Health-related fitness of youths with visual impairments.
Article Type: Report
Subject: Vision disorders (Health aspects)
Teenagers (Health aspects)
Youth (Health aspects)
Exercise (Health aspects)
Blind (Health aspects)
Authors: Lieberman, Lauren J.
Byrne, Heidi
Mattern, Craig O.
Watt, Celia A.
Fernandez-Vivo, Margarita
Pub Date: 06/01/2010
Publication: Name: Journal of Visual Impairment & Blindness Publisher: American Foundation for the Blind Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 American Foundation for the Blind ISSN: 0145-482X
Issue: Date: June, 2010 Source Volume: 104 Source Issue: 6
Product: Product Code: E121930 Youth
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 228331098
Full Text: Abstract: This study analyzed the passing rates on five health-related fitness items on the Brockport Physical Fitness Test of youths aged 10-17 with visual impairments. It found that the youths had low passing rates on upper-body strength, cardiovascular endurance, and body composition.

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According to the most recent Physical Activity and Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 1996), physical inactivity is a major health concern for all, but individuals with disabilities are at a higher risk of developing sedentary lifestyles. The health-related fitness levels of individuals with visual impairments are generally lower than are those of sighted individuals (Houwen, Hartman, & Visscher, 2009; Kozub & Oh, 2004; Lieberman & McHugh, 2001; Lieberman, Stuart, Hand, & Robinson, 2006; Longmuir & Bar-Or, 1994, 2000). This fact is not surprising, given that as many as one-third of individuals with visual impairments lead sedentary lives (Longmuir & Bar Or, 2000) and that adolescents with low vision perform fewer activities than do sighted adolescents (Kroksmark & Nordell, 2001). Compounding this issue is the fact that physical activity is inversely correlated with age; the older the individual, the less engagement in physical activity, particularly for those with visual impairments (Kozub & Oh, 2004; Longmuir & Bar-Or, 1994, 2000).

Furthermore, the findings of previous research have highlighted the fact that individuals with visual impairments are at a risk of health-related illnesses that are attributed to inactivity and low fitness, as well as a compromised quality of life. It is particularly alarming when one takes into consideration the fact that the energy requirements for activities of daily living increase as vision decreases, because of less efficient movement (Kobberling, Jankowski, & Leger, 1989). A by-product of this inactivity is that individuals with visual impairments who lack motivation to engage in physical activity often become dependent members of society who rely on others for success in navigating the community (Skaggs & Hopper, 1996).

Researchers have contended that students with visual impairments have the same potential to develop motor skills and fitness as do sighted students (Shephard, Ward, & Lee, 1987; Winnick, 1985). This point is encouraging, since the need to be in good health is of greater importance for individuals who are visually impaired than for the general population owing to the increased exertion necessary for activities of daily living (Buell, 1973; Skaggs & Hopper, 1996). Health-related fitness can play an important role in being prepared for these added stresses. The components of health-related fitness are aerobic functioning (cardiovascular), muscular strength, endurance, body composition, and flexibility.

Students with visual impairments who are included in general physical education classes or physical activity in their schools often do not participate in vigorous physical activities with sighted students (Lieberman & McHugh, 2001; Longmuir, 1998; Longmuir & Bar-Or, 2000). According to Robinson and Lieberman (2004), students who are visually impaired are typically not afforded the same opportunities to participate in various aspects of inclusive general physical education classes or activity environments in the same manner as their sighted peers. Unfortunately, one study documented that at least 42% of students with visual impairments received no or limited access to physical education and athletic opportunities, and 58.9% of the participants reported that they lacked opportunities to be involved in local sports with others (Ponchillia, Armbruster, & Wiebold, 2005). In contrast, when children with visual impairments are involved in appropriate physical education classes, they are more likely to engage in sports (Ponchillia, Strause, & Ponchillia, 2002).

Few would argue that physical activity is an important contributor to the growth and development of individuals in the areas of emotional and social development as well as physical development (American Alliance for Health, Physical Education, Recreation, and Dance, AAHPERD, 1999). Many researchers have found that people with visual impairments who engage in regular physical activity are able to improve their fitness levels and even reach levels of fitness that are comparable to those of sighted people (Blessing, McCrimmon, Stovall, & Williford, 1993; Gleser, Margulies, Nyska, Porat, & Mendelburg, 1992; Ponchillia, Powell, Felski, & Nicklawski, 1992; Williams, Armstrong, Eves, & Faulkner, 1996). Individuals with visual impairments can and do benefit from physical activity programs; it is unfortunate that they are given few opportunities and little encouragement to do so (AAHPERD, 1999; Lieberman & McHugh, 2001; Ponchillia et al., 2002).

