2020-Os efeitos do treinamento aquático versus técnicas de kata no equilíbrio estático e dinâmico em crianças com transtorno do espectro do autismo

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Journal of Autism and Developmental Disorders 
https://doi.org/10.1007/s10803-020-04785-w
ORIGINAL PAPER
The Effects of Aquatic Versus Kata Techniques Training on Static 
and Dynamic Balance in Children with Autism Spectrum Disorder
Soleyman Ansari1 · Abbas Ali Hosseinkhanzadeh2 · Fahimeh AdibSaber3  · Masoumeh Shojaei4 · 
Afkham Daneshfar4
Accepted: 4 November 2020 
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract
The present study aimed to compare the effect of a land-based and a swimming-based exercise program on balance abilities 
in children with autism. Thirty children were voluntarily selected and randomly assigned to karate exercise, aquatic training 
and control groups. Participants practiced for 10 weeks, 2 sessions of 60 min per week. Before and after the 10-week interven-
tion, static and dynamic balance tests were administered. The results showed that both interventions had a significant effect 
on balance abilities (p < 0.001); interestingly, we found the greater improvement in balance performance in kata techniques 
group. Due to the importance of balance performance on daily functions, communication and interaction skills, karate and 
swimming exercises can be the valuable interventions added to autism’s daily programs. Iranian Registry of Clinical Trials 
number: IRCT20180626040242N1
Keywords Static balance · Dynamic balance · Autistic children · Kata techniques · Swimming
Introduction
Autism spectrum disorders (ASD), diagnosed by significant 
impairment in behavior and communication, are multifacto-
rial and neurodevelopmental disorders that appear in early 
childhood and last until late in life (American Psychiatric 
Association, 2013). In 2019, it was estimated that the overall 
prevalence of ASD was 10 per 10,000 among Iranian chil-
dren (Mohammadi et al. 2019).
In addition to communication and behavioral concerns, 
studies have addressed that children with ASD have a higher 
motor and postural abnormalities, and poorer coordination 
and balance than typically developing children (Bhat et al. 
2011; Memari et al. 2013; Sam et al. 2017; Stins et al. 2015; 
Travers et al. 2013). Balance control is derived from the inte-
gration of three major sensory inputs: visual, vestibular, and 
somatosensory systems (Cordo and Nashner 1982). Chil-
dren with motor disabilities and disturbed balance are likely 
susceptible to more falling during a daily performance and 
may experience increased impairment in the development 
of communication and interaction skills (Stins et al. 2015).
Because of the consequences of impairments and associ-
ated problems on the daily functions and quality of life of 
ASD children and their parents, researchers in various fields 
of behavioral, psychological, and medical sciences tried to 
find effective interventions to reduce its complications. In 
recent years, physical activity and exercise interventions are 
known to be beneficial for decreasing repetitive behaviors 
(Liu et al. 2016), increasing physical fitness (Azimigarosi 
et al. 2020; Fragala-Pinkham et al. 2011; Yilmaz et al. 2004), 
improving communication and social interaction (Azimiga-
rosi et al. 2020; Guest et al. 2017; Movahedi et al. 2013; Pan 
2010; Zhao and Chen 2018), balance and motor abilities 
(Cheldavi et al. 2014; Ketcheson et al. 2017; Lourenço et al. 
2015; Salar et al. 2014) in children with ASD.
Swimming-based exercise intervention is a potentially 
safe and recreational activity for children with disabilities, 
 * Fahimeh AdibSaber 
 adibsaber@iaurasht.ac.ir
1 PhD of Exercise Physiology, Department of Physical 
Education, Rasht Branch, Islamic Azad University, Rasht, 
Iran
2 Department of Psychology, Faculty of Literature 
and Humanities, University of Guilan, Rasht, Iran
3 Department of Physical Education, Rasht Branch, Islamic 
Azad University, Rasht, Iran
4 Department of Motor Behavior, Faculty of Physical 
Education and Sport Sciences, Alzahra University, Tehran, 
Iran
http://orcid.org/0000-0002-5668-948X
http://crossmark.crossref.org/dialog/?doi=10.1007/s10803-020-04785-w&domain=pdf
 Journal of Autism and Developmental Disorders
1 3
including autism (Fragala-Pinkham et al. 2011; Stan 2012). 
