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School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
For children with autism, does physical exercise reduce self-stimulatory behaviors?
Prepared By:
Austin Lepper, OTS and Kerielle Williams, OTS
Department of Occupational Therapy
Touro University of Nevada
874 American Pacific Drive
Henderson, NV 89014
Date Review Completed:
10/13/2014
Clinical Scenario:
Many children seen for outpatient occupational therapy (OT) services have some form of
Autism Spectrum Disorder (ASD). To minimize an inactive lifestyle leading to health problems
among children with ASD, there is a need to identify modes or types of recreational activity to
promote physical activity, motor skills, and physical fitness with these children. Autism is
typically not diagnosed until around 2 years of age. However, parents often notice symptoms
before then (Magnusson and Cobham, 2012).
Teaching and encouraging self-monitoring of an exercise program may be one method of
promoting a physically active lifestyle for individuals with autism. Occupational therapists are
qualified to create an intervention program that includes edible reinforcement, verbal cuing, and
self-monitoring on sustained physical activity of adolescents and young adults with autism (Todd
and Reid, 2006). Unfortunately, physical activity intervention is often overlooked in individuals
with ASD. The evidence suggests that children with ASD can be introduced to a physical activity
training program and learn a variety of skills under close supervision as well as structured
teaching and various supports. Such programs can be performed in addition to their regular
treatments and might enhance the results of such interventions.

For example, studies show that swimming can enhance a childs competence and foster an
appreciation of proficient movement. Aquatic activity exercises the total body without putting
excessive stress or tension on specific body parts. The warm aquatic environment and splashing
enhance normal muscle tone, allowing more efficient movement (Pan, 2010). Evidence show
relationship between motor skills and intelligence has been demonstrated in various motor fields
such as performance skills, gross and fine motor skills, coordination, and balance. Additionally,
physical exercise plays a central role in developing cognitive functioning in intellectual disability
individuals. Furthermore, exercise not only improves the physical condition of individuals with
ASD but also reduces maladaptive behaviors (Aksay and Alp, 2014).
Summary of Key Findings:
Summary of Levels I, II and III:

Autistic children in the experimental group showed better self-control than those
in the control group after the one month intervention. (Chan, Sze, Siu, Lau,
Cheung, & Fatemi, 2013, Level I)

Results indicate that the environment provided enables individuals to develop

physical skills within the intervention process and enhances their behavioral and
social skills in the future. (Pan, 2010, Level II)

Both aerobic and muscular strength-training programs produce positive fitness

gains. (Lochbaum & Crews, 2003, Level III)

Results indicated that students with and without ASD spent a larger percentage
of time in MVPA during physical education compared with recess period,
relative to the amount of time spent in those settings. (Pan, 2008, Level III)

Significant overall group differences were found on muscular strength and

endurance as well as aquatic skills. (Pan, 2010, Level II)

The participants overall scores increased significantly on the push-up and pullup tests. (Aksay & Alp, 2014, Level III)

The benefits of engaging individuals with ASD in an individually-tailored, highintensity exercise program improves all physical fitness and behavioral outcomes
for cardiorespiratory fitness and abdominal strength as well as positive behaviors
in physical activity. (Magnusson, Cobham, McLeod, 2012, Level III)

No significant between-group differences were found. (Fragala-Pinkham, Haley,

ONeil, 2011, Level II)

Summary of Level IV:

The results suggest that interventions can be developed to promote sustained

participation in physical activity for individuals with autism. (Todd & Reid,
2006, Level IV)

Contributions of Qualitative Studies:

Not included in this review
Bottom Line for Occupational Therapy Practice:
The clinical and community-based practice of OT:
Practicing occupational therapists (OT) should be aware that physical exercise has been found
effective in enhancing the self-control of individuals with various brain disorders, such as autism
spectrum disorder (ASD). Therapists should implement a physical activity program involving
training three times a week to improve motor skills and positively affected physical performance
when working with children with ASD. Implication of physical activity helps to develop physical
skills and possibly enhance behavioral and social skills in the future with this particular
population. OTs should know that children with ASD can respond to a training stimulus as
physical fitness components especially muscular strength and endurance, which is an important
factor when designing an appropriate client-centered intervention plan.
Program development:
When implementing a physical exercise program into an intervention for a child with ASD, it is
important to remember these activities will be more effective when used in conjunction with
other evidence-based research practices and techniques. The training discussed within these
studies could be used as a guide for OTs to use in practice and could be used to help develop
future protocols when working with children with ASD.
Societal Needs:
Due to the occurrence of ASD in children, OTs need to learn how to address physical activity in
the context most effective with the client in order to maximize societal need. With further
research, these interventions have the potential to maximize the number of individuals with ASD
who can receive physical exercise in therapeutic rehabilitation, and implementation of these

