was used to compare differences in gender
and preferred hand between groups. ShapiroWilks tests showed that tness data were not normally distributed, thus raw
scores were transformed using natural logs. Independent t-tests (two-tailed) were used to compare outcomes between
groups. The post hoc ANCOVA procedure was used to test if the between-group effect remained signicant if BMI was used as
a covariate. Alpha was set at 0.05. Estimates of effect size (Cohens d) were calculated for group comparison. This measures
the magnitude of the difference between the mean scores of groups, divided by a pooled SD. The magnitude of the mean
effect size estimates (d) were interpreted according to the conventions of Cohen: 0.30 (small), 0.50 (moderate), 0.80 (large)
and >1.00 (very large effect size) (Fern & Monroe, 1996).
3. Results
Groups (TD n = 70, DCD n = 70) were comparable in terms of age, gender, handedness and height. However, weight, BMI,
and waist circumference were signicantly higher for the DCD-group. Four children were overweight (>85th percentile) in
the TD and nine in the DCD-group. The differences between the two groups of children are presented in Table 1.
Table 2 shows the results of the group comparison on the physical tness tests.
Table 1
Characteristics of participants with Developmental Coordination Disorder (DCD) and age-matched Typically Developing (TD) children.
Variable
TD (N = 70)
DCD (N = 70)
Statistics
MABC-2 standard score

Gender (n)
11.2 (2.1)
Boys = 35
Girls = 35
92.9
7y 9mo (1y 4mo)
1.3 (0.1)
27.4 (5.5)
57.0 (9.6)
16.4 (1.8)
3.7 (1.4)
Boys = 36
Girls = 34
91.4
8y 1mo (1y 3mo)
1.3 (0.1)
30.2 (9.3)
60.4 (8.7)
17.6 (3.2)
t = 25.3, p < 0.001

Chi = 0.03; p = 0.87
Preferred hand (% right handed)

Age (mean (SD) in years, months)
Height (mean (SD) in m)
Weight (mean (SD) in kg)
Waist circumference (mean (SD) in cm)
BMI (mean (SD) in kg/m2)
Chi = 0.10; p = 0.75

t = 0.8; p = 0.45
t = 0.5; p = 0.62
t = 2.2; p = 0.03
t = 2.2; p = 0.03
t = 2.8; p = 0.05
MABC-2: Movement Assessment Battery for Children 2nd Edition; SD: standard deviation; m: meters; kg: kilogram; cm: centimeters; BMI: body mass
index; TD: Typically Developing; DCD: Developmental Coordination Disorder.
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Table 2
Descriptive results [mean (SD)] of aerobic capacity, muscle strength and muscle power of the Developmental Coordination Disorder (DCD) and agematched comparison group (TD).
Variable
TD (n = 70)
Mean (SD)
DCD (n = 70)
Mean (SD)
Functional strength measure

Overarm throwing [cm]
Standing-long-jump [cm]
Underarm throwing [cm]
Chest pass [cm]
Sit-to-stand [repetitions/30 s]
Lifting box [repetitions/30 s]
Stair climbing [steps/30 s]
Lateral step-up (preferred leg) [repetitions/30 s]
Lateral step-up (non-preferred leg) [repetitions/30 s]
204.9
112.2
284.2
170.4
26.9
19.7
73.6
35.1
32.3
(55.1)
(22.4)
(68.2)
(32.4)
(4.4)
(5.6)
(11.1)
(5.7)
(4.9)
201.0 (63.3)
99.19 (27.31)
262.8 (81.2)
161.6 (44.2)
20.0 (4.8)
16.2 (5.9)
61.0 (11.3)
27.8 (5.6)
25.5 (5.8)
0.61
3.39
1.99
1.74
8.87
3.94
6.66
7.30
7.14
0.54
0.001
0.048
0.08
<0.001
<0.001
<0.001
<0.001
<0.001
Muscle Power Sprint Testa