Water properties such as buoyancy and hydrostatic pressure 
might provide sensory input, enjoyable environment, and sim-
ple movements to improve wellbeing (Mills et al. 2017), com-
munication skills (Azimigarosi et al. 2020), sensory and social 
behaviors in autism (Fragala-Pinkham et al. 2011; Pan 2010), 
but there is little information regarding its effects on balance 
control in children with ASD. Just two intervention studies 
including swimming were performed in order to evaluate its 
effect on static and dynamic balance in the ASD population. 
Yilmaz et al. (2004) reported swimming could significantly 
improve the duration of static balance in children with ASD. 
Furthermore, Bumin et al. examined the effect of hydrother-
apy on an 11-year-old girl with Rett syndrome. After 8 weeks 
of hydrotherapy, they found that her walking balance was 
improved (Bumin et al. 2003).
However, martial arts are a different form of physical activ-
ity which are very popular among children and teenagers, 
especially among children aged 10–15 around the world (Knop 
et al. 1996). A number of experiments have been studied to 
examine its impact in improving behavioral (Bahrami et al. 
2012), social (Movahedi et al. 2013), communication (Bahrami 
et al. 2016) and balance deficits (Kim et al. 2016; Sarabzadeh 
et al. 2019) in ASD populations. Karate training, a Japanese 
form of martial arts, is commonly divided into kihon (basics 
or fundamentals), kata (forms), and kumite (sparring). The 
Kata of karate are logical arrangements of blocking, punching, 
sticking, and kicking techniques in a set sequence (Bahrami 
et al. 2012). It has been demonstrated that karate training has 
a beneficial influence on postural sway and balance control 
in healthy and normally developing children (Vando et al. 
2013; Violan et al.1997); however, researchers have not yet 
experimentally studied its effect on improvement in balance 
in children with ASD.
Because swimming and karate techniques programs rely 
on different inputs (somatosensory versus visual and soma-
tosensory signals) (Baccouch et al. 2015) and regarding 
the importance of balance performance on daily functions, 
communication, and interaction skills, it may be suggested 
that aquatic exercises and kata of karate might impact dif-
ferently on the balance control of ASD children. Therefore, 
this study aimed to compare the effects of these two types 
of exercises on static and dynamic balance abilities of chil-
dren with ASD in order to find out which of these physical 
activities is the most effective in improving balance abilities.
Methods
Participants
Participants in this study were 56 children with ASD from 
Guilan Autism Society Institute who received the same 
treatment strategies (such as occupational therapy, speech 
therapy, and play therapy). The inclusion screening criteria 
were: (1) aged 8–14 years; (2) ASD diagnosed by a psy-
chiatrist based on the Diagnostic and Statistical Manual of 
Mental Disorders, 5th edition, (DSM-5) (APA, 2013), (3) 
Gender (boy), (4) no change in any medication, diet or treat-
ment during the study, (5) having 1 and 2 levels of autism 
severity based on Gars-2, and (6) ability to perform the 
requested exercise interventions. Meanwhile, participants 
were excluded from the experiment if (1) being absent more 
than two times in exercise sessions and (2) having a complex 
neurologic disorder (e.g. epilepsy, phenylketonuria, fragile 
X syndrome, and tuberous sclerosis). Finally, 30 children 
were voluntarily selected, matched based on age and sever-
ity of autism, and were randomly divided into three groups 
(using a randomized block design), including the kata tech-
niques training group (N = 10), aquatic exercise training 
group (N = 10),and control group (N = 10). Written consent 
was obtained from all participants’ parents. All participants 
were screened by an experienced physician whether have 
other medical conditions that limited their physical activity 
capacities (such as asthma, seizure, cardiac disease) and to 
be eligible for performing the exercise training protocols. 