programs can be used in the both home environment as well as during inpatient or outpatient
rehabilitation
Healthcare delivery and policy:
Although results from this study are preliminary, they are statistically significant enough to
impact health care and the way OTs administer physical exercise programs with children with
ASD. However, due to low representativeness from the larger ASD population, it would be
advisable to accumulate further evidence before recommending this physical exercise program to
address appropriate interventions with ASD clients. Further accumulation of evidence with a
larger, more representative sample is necessary. Further research is warranted prior to advising
healthcare policy-makers.
Education and training of OT students:
Children with ASD are a high risk population and it is recommended that OT students receive the
proper training during their school course work and they should be educated on the importance
of physical activity implementation in their intervention. Knowledge on the interventions
included in rehabilitation in children with ASD, specifically in regards to the use of physical
exercise, should be included in the general education and training of OT students.
The completion of more evidence-based research studies, perhaps more guidelines can be
established and taught to OT students regarding how to improve behaviors in children with ASD.
Refinement, revision, and advancement of factual knowledge or theory:
The results of these studies show that physical exercise programs can be an effective treatment
strategy for reducing negative behaviors and improving daily functioning is strong enough
evidence to justify further research in this area. These exercise programs and the concepts behind
them should be utilized by more OTs, as it uses purposeful activity to promote appropriate
behaviors and make changes in the way in which clients with ASD respond to therapy. These
studies confirm results consistent with other articles and reviews, stating that physical activity
improves performance but not disability in children with ASD. Further research is warranted
with this population as well as the interventions that are found successful in children with ASD.
Review Process:

Topic was selected by two second year students in masters program

Focused question was developed by student with input and submitted for approval from
course instructor
Key terms for Patient Population, Intervention, and Outcome were developed by student
Student conducted a comprehensive literature search of databases
Abstracts which matched the P, I, O criteria were included in literature search
Full-text copies of articles identifies as relevant were located and saved for review
Databases were searched individually to ensure all relevant research was included in
literature search
Course instructor reviewed literature search for completeness

Based on this review, some articles were eliminated as they did not meet inclusion
criteria
Articles that met all inclusion criteria were included in the Evidence Table and analyzed
Evidence table was submitted for approval from course instructor
Completed CAT based on information from evidence table and supporting articles found
during comprehensive literature search
CAT was submitted to course instructor for final approval.

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:

Research articles published in peer review journals

Articles written in English
Research articles fit the population, intervention, and outcome

Exclusion Criteria:

Qualitative data was excluded from this critical analysis

Dissertations, thesis papers, and articles not written in English
Articles that included participants older than 21 years of age
Studies that were conducted prior to 2003

Search Strategies:
Categories
Patient/Client Population

Key Search Terms

Child, adolescence, Autism Spectrum Disorder

Intervention

Physical exercise

Outcomes

Strength, motor, performance, endurance, activity

Databases and Sites Searched

EBSCO, PsychInfo, Google Scholar
Quality Control/Peer Review Process

Search terms were developed in consultation with the instructor of record for OCCT 643

Systematic Reviews of the Literature in Occupational Therapy

Search terms were expanded through EBSCO Host
Searches of all relevant databases were conducted
Literature review was submitted to instructor of record to ensure all relevant literature
was identified and included in the study
Instructor of record confirmed correct identification of levels of evidence
An evidence table was completed using all articles relevant to focused question
Evidence table was submitted to instructor of record for review of thoroughness and
inconsistencies
Students completed the CAT and submitted for final instructor of record approval

Results of Search
Summary of Study Designs of Articles Selected for Appraisal
Level of
Evidence
I