Assessment of physical fitness

Numerous instruments exist for measuring the fitness of children with and without disabilities. The Fitnessgram, a criterion-referenced test that represents levels of performance related to good health and improved physical functioning, operationalizes the healthy fitness zone (consisting of low-end and high-end scores) for children without disabilities (Cooper Institute for Aerobics Research, 1994). Children are encouraged to achieve at least the lower-end scores to meet health-related recommendations (Short, 2005).

The Brockport Physical Fitness Test (BPFT) (Winnick & Short, 1999) is a validated health-related fitness test that was developed to assess children with visual impairments in a manner similar to the Fitnessgram. The BPFT includes items in five areas of fitness and provides a healthy fitness zone for children with intellectual disabilities, visual impairments, and orthopedic impairments. Its validity has been determined using concurrent, construct, and content validity on each item with each disability involved (Winnick & Short, 1999).

Lieberman and McHugh (2001) conducted a study using the Fitnessgram with students with visual impairments before the BPFT was developed. They found that the scores of the students who were totally blind and those with low vision were similar to one another. When the Fitnessgram passing rates of the students with visual impairments were compared to those of sighted students, it was found that the sighted students had significantly higher scores than did those with visual impairments. The most notable differences were in abdominal strength, upper-body strength, and body composition. The passing rates for the cardiovascular endurance of the boys with visual impairments were lower than those of the sighted boys, whereas the differences between the girls were not statistically different. In addition, the girls with visual impairments had better passing rates than did the boys with visual impairments on the components of muscular strength (upper-body strength and abdominal strength). The upper-body endurance rates (push-up test) of the girls with visual impairments exceeded those of the boys by 15%; the girls' performance on the abdominal muscular endurance test, as measured by the number of curl-ups performed, exceeded the boys' performance by 14%. Lieberman and McHugh noted that although the girls with visual impairments performed better than did the boys with visual impairments, they performed poorly on upper-body strength compared to the boys who were sighted.

Lieberman and McHugh (2001) found that fewer than 20% of the students with visual impairments passed four items on the Fitnessgram, compared to 48%-70% of the sighted students. In addition, these students performed below the levels of sighted children who did not participate regularly in physical activity. It should be noted that Ayvazoglu, Oh, and Kozub (2006) found that younger children with visual impairments were more active than were older children with visual impairments. Thus, it appears that a higher level of activity when younger may not lead to continued activity as the students age.

Having few opportunities for physical activity leads to poor fitness, which may lead to a decreased ability to perform daily tasks and an even lower level of fitness (Lieberman & McHugh, 2001; Lieberman et al., 2006; Robinson & Lieberman, 2004). This problem can be avoided because children with visual impairments are born with the potential to achieve a healthy level of physical fitness (Lieberman & McHugh, 2001; Shephard et al., 1987; Winnick, 1985). Many children with visual impairments are not given opportunities to participate in physical activities because of limited expectations for their performance (Lieberman & McHugh, 2001; Lieberman et al., 2006; Robinson & Lieberman, 2004; Shephard et al., 1987; Stuart, Lieberman, & Hand, 2006; Winnick, 1985). It is evident that steps need to be taken to increase the opportunities for all children to work on improving and maintaining the components of health-related fitness.

The study

PURPOSE

Before our study was conducted, no studies bad used the BPFT to determine the passing rates of children with visual impairments on the components of basic health-related fitness. The previous study (Lieberman & McHugh, 2001) compared the scores of children with visual impairments to those of sighted children using the Fitnessgram assessment. The purpose of the study presented here was to determine the passing rates on the five health-related fitness tests of boys and girls with various levels of visual impairments using a health-related fitness test validated for children with visual impairments. The aims of the study were as follows:

1. To determine if the passing rates on all five health-related fitness tests of boys and girls who are totally blind (B1)

will be significantly lower than those of boys and girls with travel blindness (B2), legal blindness (B3), and visual acuities of 20/200 to 20/70 (B4).

