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Performance on Functional Strength Measurement and Muscle Power Sprint

Test confirm poor anaerobic capacity in children with Developmental
Coordination Disorder

Article  in  Research in Developmental Disabilities · August 2016

DOI: 10.1016/j.ridd.2016.08.002

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Contents lists available at ScienceDirect

Research in Developmental Disabilities

Performance on Functional Strength Measurement and

Muscle Power Sprint Test confirm poor anaerobic capacity in
children with Developmental Coordination Disorder
Wendy F.M. Aertssen a,∗, Gillian D. Ferguson b, Bouwien C.M. Smits-Engelsman b
a
Avansplus, University for Professionals, Breda, The Netherlands
b
Department of Health and Rehabilitation Sciences, Division of Physiotherapy, Faculty of Health Sciences, University of Cape Town,
South Africa

a r t i c l e i n f o a b s t r a c t

Article history: Background: There is little and conflicting information about anaerobic performance and
Received 24 March 2016 functional strength in children with Developmental Coordination Disorder (DCD).
Received in revised form 17 July 2016 Aims: To investigate anaerobic capacity and functional strength in children with a clini-
Accepted 4 August 2016
cal diagnosis of DCD (clin-DCD) and if differences were larger in older (age 7–10 years)
Number of reviews completed is 2 compared to younger children (age 4–6 years). Furthermore to determine the percentage
of children with clin-DCD that scored <15th percentile on the norm-referenced Functional
Keywords: Strength Measurement.
Anaerobic capacity Method: A clin-DCD group (36 boys, 11 girls, mean age: 7y 1mo, SD = 2y 1mo) and a typically
DCD
developing group (TD) (57 boys, 53 girls, mean age: 7y 5mo, SD = 1y 10mo) were compared
Children
on Muscle Power Sprint Test (MPST) and Functional Strength Measurement (FSM).
Functional strength measurement
MPST Results: Children with clin-DCD performed poorer on the MPST and FSM, especially on the
muscle endurance items of the FSM. The differences were larger in the older children com-
pared to the younger on the cluster muscle endurance and the FSM total score. Over 50% of
clin-DCD group scored <15th percentile on the FSM.
Interpretation: Differences between children with clin-DCD and TD children are even more
pronounced in the older children, especially when tested on items requiring fast repetitive
movements.
© 2016 Elsevier Ltd. All rights reserved.

What this paper adds

• Children with a clinical diagnosis of DCD (clin-DCD) have lower anaerobic capacity.
• Lower anaerobic capacity is more pronounced in tests involving fast repetitive movements.
• The differences between children with clin-DCD and their typically developing peers is larger in older children.
• Half the children with clin-DCD have functional strength items that are below age-related norms.

∗ Corresponding author at : Heerbaan 14-40, 4817NL, Breda, The Netherlands.

E-mail address: wendyverhoef@live.nl (W.F.M. Aertssen).

http://dx.doi.org/10.1016/j.ridd.2016.08.002
0891-4222/© 2016 Elsevier Ltd. All rights reserved.
116 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126