MPST mean power [W]
MPST peak power [W]
20mSRT [level]
VO2max [ml/min/kg]-Leger
VO2max [ml/min/kg]-Matsuzaka
108.5
128.9
2.4
45.9
45.4
(39.6)
(49.1)
(1.3)
(2.7)
(3.3)
100.7 (42.5)
122.0 (50.5)
1.4 (0.7)
43.6 (2.7)
42.3(4.0)
1.49
1.07
6.50
4.94
4.81
0.14
0.28
<0.001
<0.001
<0.001
103.2
91.7
82.2
73.6
50.0
44.0
142.1
(25.8)
(24.8)
(19.1)
(19.1)
(13.5)
(12.1)
(37.3)
103.6
93.3
87.6
75.7
42.6
36.2
157.3
0.15
0.53
1.45
0.64
3.20
3.83
2.08
F = 1.54, p = 0.22
2.1
F = 1.70, p = 0.19
0.88
0.60
0.15
0.52
0.002
<0.001
0.04
Handheld dynamometera
Flexion elbow (preferred arm) [N]
Flexion elbow (non-preferred arm) [N]
Extension elbow (preferred arm) [N]
Extension elbow (non-preferred arm) [N]
Three-point grip (preferred hand) [N]
Three-point grip (non-preferred hand) [N]
Extension knee (preferred leg) [N]
Extension knee (preferred leg): ANCOVA with BMI as covariate
Extension knee (non-preferred leg) [N]
Extension (non-preferred leg): ANCOVA with BMI as covariate
124.9 (32.6)
Flexibility
Number of children able to get hands on oor in standing
(27.6)
(26.8)
(22.7)
(20.2)
(11.1)
(9.5)
(43.1)
139.6 (41.3)
0.04
Chi = 0.15, p = 0.70
TD: Typically Developing; DCD: Developmental Coordination Disorder; CI: Condence Interval; SD: standard deviation; cm: centimeters; s: seconds; MPST:
Muscle Power Sprint Test; 20mSRT: 20 m Shuttle Run Test; N: Newton.
a
Data of 8 TD children missing from this analysis.
Analysis of the FSM-items showed that the items requiring more isolated explosive movement of the upper extremities
(Overarm throwing, and Chest pass) were not different, while items requiring whole body explosive movement with large
arm swings-underarm throwing (p = 0.048) and the standing-long-jump were signicantly different (p = 0.001). The muscle
power items, requiring as many repetitions as possible in 30 s, were all signicantly lower for the DCD group (Table 2) and
yielded large to very large effect sizes (d = 0.621.50) (Table 3).
Table 3
Effect sizes of the variables that were signicantly different between groups.
Variable in descending order of effect size
MABC-2 total standard score
Sit to stand
FSM total standard score
Lateral step-up (preferred)
Climbing stairs
Lateral step-up (non-preferred)
20 m shuttle run
VO2max-Le`ger formula
VO2max-Matsuzaka formula
Grip force (non-preferred)
Lifting a box
Grip force (preferred)
Standing long jump
Weight
Waist circumference
Knee extension (preferred)
Knee extension (non-preferred)
Body mass index (BMI)
Effect size (Cohen d)