2. To determine if the passing rates on all five health-related fitness tests of girls with visual impairments (B1-B4) will be significantly lower than those of boys with visual impairments (B1-B4).

3. To determine which health-related fitness components are the weakest for boys and girls with visual impairments at all levels.

METHODS

Participants and setting

A total of 152 children (91 boys and 61 girls) with visual impairments aged 10-17 participated in the study. The students were categorized according to the sport classifications of the United States Association for Blind Athletes (USABA, 1982): Group B1--totally blind, that is, no light perception in either eye up to light perception, but an inability to recognize the shape of a hand at any distance or in any direction (n = 42); Group B2--travel vision, that is, from the ability to recognize the shape of a hand up to a visual acuity of 20/600 or a visual field of less than 5 degrees in the best eye with the best practical eye correction or both (n = 31); Group B3--legally blind, that is, from a visual acuity of 20/600 up to a visual acuity of 20/200 or a visual field of less than 20 degrees and more than 5 degrees in the best eye with the best practical eye correction or both (n = 76); and Group B4--visual acuities of 20/200 to 20/70 and a visual field larger than 20 degrees in the best eye with the best practical eye correction (n = 1). The participants were tested during a one-week sports camp in one of five locations throughout the United States. Two camps were in the Northeast, one was in the Southwest, one was in Alaska, and one was in Puerto Rico.

Data collection

The study protocol was approved by the primary investigator's College Institutional Review Board and the host institutions, and written informed consent was obtained from all the participants and their parents. The following physiological assessment items from the BPFT (Winnick & Short, 1999) were performed on all the participants: (1) a sit-and-reach test to determine flexibility, (2) a one-mile run to measure cardiovascular fitness, (3) a push-up test to determine upper-body muscular endurance, (4) a curl-up test to evaluate abdominal muscular endurance, and (5) two site skinfold measures to estimate body composition. All assessments were performed in the morning during the participants' track-and-field lesson.

Flexibility. The sit-and-reach box that was used was a 1.5-foot wooden box set against the wall with a 6-inch extension of wood from the front. The participants put one leg out straight against the box under the 6-inch extension. They sat with one leg straight and the other leg bent with the foot of the bent leg placed at the knee of the straight leg. Then they reached as far as they could with both hands to obtain a measure of flexibility.

All the participants initially felt the structure of the sit-and-reach box and the technician's hand move the sit-and-reach bar. They were then asked if they knew how to perform a hurdler's stretch. Those who said yes were asked to demonstrate the stretch to confirm their ability. Those who said that they did not know how to perform the stretch or performed it inaccurately were taught how to do so correctly using physical guidance and tactile modeling. Physical guidance was used to move the participants into the hurdler's stretch position. The participants then felt a person perform the stretch and mimicked this motion themselves (tactile modeling). They practiced the test two to three times with verbal and physical feedback from their technician to enhance the accuracy of the assessment. They then performed the sit-and-reach stretch twice on each leg. The highest value measured with no knee flexion was used for the data analysis.

Cardiovascular fitness. All the participants ran one mile on an outdoor track to evaluate their cardiovascular fitness. The evaluation was performed in small groups of 10-12 participants. All the participants were instructed to complete the distance in the shortest time possible and were told their split times every quarter mile. Some participants in the B2 group and all the participants in the B3 group ran independently with a counselor running alongside but not touching them. All the participants in the B1 group and some in the B2 group chose to run with a tether or to use a sighted guide (Lieberman, 2005).

Upper-body muscular endurance. The participants were asked if they knew how to perform a push-up. Those who said yes were asked to demonstrate their technique to confirm their ability. Those who said that they were not familiar with a push-up or performed it inaccurately were taught the correct form and technique. In brief, they were asked to lie down with their hands next to their shoulders and push themselves up off the floor. An assistant positioned each participant's body such that a straight line was maintained among the shoulders, pelvis, knees, and feet. The participants were assessed once they could independently demonstrate the proper form and technique. Once the assessment began, the participants were allowed three seconds to complete each push-up and were instructed to complete as many as possible. There was no time limit to this test. The test was terminated when the participant was no longer able to perform push-ups with appropriate form.