1. Introduction

Although children with Developmental Coordination Disorder (DCD) are characterized as having impaired motor coordi-
nation, recent studies have focused on the reduced levels of physical fitness commonly seen in this group (Cantell, Crawford,
& Doyle-Bakker, 2008; Ferguson, Aertssen, Rameckers, Jelsma, & Smits-Engelsman, 2014; Haga, 2009; Hands, 2008;; Hoek
et al., 2012; Kanioglou, 2006; Li, Wu, Cairney, & Hsieh, 2011; Rivilis et al., 2011; Schott, Alof, Hultsch, & Meermann, 2007;
O’Beirne, Larkin, & Cable, 1994; Hands & Larkin, 2006;; Farhat et al., 2015). Lower scores on several measures of physical
fitness, including cardiorespiratory endurance and isometric muscle strength have been reported in several studies (Rivilis
et al., 2011), but the number of studies examining anaerobic performance and functional strength in children with DCD are
less extensive.
In everyday life, children tend to participate in short bursts of high intensity activity or play far more frequently than
they do in games that require aerobic endurance (Bailey et al., 1995). Moreover, children’s games seldom involve activities
in which isolated muscles are engaged in prolonged isometric contraction. These important aspects regarding children’s
participation in everyday activities are of particular interest to rehabilitation professionals who treat children with motor
impairments. Therefore, besides aerobic capacity, it is equally important to assess anaerobic and functional strength in
children with DCD. To ensure that these assessments are ecologically valid, it would be preferable to use tests that closely
resemble typical playground skills (e.g. throwing a ball, jumping, and sprinting) and everyday activities (e.g. getting up from
a chair, going up and down stairs).
One aspect of anaerobic capacity concerns muscular endurance; which refers to the ability to repeat a series of muscle
contractions or sustain a muscle contraction for a set period of time without fatiguing. In terms of assessment, the maximal
number of repetitive movements to fatigue (RTF) is commonly used to evaluate anaerobic capacity. Importantly, repetitive
movements require the ability to switch rapidly between different types of muscle contractions (e.g. eccentric and concentric)
or to switch between contractions of different muscle groups (e.g. agonists and antagonists).
The few studies that have evaluated RTF in children with DCD included only one or two RTF items and predominantly
assessed core muscles (Hands, 2008; Kanioglou, 2006; Li et al., 2011; Hands & Larkin, 2006). The results of those studies
were equivocal and, taken together, suggested that anaerobic capacity was influenced by age. A three-year longitudinal study
reported no differences in performing repeated sit-ups (Li et al., 2011) between children with DCD and TD children when the
children were nine-years old. However, differences between groups became apparent at the age of 10 and 11 years, with TD
children performing significantly more sit-ups than their counterparts with DCD. However, other studies found differences
in sit-up performance between younger children (5–9 years) with and without DCD (Kanioglou, 2006; Hands, 2008). On
examination of curl-ups or abdominal crunch performance in TD children and children with DCD, (Schott et al., 2007) found
no differences in young children (4–9 years), but significant differences in the older age group (10–12 years). (Cantell et al.,
2008) however, reported differences in performance of curl-ups among 9 year olds, while (Nascimento et al., 2013) found no
differences in children over a larger age range (6–10 years old). Lastly, (Ferguson et al., 2014) used the Functional Strength
Measurement to assess RTF of other muscle groups during functional tasks. Their results showed differences on four repetitive
muscle endurance items (i.e. lateral step-up, sit to stand, lifting a box and stair climbing) between children with and without
DCD aged 6–10 years old.
An additional aspect of anaerobic capacity is explosive muscle power. Power can be defined as the product of force and
velocity per unit of time (Watts). By definition, explosive power tests require adequate force generation in a short period of
time. Field tests commonly used to assess muscle power of the upper-body evaluate throwing distance (e.g. medicine ball
throwing, chest pass, overarm throwing, and underarm throwing). Again, studies examining these aspects report conflicting
results. (Schott et al., 2007) reported no significant differences in children aged 4–9 years old, but reported that children aged
10–12 years old were significantly different in medicine ball throwing. (Ferguson et al., 2014) found differences in underarm
throwing but no significant differences between DCD and TD children (age 6–10 years) on the chest pass and overarm throwing.
(Hands & Larkin, 2006) also found no significant differences in chest pass (5–8 years).
Assessing lower limb muscle power involves measuring whole body displacement in activities such as vertical, squat or
standing long jump. Two studies, comparing DCD and TD, found that children aged 10–12 years were different in jumping
but younger children (4–9 years) were not (Li et al., 2011; Schott et al., 2007). Other studies, however revealed differences
between 5 and 10 year old TD children and children with DCD (Ferguson et al., 2014; Haga, 2009; Hands, 2008; Hands &
Larkin, 2006). (Farhat et al., 2015), using the 5-jump test and the triple hop distance test, reported that children with DCD,
aged 7–10 years, covered less distance than TD children.
Sprinting tests are commonly used to assess general anaerobic capacity in children with DCD. Different studies reported
poorer performance in DCD on anaerobic sprint test such as the 20 m run (O’Beirne et al., 1994), 10 × 5 m sprint (Haga, 2009),
50 m run (Hands, 2008;; Hands & Larkin, 2006) and 50 yards run (Kanioglou, 2006). However, Ferguson at al. (2014) found
no significant differences between children with and without DCD on the Muscle Power Sprint test (MPST). (Hands, 2008)
and (O’Beirne et al., 1994) found an interaction between group and time meaning that children with motor coordination
problems become worse over time.
In summary, the reason for these conflicting results on anaerobic muscle endurance and muscle power as discussed above,
may be partly accounted by the age of the children in the study groups, the variety of measures used (Ferguson et al., 2014)
and the extremities measured. Another, less considered reason could be due to the heterogeneity of the participating DCD
groups used in the various studies in terms of their diagnosis. Reflecting on the studies mentioned before, only one (Hoek
 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126 117