4.35
1.50
1.46
1.30
1.28
1.18
1.06
0.86
0.85
0.73
0.62
0.60
0.52
0.38
0.37
0.38
0.40
0.50
Effect sizes (d) are interpreted according to the conventions of Cohen: 0.30 (small), 0.50
(moderate), 0.80 (large) and >1.00 (very large effect size). MABC-2: Movement
Assessment Battery for Children 2nd Edition. FSM: Functional Strength Measure.
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Apart from the strength of the knee extensors being higher in DCD, there was no signicant difference in the results of
isometric break test items between groups. After correcting the comparison for higher BMI by means of an ANCOVA these
effects were not longer signicant. Three-point grip strength was less in DCD (p 0.002).
Data were not available for eight TD children on the MPST and 20mSRT due to absence on day of testing. The overall
measures of aerobic tness (20mSRT, VO2max-Leger, VO2max-Matsuzaka) were much lower for the DCD-group, showing
very large effect sizes (d = 1.06, 0.86 and 0.85, respectively) even after correction for BMI. The anaerobic test (MPST) yielded
no signicant difference between groups.
Flexibility scores based on the stand and reach test revealed no signicant differences when comparing the two groups
(p = 0.70).
4. Discussion
Skilled motor performance requires the integration of multiple systems, including the neuromuscular, sensory,
cardiopulmonary and cognitive systems. We hypothesized that different measures of cardiorespiratory and muscle tness
would highlight the differences in performance between groups of children with and without DCD. Our ndings are that
children with DCD respond differently to TD children on tests of physical tness and that the difference is larger in tasks that
require more coordination.
4.1. Body composition
Our ndings support conclusions from other studies reporting higher BMI, weight and waist circumference
measurements in DCD (Rivilis et al., 2011; Zhu, Wu, & Cairney, 2011). These ndings are likely a reection of decreased
physical activity levels and lower tness often reported in overweight children with DCD (Cairney, Hay, Veldhuizen, &
Faught, 2010) or may be due to alternative hypotheses suggested by Cairney and Veldhuizen (2013). Obesity among children
with DCD may also arise from other factors related to diet, appetite and metabolism (Cairney & Veldhuizen, 2013).
While it is known that obesity affects motor performance outcomes (DHondt et al., 2011, 2013) the present study, using
comparative analysis with correction of BMI levels, still revealed disparities in the execution of most of the activities in which
moving the whole body was required (e.g. standing-long jump, stairs, lateral step-up and sit to stand) highlighting the
importance of motor skill level in tness testing.
4.2. Aerobic capacity
Our ndings regarding aerobic capacity are congruent with previous studies demonstrating decreased aerobic capacity in
children with DCD relative to their TD peers (Rivilis et al., 2011). The use of the Matsuzaka formula (Matsuzaka et al., 2004)
yielded similar ndings to the Leger formula, suggesting that BMI and gender do not have a large inuence on aerobic
capacity as suspected (Tsiotra et al., 2009).
The fact that children with DCD performed poorly in the 20mSRT may be due to the variation in running style and
consequent physiological response to running compared to their TD peers. Reports showing greater kinetic and kinematic
variation in running style along with higher metabolic costs and greater sensitivity to pain (Chia et al., 2013) may explain
why children with DCD withdraw from the 20mSRT sooner than the TD children.
The poor performance seen in DCD may be due to constraints related to coordination, timing and pacing. The 20mSRT
requires participants to pace themselves according to the time between beeps. This pacing is reliant on perception of
available time and planning running speed. It is reported that children with DCD have problems with timing and planning.
Correlations between eld-based testing and lab-based measures are reported to be signicantly lower among children
below the 6th percentile on the MABC-2, specically girls (Cairney, Hay, Veldhuizen, & Faught, 2010). There is the potential
that in children with DCD, the 20mSRT measures ability to match the speed and task requirements of the activity rather than
aerobic endurance.
4.3. Muscle tness
Regarding muscular tness, we offer new insights by identifying no difference in scores related to the generation of peak
isometric strength in elbow exors and extensors and knee extensors; no differences in more isolated explosive power
movements of the upper limbs; poor performance on repetitive dynamic strength tasks; weakness in three-point grip
strength, and decreased explosive power in items requiring whole body explosive movements. Effect sizes for the different
physical tness outcomes indicate that tasks with higher coordination demand show larger differences between TD and DCD
groups. Our ndings suggest that one should chose tests that require less coordination when assessing physical tness in
DCD.
Isometric muscle testing is interpreted as a valid measure of muscle strength (Beenakker et al., 2001) and the advantage of
this form of testing is that due to the xed measurement position little confounding by motor control problems can occur.
We found no differences in isometric break tests for the elbow exors and extensors. In contrast, others report signicantly
decreased isometric muscle strength in these muscle groups using handheld dynamometry (van der Hoek et al., 2012).
j.ridd.2014.01.031
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8
Three-point grip strength was signicantly decreased (1518%) in DCD implying that isometric force generation of wrist
and ngers muscles specically is impaired consistent with ndings, which may lead to problems in manual tasks where
force generation is required. A study by van der Hoek and colleagues, contradicts our ndings as they reported no difference
in grip strength in DCD compared to TD children (van der Hoek et al., 2012).
The difference is likely due to differences in the grip type of different dynamometer. Whereas the protocol for measuring