Abdominal muscular endurance. As with other assessments, the participants were asked if they knew how to perform a curl-up. Those who said yes were asked to demonstrate their technique to confirm their ability. Those who said no or performed it inaccurately were physically assisted into the position and taught the movement by physical guidance and tactile modeling. All the participants began by lying in a supine position while maintaining 90 degrees of knee flexion with their hands at their sides. They contracted their abdominal musculature until their hands had traveled along the mat to a point below their knees and then returned their shoulders to the mat in a controlled movement. The test was terminated when the participant was no longer able to perform sit-ups with appropriate form. Body composition. The percentage of body fat was estimated using a two-site (calf and triceps) skinfold technique (Winnick & Short, 1999). All the measurements were taken on the right side, and each skinfold thickness was measured two to three times (depending on the repeatability of the measurements) using Lang calipers. Since some participants were anxious about having the measurements performed, all the participants were encouraged to feel the calipers prior to being measured. The technician also placed the jaws of the caliper on the participants' fingers, such that they could gain a better understanding of how the tool would feel on their skin. Once the data were collected, the sum of the skinfolds was then used to estimate body density and subsequently the percentage of body fat (Siri, 1961). All the data were converted into pass or fail scores according to the BPFT. Two-tailed Pearson chi-square tests were used to determine if there were differences in the passing rates on the five health-related fitness tests and gender and level of visual impairment.

Results

There were no significant differences in any of the five health-related fitness variables among the various levels of visual impairments. In addition, there were no differences between the boys and girls on any component of health-related fitness. Although there were no significant differences, there are clear areas of weakness (passing rates lower than 50%) among all the participants. The results indicated that cardiovascular endurance, upper-body strength, and body composition are areas that need to be strongly addressed in this population.

LEVEL OF VISION

The findings revealed no significant difference between the levels of vision and any of the measures that were tested. Table 1 shows the passing rates among the levels of visual impairments for the five health-related fitness components.

In the area of upper-body endurance, as measured by the number of push-ups completed, the participants who were blind (B1) obtained the lowest passing rates (19.5%), followed by those who were legally blind (B3; 31.6%) and those with travel vision (B2; 32.3%). There were no significant differences among the passing rates, but a difference of 12.8% between B1 and B2 and a 12.1% difference between B 1 and B3 highlight a trend of the B 1 participants having lower rates compared to those who are classified as B2 and B3. These findings parallel those of a previous study (Houwen et al., 2009), which reported that visual acuity and physical activity are inversely related.

The passing rates on the curl-up test for abdominal strength were a bit different among the groups. The participants who were legally blind (B3) had the lowest passing rates (51.6%), followed by those who were blind (B1; 57.1%), and those with travel vision (B2; 67.7%). There were no specific tendencies or trends in these data.

On the sit-and-reach test for flexibility, the participants with travel vision (B2) had the lowest passing rates (53.3%), followed by those who were blind (B1; 55.5%) and those who were legally blind (B3; 60.0%). More than half the participants passed the BPFT standards for this component. In this area, there were also no trends or tendencies.

The results presented in Table 1 for the body-composition component of the BPFT represent no significant differences among the levels of visual impairments. The participants who were legally blind (B3) obtained the lowest passing rates (31.1%), followed by those with travel vision (B2; 32.3%), and those who were blind (BI; 46.3%). This finding was surprising, since the participants who were blind (B 1) had the lowest passing rates for cardiovascular endurance (9.5%), yet had somewhat higher passing rates on the body-composition scores (46.3%) (not statistically different).

On the one-mile-run test for cardiovascular endurance, the participants who were blind (B 1) had the lowest passing rate (9.5%), followed by those with travel vision (B2; 12.9%), and those who were legally blind (B3; 22.4%). Even though there was no significant difference between the groups, it is important to note that the passing rates on the one-mile-run test for cardiovascular endurance were low (only 16.7%) for all the participants. Although not encouraging, these findings are not surprising, given the number of studies that have reported that the physical activity levels of children who are blind (B 1) are low (Houwen et al., 2009; Kozub & Oh, 2004; Lieberman & McHugh, 2001; Longmuir & Bar-Or, 1994, 2000).