Table 2 shows the participants’ demographic information 
in detail.
Procedure
There were two assessments before the intervention (T1: 
baseline) and after the intervention (T2: post-intervention), 
in which participants’ static and dynamic balance were 
evaluated.
Assessments
The anthropometric measurements included standing height 
and weight. Body Mass Index (BMI) was calculated by 
dividing a person’s body weight in kilograms by his or her 
height in meters squared.
Stork Test
The modified stork standing test was used to measure static 
balance. In this test, the subjects were requested to stay on 
a flat surface with one leg (only the dominant leg), raise the 
free leg to the ankle of the dominant leg, and put their hands 
beside the body. When the free leg was returned to the floor, 
the time was stopped and recorded (Golsefidi et al. 2013; 
Salar et al. 2014). This test was performed twice and the best 
time was recorded as a record.
Journal of Autism and Developmental Disorders 
1 3
Walking Heel to Toe Test
To assess dynamic balance, the heel-to-toe walking test 
was used. In this test, a person’s ability to walk in a 
straight line from heel to toe is measured. The subjects 
were asked to walk in a specified path with a length of 15 
steps from heel to toe. If the subjects stray from the path 
before completing the 15 steps, the test is stopped and the 
number of steps is recorded as their score. This test was 
performed two times and the best score was considered as 
the record of subjects (Pan 2014).
Aquatic Exercise Intervention
A 10-week aquatic exercise program consisting of 20 
sessions (2 sessions per week; 60-min per session) was 
accomplished in Arsen swimming pool in Rasht city 15 to 
16 pm (Sundays and Thursdays). Five qualified and certi-
fied swimming trainers who had previous experience to 
teach swimming to children with special needs, includ-
ing autism, were instructed with the schedule of train-
ing techniques to ensure safety and that the intervention 
was delivered uniformly across settings and to maintain 
a child-to-trainer of 2:1 ratio. One parent was asked to 
attend training sessions and when a child did not obey the 
rules or expectations, could help and participate in the 
intervention program.
In this study, the aquatic program consisted of a pedi-
atric aquatic exercise program combined with the Holly-
wick method. The base of this method is the mechanical 
principles designed for people with disabilities to move 
in the water without assistance (Kolachahi et al. 2020). 
Each training session lasted 60 min, including a 5-min 
warm-up (walking, running, jumping jacks, and moving 
arm and leg), 15-min orientation training (Sagittal, trans-
versal and longitudinal rotation), 20-min basic swimming 
skills (Breathing, Floating and Stroke skills), 15-min free 
swim (group activities and playing with pool toys) and a 
5-min cooldown. Table 1 shows the aquatic exercise pro-
gram protocol.
Kata Techniques Intervention
A 10-week kata techniques program consisting of 20 ses-
sions (2 sessions per week; 60-min per session) was imple-
mented under the direct supervision of the researcher and 
the Iranian head of the Gōjū-ryū Watanabe style. Each ses-
sion was held in Ansar Club in Rasht between 5 and 7 pm 
(Saturdays and Wednesdays). Participants were adminis-
tered adapted instruction in Taikyoku Jodan Kata which 
is taught to newcomers to the Gojuryu style. It consists 
of a series of blocking, punching, sticking, and kicking 
movements with explosive speed against an imaginary 
opponent. Participants move in several directions in space 
through a specific order. However, each movement has its 
own meaning and function. When performing a kata, kara-
teka must imagine himself surrounded by opponents and 
be ready to perform defensive and offensive techniques in 
any direction (Nakayama 1979).