grip strength using the MicroFET HHD in the present study (Beenakker et al., 2001) requires two ngers and the thumb to
push in opposite directions, the protocol for the Jamar HHD, used by van der Hoek and colleagues required a full st grip (van
den Beld, van der Sanden, Sengers, Verbeek, & Gabreels, 2006). Thus depending on the instrument protocol used, grip
strength is likely to vary.
In the present study, grip force was measured using a make test where participants were required to push against a
transducer head using their own maximal generated effort and not oppose the force of the examiner. In comparison, other
isometric tests used in this study involved the break method where tactile feedback is given in terms of the direction. This
may imply that generation of force in the absence of feedback resistance (as in break tests) is more difcult for children with
DCD.
Knee extensor strength was higher in the DCD group. This was considered an unusual nding as all other HHD values
were poorer for the DCD group and a previous study reported lower knee extension strength in DCD (Raynor, 2001). A
possible explanation may be that lower limb muscle strength in children with higher BMI would have adapted in response to
their walking about with increased body weight. We therefore added BMI as covariate and re-examined the differences
between groups. As hypothesized, the differences in knee extensor strength were no longer signicant. Similar ndings
regarding no differences in knee extension strength are conrmed by van der Hoek et al. (2012).
Our results imply that a routine clinical examination using dynamometry may not identify functional strength problems
in children with DCD, who may appear to have comparable levels of muscular strength to TD children.
4.4. Anaerobic capacity
Signicant differences between groups were noted during explosive power tasks on the FSM depending on the nature of
the task. Standing-long-jump, a commonly used test of explosive leg strength (Castro-Pinero et al., 2010) and underarm
throwing was signicantly poorer whereas tasks involving overhand throwing or pushing a heavy weight (chest pass)
showed no difference between groups. Our ndings regarding performance on standing long jump tests are supported by
other studies where children with DCD are reported to have poorer performance on explosive tests such as the standing
broad jump (Hands & Larkin, 2006; Kanioglou, 2006) or vertical jump test (Tsiotra et al., 2009).
Differences in outcome may be attributed to the technique used to perform these movements. During the overhand
throwing item, the child is required to lift a beanbag weighing 23 kg using two hands to behind the head and throw it from
this position as far as possible forwards.
The item was designed to limit the amount of trunk rotation as he child adopts a wide stance and the generation of force is
more isolated to the upper extremities. In the same way, the execution of the chest pass, attempts to isolate force to the
upper extremities by ensuring the childs back remains rmly against the wall during the throw.
In contrast to these more isolated explosive movements, the standing long jump and underhand throw allow for more
whole body movement. The ability to jump requires coordination of both the upper and lower limbs to generate sufcient
power at the right time to propel the body forward. Releasing energy stored during the preparatory movement at the
appropriate moment allows the child to jump further. In the same way, the underarm throw involves inging a weighted bag
from between the legs while rapidly extending the legs at the end of the arm swing to propel the bag through the air. The
timing and coordination of the arm swing along with muscle power therefore allows the bag to travel further.
Our ndings suggest that children with DCD may have difculty coordinating the throw and the jump and not necessarily
generating force as the isometric tests show that their knee extensors and elbow extensors were as strong as the TD group.
We therefore conclude that the timing and coordination components may be more important than strength in the
performance of these specic tests of explosive power.
Muscle power is most frequently tested using timed tests, in which body weight has to be moved with maximal speed
related to a high number of repetitions. Studies suggest that children with DCD perform poorly in this type of test (Cantell
et al., 2008; Kanioglou, 2006). As the coordinative demand of an anaerobic task increases, differences in performance power
emerge.
It appears that while children with DCD have the capacity to keep up with peers by generating enough power to sprint
short distances in a straight line, as in the MPST, problems with running emerge in the 20mSRT when longer running (aerobic
capacity), plus motor planning and pacing are required. The MPST has lower coordinative requirements as it was originally
designed for use among children with CP and therefore does not require high levels of agility (Verschuren et al., 2007). That
children with DCD performed well implies task complexity mediates performance.
In our study, differences in stair climbing, sit-to-stand and lateral step-up were large (d > 1) in the DCD group, even
though knee extension strength and sprint test outcomes in the DCD group were similar to the TD children. The motor
coordination requirements of muscle power items of the FSM are considered higher compared to isometric tests and
movement problems can decrease the outcome on dynamic strength tests. Indeed, our ndings support the hypothesis that
children with DCD exhibit greater difculty in tasks where multiple repetitions of the same movement are executed under a
j.ridd.2014.01.031
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load. We attribute their poor performance to difculty in automating movements. Failure to generate stable and efcient
movement representations makes the execution of repetitive consecutive movements less predictable, which would elicit
higher levels of co-activation and consequently restricts agility (Damiano, 1993).
Compelling evidence suggests that cerebellar learning helps to automate timing and sensory prediction with respect to