The passing rates obtained on the five BPFT health-related fitness components among levels of visual impairments were congruent with the results obtained by Lieberman and McHugh (2001), in which children who were totally blind and those with low vision achieved similar results in the health-related fitness components of the Fitnessgram. This finding is contrary to that of Houwen et al. (2009), which found that children with lower levels of vision were more sedentary than were those with low vision and those who were sighted.

GENDER

Table 2 shows the passing rates grouped by gender on the BPFT health-related fitness components. No significant difference was found between the boys and the girls on the passing rates across the five components of health-related fitness.

Even though the differences in passing rates between the boys and girls on upper-body muscular endurance were not statistically significant, both groups obtained low passing rates (girls = 36.1%; boys = 23.3%). Although not significant, the 12.8% difference between the passing rates of boys and girls was congruent with the results reported by Lieberman and McHugh (2001) that girls with visual impairments scored better than boys with visual impairments on the muscular-strength components of the Fitnessgram.

As Table 2 shows, the girls also had almost similar passing rates (65.6%) as boys (62.6%) on the curl-up test. There was no significant difference between the groups. These results were somewhat different from the results obtained by Lieberman and McHugh (2001), who found that the curl-up rates of the girls with visual impairments exceeded the boys' by 14% on the Fitnessgram.

For the sit-and-reach test of flexibility, more boys (62.9%) than girls (53.3%) passed, but not significantly. In addition, the boys had a higher passing rate (39.3%) on the body-composition test than did the girls (28.3%). This is approximately a 10% difference in both areas.

The passing rates for the one-mile-run test for cardiovascular endurance did not show a significant difference but were low for both groups (18.7% for the boys and 13.1% for the girls). This finding is alarming yet not surprising, since several studies have shown that children who are totally blind have lower levels of endurance (Houwen et al., 2009; Lieberman & McHugh, 2001; Stuart et al., 2006). The reality is that children with visual impairments need more endurance to do the same everyday activities than do sighted children (Buell, 1973; Skaggs & Hopper, 1996).

PASSING RATES

The five areas of health-related fitness were studied to determine the passing rates for children with visual impairments at three levels. Three of the areas of health-related fitness--upper-body strength, body composition, and cardiovascular endurance-showed low passing rates for both genders and all three levels of visual impairment. Individuals with visual impairments need adequate levels of health-related fitness to participate in daily independent mobility and routine activities at work or in school. Programming related to the education of children with visual impairments should focus on these important areas.

On the basis of the results, children with different levels of visual impairments (B 1, B2, and B3) tend to have low passing rates on the components of health-related fitness on the BPFT. The level of visual impairment and gender did not make a significant difference in the passing rates. A possible reason for this tendency is that students with visual impairments typically are not afforded the same opportunities to participate in various aspects of inclusive general physical education classes or activity environments in the same manner as are sighted children (Ponchillia et al., 2002; Robinson & Lieberman, 2004). In fact, Robinson and Lieberman (2004) found that many children with visual impairments are excluded from physical education classes.

Studies have shown that individuals with visual impairments who are engaged in regular physical activities improve their fitness levels comparably to those of sighted individuals, but that the opportunities for them to do so are not readily available (AAHPERD, 1999; Ponchillia et al., 2002). There is a great need to provide these opportunities to individuals with visual impairments so they can improve their fitness levels and quality of life. The next section presents some ways for parents, teachers, specialists, and the children themselves to increase the children's opportunities for physical activity.

Implications for practice

The following ideas are just a few ways that the cardiovascular endurance, upper-body strength, and body mass index of children with visual impairments can be improved.

CARDIOVASCULAR ENDURANCE

Because so few children passed the area of cardiovascular endurance, we suggest the following ways to help children who are visually impaired improve in this area:

* Walk rather than drive to school, the playground, or a friend's house.

* Run with a friend or sibling using a tether (a short rope held between two people).

* Run using a sighted guide while holding his or her elbow or shoulder.

* Run on a treadmill or independently around a quiet track.

* Run independently using a guide wire (a long rope pulled between two poles with a key ring and a short loop rope that slides along the rope. Be sure to add a warning knot at each end near the ends).

* Swim for endurance in a pool.

* Ride a bike, such as a tandem bike, a side-by side bike, or a stationary bike.

If a child has enough vision, he or she can ride a bike independently in a safe area.

* Use a talking pedometer to count steps walked daily and for motivation.