In this study, the Kata technique program was per-
formed based on a two-to-one intervention (two-student 
to one-teacher ratio). The exercise program was instructed 
by a researcher and four other instructors, all of whom 
had aofficial coaching certificate. They had 5 experience 
sessions in play sessions of children with autism in the 
Autism Association to know and learn more about par-
ticipants. One parent was asked to attend the training ses-
sions and relax his child, if necessary (only one child was 
present at the training sessions with their instructor). Each 
session lasted 30 min in the first two weeks, 45 min in 
the second two weeks, and 60 min in the fifth to the tenth 
week, including 10 min of warm-up (jogging and stretch-
ing), 45 min of basic training (Kata practice techniques), 
and 5 min of cooling down (such as warm-up). Warming 
up and cooling down stages were performed in groups, 
while a two-to-one ratio was performed in the main train-
ing phase.
Table 1 Aquatic exercise protocol
Program activity Length (min) Content Goal
Warm-up 5 Walking clockwise and counter clockwise, running 
in place, jumping jacks, blowing bubbles and 
reciprocal arm and leg movements
Warm-up and Water adjustment
Orientation training 15 Sagittal, transversal and longitudinal rotation Water orientation
Basic swimming skills 20 Breathing, Floating and Stroke skills Swimming skills
Free swim 15 Group activities: Ball toss and catch, cross through 
hula-hoop, red light/green light, allowed to play 
pool toys, noodles, and kickboards
Communication and Social interaction
Cool down 5 The same as warm up
 Journal of Autism and Developmental Disorders
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Control Group
Participants in the control group received no intervention. 
They were asked to continue their daily routine, programs, 
and treatments, maintain their usual physical activity level, 
and not participate in a new sport program throughout the 
study period (T1–T2).
Statistical Analysis
Descriptive data, involving demographic characteristics of 
participants, age, weight, height, BMI, and autism sever-
ity was reported as mean and standard deviation (as shown 
in Table 2). Meanwhile, statistical tests, including Shap-
iro–Wilk and Leven’s tests were used to check the normality 
and homogeneity of variances of the data, respectively; and 
ANCOVA was utilized to evaluate the research hypotheses, 
as the data were normally distributed. In the event of a sig-
nificant F ratio, the Bonfferoni post-hoc test was utilized for 
pairwise comparisons. The effect size was computed and 
reported as a η2 value for ANCOVA evaluations. P values 
less than 0.05 were considered statistically significant. SPSS 
(Version 25.0) software was used for statistical analyses.
Results
In total, thirty children with ASD were recruited for this 
study. Table 2 shows the demographic information for the 
three groups at baseline measurement. There was no statis-
tically significant difference in any demographic variables 
including age, height, weight, BMI, and autism severity 
at the beginning of the intervention. Changes in static and 
dynamic balance values are shown in Table 3.
Static Balance
According to analysis of Covariance, there was a signifi-
cant difference in mean static balance [F (2, 26) = 10.23, 
p = 0.001, ƞ2p = 0.440)] between the groups, whilst adjusting 
for pretest of static balance. Post hoc tests showed there was 
a significant difference between aquatic exercise and control 
groups (p = 0.012) and karate and control groups (p = 0.001).
Dynamic Balance
According to analysis of Covariance, there was a signifi-
cant difference in mean dynamic balance [F (2, 26) = 65.78, 
p = 0.001, ƞ2p = 0.835)] between the groups, whilst adjust-
ing for pretest of Dynamicbalance. Post hoc tests showed 
there was a significant difference between aquatic exer-
cise and control groups (p = 0.001) and karate and control 
groups (p = 0.001) and aquatic exercise and karate groups 
(p = 0.001).