specic motor responses (Fawcett & Nicolson, 1992; Miall, 1998; Nicolson, Fawcett, & Dean, 2001). The deviant functioning
of the cerebellum has been implicated as one of the primary causes that hampers the ability to predict the sensory
consequences of actions in DCD (Wilson, Ruddock, Smits-Engelsman, Polatajko, & Blank, 2013). This leads to a lack of
anticipatory postural adaptations and an increased need for balance responses. As a result, skills like running up and down
stairs or lifting boxes up and down fast will become slower and inaccurate, and in need of more visual control.
4.5. Flexibility
Flexibility outcomes are consistent with ndings suggesting that children with DCD are not different to TD children
(Schott et al., 2007; Tsiotra et al., 2009) and contradicts ndings from other studies suggesting that exibility is poorer in
DCD (Cantell et al., 2008; Li, Wu, Cairney, & Hsieh, 2011). The present study used the stand and reach test whereas other
studies have used sit and reach tests and this may have inuenced the outcome. Nevertheless, our ndings suggest that
exibility is highly individualized among children with DCD.
4.6. Limitations and recommendations
In the current study the TD group performed better than the DCD group on the aerobic tness test. This may support those
studies which have attributed the decreased aerobic capacity to the variable running style seen in DCD. However, our
ndings are limited by the absence of physical activity measures and we recommend the inclusion of accelerometers in
future studies to conrm level of physical activity since this could be a moderating factor.
Considering that children with DCD have difculty learning new motor tasks, it is possible that some of the observed
differences in performance between groups may have been due to the novelty of the tasks presented. Task novelty implies
that the task presented is new to the child and has never been executed in this manner before. Importantly, in the FSM,
shuttle run and sprint tests, most items, are consistent with everyday activities that children (including those with DCD)
would learn implicitly during play. However, performing a repetitive lateral step up or repeatedly lifting a box are examples
of activities that may be less familiar to the child as the repetitive action required in the test could be viewed as an
uncommon activity in everyday life.
According to the stages of motor learning theory described by Fitts and Posner (1967), learning to perform a novel task
occurs in the cognitive phase. During this phase, motor performance is characterized by inconsistent and less coordinated
movement patterns. Thus, even though researchers included practice trials before the start of formal trials on all tests, to
minimize the impact of novelty, it is likely that children with DCD struggled or failed to automatise these skills within the
short duration of the practice phase. The impact of task novelty on motor performance suggests that motor learning may
plays an important role in the skilled execution of physical tness tasks in children with DCD. Moreover, poor performance in
endurance tasks could be attributed to the relative increase in co-contraction or less well-predicted movement outcomes.
However, since this was not explicitly tested in this study these factors may be of important consideration for future studies.
5. Conclusions
It appears that physical tness testing in children with DCD is confounded by their motor coordination ability. Our results
suggest that performance in tness tests is largely dependent on the constraints of the task used in assessment. It seems that
children with DCD are not merely lacking the ability to exert maximal force (apart from three-point grip strength), but have
deciencies in performing dynamic activities at a high rate. Comprehensive assessment, while including functional testing,
requires that measures of strength and aerobic capacity should isolate these from co-ordination ability.
As we have demonstrated that measurement matters we propose that the way in which physical tness is measured in
DCD children should be adapted to the reported neuromotor constraints. Measurements with low coordination, agility and
balance requirements would be ideal.
Through analysis of the results in this paper we are reminded that our understanding of physical tness in children with
DCD is intrinsically linked to understanding aspects of motor control and motor learning. Fitness interventions on their own
will not necessarily result in improved performance, unless coordinative ability within functional tasks is similarly
addressed. For optimal results, improving physical tness in children DCD requires methods based on functional task
training and encompassing aspects of motor learning.
Acknowledgements
The rst author received funding from the University of Cape Town Research Committee. The funders had no inuence on
the nature or design of the study. The authors acknowledge the contributions of the physiotherapists and students who
j.ridd.2014.01.031
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10
assisted with data collection. We also acknowledge the support of the principals, teachers and support staff at each school as
well as the parents and children who participated in the study.
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RIDD-2199; No. of Pages 11

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Physical tness in children with Developmental Coordination

Children with Developmental Coordination Disorder (DCD) experience considerable

RIDD-2199; No. of Pages 11

G.D. Ferguson et al. / Research in Developmental Disabilities xxx (2014) xxxxxx

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2.3. Outcome measures

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MABC-2 standard score

t = 25.3, p < 0.001

Preferred hand (% right handed)

Chi = 0.10; p = 0.75

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Functional strength measure

Muscle Power Sprint Testa

Chi = 0.15, p = 0.70

Effect size (Cohen d)

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RIDD-2199; No. of Pages 11

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