UPPER-BODY STRENGTH

* Play on a playground and use the monkey bars and ladders and go down the slides.

* Use a scooter and have the child pull himself or herself along the floor to a sound or along a rope that is tied to a wall or pole.

* Jump rope to improve upper body strength, endurance, and balance. See Lieberman, Schedlin, and Pierce (2009) for modifications to jumping rope.

* Practice push-ups and pull-ups or lift weights to improve upper-body strength.

BODY MASS INDEX

" Use the tactile food pyramid (http://www.APH.org) to teach children about the balance in foods.

* Increase cardiovascular endurance activities.

* Help children learn about healthy and unhealthy drinks such as soda and sugary fruit drinks.

In addition to the activities just mentioned, we suggest that readers see the products and curricula available through the American Printing House for the Blind on its physical education resources web site. It is through greater opportunities and experiences that children with visual impairments will be able to maintain healthy levels of physical activity.

References

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Lauren J. Lieberman, Ph.D., professor, Department of Kinesiology, Sport Studies, and Physical Education, College at Brockport, State University of New York, 350 New Campus Drive, Brockport, NY 14420; e-mail: . Heidi Byrne, Ph.D., associate professor, Department of Kinesiology, Sport Studies, and Physical Education, College at Brockport, State University of New York; e-mail: . Craig O. Mattern, Ph.D., assistant professor, Department of Kinesiology, Sport Studies, and Physical Education, College at Brockport, State University of New York; e-mail: . Celia A. Watt, Ph.D., associate professor, Department of Health Sciences, College at Brockport, State University of New York; e-mail: . Margarita Fernandez- Vivo, Ph.D., Department of Physical Education, University of Puerto Rico, P.O. Box 9000, Mayaguez, Puerto Rico 00681-9000; e-mail: .
Table 1
Passing rates, by level of vision (percentage).

                              Push-up:
                             Upper-body   Curl-up:
                              muscular    Abdominal   Sit-reach:
Level of vision               strength    strength    Flexibility

Blind: B1 (n = 42)              19.5        57.1         55.5
Travel vision: B2 (n = 31)      32.3        67.7         53.3
Legally blind: B3 (n = 76)      31.6        51.6         60.0
Low vision: B4 (n = 1)        100.0        100.0        100.0

                             Skinfold:     Mile run:
                             Body mass   Cardiovascular
Level of vision                index       endurance

Blind: B1 (n = 42)             46.3            9.5
Travel vision: B2 (n = 31)     32.3           12.9
Legally blind: B3 (n = 76)     31.1           22.4
Low vision: B4 (n = 1)          0.00           0.00

Note: The numbers of participants total less than 152 because
of missing data.

Table 2
Passing rates, by gender and age (percentage).

                             Push-up:
                            Upper-body   Curl-up:
                             muscular    Abdominal  Sit-Reach:
     Gender and age          strength    strength   Flexibility

Girls and boys aged            28.5        63.8        59.1
 10-17 (n = 152)
Girls and boys aged            37.9        71.6        65.9
10-13 (n = 88)
Girls and boys aged            15.6        53.1        49.2
  14-17 (n = 64)

Boys aged 10-17 (n = 91)       23.3        62.6        62.9
Boys aged 10-13 (n = 49)       31.2        69.4        67.3
Boys aged 14-17 (n = 42)       14.3        54.8        57.5

Girls aged 10-17 (n = 61)      36.1        65.6        53.3
Girls aged 10-13 (n = 39)      46.2        74.4        64.1
Girls aged 14-17 (n = 22)      18.2        50          33.3

                            Skinfold:     Mile run:
                            Body mass   Cardiovascular
     Gender and age           index       endurance

Girls and boys aged           34.9           16.4
 10-17 (n = 152)
Girls and boys aged           39.5           22.7
10-13 (n = 88)
Girls and boys aged           28.6            7.8
  14-17 (n = 64)

Boys aged 10-17 (n = 91)      39.3           18.7
Boys aged 10-13 (n = 49)      41.7           24.5
Boys aged 14-17 (n = 42)      36.6           11.9

Girls aged 10-17 (n = 61)     28.3           13.1
Girls aged 10-13 (n = 39)     36.8           20.5
Girls aged 14-17 (n = 22)     13.6            0
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