Discussion
In the present study, for the first time, we compared the 
effectiveness of Karate techniques training and aquatic 
exercise program on the static and dynamic balance among 
ASD children aged 8–14 years. We hypothesized that an 
Table 2 Participants 
characteristics (age, height, 
weight, BMI, and autism 
severity) at baseline
Aquatic exercise group 
(n = 10)
karate group (n = 10) Control group (n = 10)
Mean (SD) Mean (SD) Mean (SD)
Age (years) 10.60 (2.50) 10.80 (2.14) 10.80 (2.44)
Height (m) 1.52 (0.156) 1.43 (0.11) 1.52 (0.156)
Weight (kg) 61.60 (17.48) 43.00 (13.93) 61.60 (17.48)
BMI (kg/m2) 26.16 (5.82) 20.42 (3.82) 23.01 (5.32)
Autism severity (total 
score)
45.90 (9.42) 47.40 (11.78) 48.20 (10.59)
Table 3 Static and dynamic balance values in three research groups
Variables AG KG CG Statistics ANCOVA Group differences
Mean (SD) Mean (SD) Mean (SD) F(3,35) P ƞ2p
Pre test Post test Pre test Post test Pre test Post test
Dynamic Balance 
(number of feet)
7.20 (1.22) 9.60 (1.34) 6.40 (1.17) 13.00 (1.49) 7.00 (1.49) 6.700 (1.59) 65.78* 0.001 0.83 KG > AG > CG
Static Balance (sec) 4.20 (0.918) 6.00 (1.15) 4.50 (0.84) 6.80 (1.03) 4.30 (0.94) 4.50 (1.43) 10.233* 0.001 0.44 KG > AG > CG
Journal of Autism and Developmental Disorders 
1 3
aqua-based exercise program could differently impact on 
balance performances of ASD children than a land-based 
exercise training.
The first result of this study showed that both aquatic and 
kata techniques training improved the time of static balance 
test in ASD children. This outcome is in line with Yilmaz 
et al. (2004) and Kim et al (2016). Yilmaz et al. resulted that 
after the 10 weeks of swimming training, the static balance 
scores significantly increased. Moreover, Kim et al. inves-
tigated the effects of an 8-week Taekwondo intervention on 
balance in 14 children with ASD. After the intervention, 
the Taekwondo group displayed greater improvement in the 
single-leg stance balance than the control group.
Another finding of this study revealed that the number 
of feet in a dynamic balance test significantly increased 
due to aquatic and kata techniques training in children with 
ASD. This result agrees with Bumin et al (2003), Kim et al 
(2016), Battaglia et al (2019), and Sarabzadeh et.al (2019) 
outcomes. Bumin et al. found that walking balance improved 
in an 11-year-old girl with Rett syndrome, after 8 weeks of 
hydrotherapy. In addition to this, Kim et al. discovered that 
the Taekwondo training program caused a greater improve-
ment in the double leg stance balance with an unstable sur-
face. Furthermore, Battaglia et al. founded that the swim-
ming-based program was effective for the development of 
gross-motor skills (including balance) in adolescents with 
ASD. Sarabzadeh et.al, also founded that six weeks of Tai 
Chi Chuan training could improve balance and motion coor-
dination in ASD children aged 6–12 years.
Previous studies have found that children with ASD are 
more likely to have disturbed motor functioning and poor 
balance compared to their normally developing peers ones 
(Bhat et al. 2011; Memari et al. 2013; Sam et al. 2017; Tra-
vers et al. 2013). It has been reported that balance, either 
static or dynamic is the main important variable for daily 
performances and motor milestones in children with and 
without disability (Baccouch et al. 2015). Furthermore, 
Radonovich et al. suggested that postural sway might be pre-
dictive of the presence and severity of stereotypic behaviors 
(Radonovich et al. 2013). Because of the influence of motor 
disabilities and disturbed balance on daily performance and 
communication and interaction skills, in recent years, a 
number of studies evaluated the effect of different forms of 
physical activities on improving balance in the ASD popula-
tion (Cheldavi et al. 2014; Kim et al. 2016; Salar et al. 2014; 
Yilmaz et al. 2004).