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized
controlled trials (RCT)
Two groups, nonrandomized studies (e.g., cohort,
case-control)
One group, nonrandomized (e.g., before and after,
pretest, and posttest)
Descriptive studies that include analysis of outcomes
(single subject design, case series)
Case reports and expert opinion, which include
narrative literature reviews and consensus statements
Qualitative Studies
TOTAL:

II
III
IV
V
Other

Number of Articles
Selected
1
3
4
1
0
0
9

Limitations of the Studies Appraised:

Levels I, II, and III

Participants belonged strictly in the Chinese culture. All of the participants were
males and had an IQ below 70. (Chan, Sze, Siu, Lau, Cheung, & Fatemi,, 2013,
Level I)
Researchers used a very small sample size and there were more male participants
than female. Also, the individualization of each subjects program could limit the
generalizability of the findings to less structure, more generic exercise programs.
(Magnusson, Cobham, McLeod 2012, Level III)
The researchers used a student of the university to administer the assessment.

The assessment used had to be adapted to meet the needs of the children with
ASD, causing the rules to be unclear. (Aksay & Alp, 2014, Level III)
The researchers used a small sample size of only male participants and their age
range was small. (Pan, 2010, Level II)
Participants ages varied only slightly and only motor skills were assessed. (Pan,
2010, Level II)
There was a small sample size used in the study and there was a lack of
randomization. Also, the outcomes were measured using the Swimming
Classification Scale and the YMCA Water Skills Checklist, neither have been
validated. 9Fragala-Pinkham, Haley, ONeil, 2011, Level II)
The study involved only five participants, a very small sample size. (Lochbaum
& Crews, 2003, Level III)
The study was conducted using a small sample size. All participants were from
the same geographical are of high social and economic deprivation in a large
urban city. The assessment was on only 1 or 2 physical education units per
student. There was a potential for cultural and educational bias, and differences
in social skills, behaviors, cognitive abilities, and gross motor skills were not
considered. (Pan, 2008, Level III)

Levels IV

There was very small sample size of three participants, all of which were
Canadian. Also, a school director had chosen the participants for the researcher.
(Todd & Reid, 2006, Level IV)

Articles Selected for Appraisal:

Aksay, E., & Alp, A. (2014). The effects of a physical activity rehabilitation program on the
motor skill and physical performance of children with autism spectrum disorder (ASD):
Movement therapy and ASD. International Journal of Academic Research, 6 (1). 12-19.
Chan, A. S., Sze, S. L., Siu, N. Y., Lau, E. M., Cheung, M., & Fatemi, H. (2013). A Chinese
Mind-Body Exercise Improves Self-Control of Children with Autism: A Randomized
Controlled Trial. PLoS ONE, 8(7), e68184.
Fragala-Pinkham, M., Haley, S., ONeil, M., (2011). Group swimming and aquatic exercise
program for children with autism spectrum disorders: A pilot study. Developmental
Neurorehabiliatation, 14(4). 230-241.
Lochbaum, M. (2003). Viability of Cardiorespiratory and Muscular Strength Programs for the

Adolescent with Autism. Complementary Health Practice Review, 8(3), 225-233.

Magnusson, J., Cobham, C., McLeod, R. (2012). Beneficial Effects of Clinical Exercise
Rehabilitation for Children and Adolescents with Autism Spectrum Disorder (ASD).
Journal of Exercise Physiology Online 15(2), 71-79.
Pan, C. (2010). Effects of water exercise swimming program on aquatic skills and social
behaviors in children with autism spectrum disorders. SAGE Publications and The
National Autistic Society, 9(28). 9-28
Pan, C., (2008). School time physical activity of students with and without autism spectrum
disorders during PE and recess. Adapted Physical Activity Quarterly, 25(2). 308-321.

Pan, C. (2010). The efficacy of an aquatic program on physical fitness and aquatic skills in
children with and without autism spectrum disorders. Research in Autism Spectrum
Disorders 5(2011). 657-665.
Srinivasan, S., Pescatello, L., & Bhat, A. (2014). Current Perspectives on Physical
Activity
and Exercise Recommendations for Children and Adolescents With Autism Spectrum
Disorders. Physical Therapy, 94(6), 875-886.
Todd, T. & Reid, G., (2006). Increasing physical activity in individuals with autism. Focus on
autism and other developmental disabilities, 21(3). 167-176