Because of water properties (e.g. buoyancy, relative density, 
viscosity, resistance, turbulence, and hydrostatic pressure), 
swimming-based exercises might provide a more enjoyable, 
safer, and easier environment for children with ASD to move 
actively, relieve weight (Mortimer et al. 2014), provide pos-
tural support, strengthen and facilitates motor skills based on 
individual abilities (Battaglia et al. 2019). In our research, 
aquatic exercise training significantly improved both static and 
dynamic balance values. This may be related to the buoyancy 
property of water which facilitates postural control along with 
a reduction in gravitational effects. Moreover, in the aquatic 
environment, the density of water is about 800 times more than 
that of air, which improves muscle power without extreme 
weight-bearing joints through a resistive medium (Sigmunds-
son and Hopkins 2010). Furthermore, particular adaptations in 
the nervous system will be prepared by the repetitive practice 
of swimming, and transmission in the neural impulses will be 
facilitated (Baccouch et al. 2015).
Martial arts, another favorable form of physical activ-
ity, have physical and psychological effects on children 
with ASD (Bahrami et al. 2016; Kim et al. 2016; Movahedi 
et al. 2013). The results of the present study demonstrated a 
notable improvement in the static and dynamic balance due 
to kata techniques training. Interestingly, we found that the 
karate group showed a greater improvement in balance per-
formance compared to the aquatic exercise group. This result 
may be explained by the indirect effect of karate training on 
body equilibrium improvement through specific movements 
and correct body alignment. Kata techniques exercises such 
as kicking and blocking could motive suitable alignment of 
the feet, knees, hips, and spine and results in a great improve-
ment in proprioception and visual inputs as components of 
balance. Full interaction between neural and biomechanical 
mechanisms would provide a suitable balance. The segments 
that may induce the balanced progress may be as following: 
cooperation of postural muscular responses; better efficiency 
in vision, vestibular and somatosensory systems; adaptive 
systems; improved muscular strength and range of motion; 
and better physical structure (Sarabzadeh et al. 2019). So, 
the development of body awareness is the most often reason 
why Martial arts enhance balance.
The present study also has some limitations. First, the 
sample size of this study was small; so, the findings could 
cautiously be generalized to the entire population with 
ASD. Second, our study population was only boys aged 
8–14 years, future studies should include girls to compare 
the effects of these interventional approaches in both gen-
ders. Third, there is a lack of follow-up assessment; so, we 
did not find the length of time that the improvements shown 
in this study remained. Finally, we assessed static balance 
only in the dominant leg. Future studies could assess the 
efficiency of the swimming and karate training programs on 
the non-dominant side.
Conclusions
Ten weeks karate training and aquatic exercises contribute to 
improvements in specific balance abilities such as the time 
of maintenance in one leg standing position (in the dominant 
 Journal of Autism and Developmental Disorders
1 3
leg) and the number of feet in heel-to-toe walking among 
children with ASD. Considering the lower cost and ease of 
physical activity and the less effort and energy of coaches 
than other treatment methods, karate and swimming may 
therefore be hopeful alternatives in the physical exercise cur-
riculum to improve the balance abilities of ASD children in 
school or institution.
Acknowledgments First and foremost, we thank all children with 
autism and their families/caregivers who volunteered as participantsin this research study. We also thank the Guilan Autism Society Insti-
tute staff, especially Mr. Zahedi, Mr. Rahpeyma and Mr. Haghighi for 
their help and support for this study. Also, we thank all karate trainers 
and lifeguards.
Author Contributions SA and FA jointly designed the study and con-
tributed to the study protocol. SA and AAH analyzed the data under 
the supervision of MS and AD. FA and AAH wrote the first draft of 
the manuscript. All authors contributed to (and agreed upon) the final 
version.
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https://doi.org/10.1155/2018/1825046
https://doi.org/10.1155/2018/1825046
	The Effects of Aquatic Versus Kata Techniques Training on Static and Dynamic Balance in Children with Autism Spectrum Disorder
	Abstract
	Introduction
	Methods
	Participants
	Procedure
	Assessments
	Stork Test
	Walking Heel to Toe Test
	Aquatic Exercise Intervention
	Kata Techniques Intervention
	Control Group
	Statistical Analysis
	Results
	Static Balance
	Dynamic Balance
	Discussion
	Conclusions
	Acknowledgments 
	References