et al., 2012) included children with a confirmed clinical diagnosis of DCD by a pediatrician. The other studies mentioned
before identified their DCD groups based on scores on a motor performance test (Diagnostic and Statistical Manual for
Mental Disorders; DSM-5 criterion A) (Cantell et al., 2008; Ferguson et al., 2014; Haga, 2009; Hands, 2008;; Kanioglou, 2006;
Li et al., 2011; Schott et al., 2007; O’Beirne et al., 1994; Hands & Larkin, 2006). (Geuze, Schoemaker, & Smits-Engelsman,
2015) suggested that children with a clinical diagnosis of DCD (clin-DCD) may be different to children with a “research-
defined” diagnosis of DCD. Children with clin-DCD are referred for treatment because their motor problems interfere with
activities of daily living and/or academic achievements (DSM 5, criterion B) to such an extent that the parent seeks help
for the child. In contrast, children with a research defined diagnosis of DCD, are considered different, as the burden of their
motor coordination difficulties on their functional capacity may be small enough not to warrant support from healthcare
services. Alternatively, children in research-defined DCD groups may be different from a socio-economic perspective in that
they face barriers in accessing support services.
To address the anaerobic performance difficulties in children diagnosed with DCD appropriately, we used a comprehen-
sive test battery to assess anaerobic performance (upper and lower extremities, muscle endurance and muscle power) and
specifically included functional activities (instead of isolated items such as curl up and sit-up) and included children with a
clinical diagnosis of DCD referred for treatment (clin-DCD) with a wide age range. The aim of our study was to investigate
differences in performance between young and older children with clin-DCD and TD children on anaerobic capacity, anaer-
obic muscle endurance and explosive muscle power. Based on the literature, we expected 1) children with clin-DCD to have
poorer performance on anaerobic capacity, anaerobic muscle endurance and explosive muscle power tests compared to the
TD group, 2) that the differences between groups would be larger in the older children.
Lastly, since group differences do not mean that the children’s performance is absolutely low if compared to age related
norms, the second aim was to determine the percentage of children, who scored below the 15th percentile on a norm-
referenced test for functional strength, the FSM. In most studies, single items without age related norm were used to compare
anaerobic capacity between groups. Examination of the norm scores is meaningful for the choices made in clinical treatment.

2. Method

2.1. Participants and setting

Children with clin-DCD, aged 4–10 years, were recruited from different pediatric physical therapy practices in the
Netherlands. All the children were referred for treatment by doctors and all presented with motor coordination prob-
lems that were interfering with their daily activities and/or sports for which the parents sought help. Their teachers also
confirmed motor coordination problems in daily school activities. Children were included if their Movement Assessment
Battery for Children-2nd edition (MABC-2) (Henderson, Sugden, & Barnett, 2007) total score was ≤16th percentile according
to the Dutch norms. (Smits-Engelsman, 2010).
TD children, aged 4–10 years, were recruited from different schools in the Netherlands using convenience sampling.
Teachers and parents confirmed that these children had no motor problems and were generally in good health.
Exclusion criteria for both groups were failing a grade at school and a history of neurologic, orthopedic and cognitive
problems as reported in a parent questionnaire. No children were excluded from both groups.
This case-control study was approved by the medical ethics committee (CCMO) and informed consent was obtained from
the parents of all the participating children.

2.2. Outcome measures

2.2.1. Muscle Power Sprint Test (MPST)

The MPST was developed to measure anaerobic power (Verschuren, Takken, Ketelaar, Gorter, & Helders, 2007). Children
have to run a distance of 15 m as fast as possible while their time in milliseconds is recorded. The sprint is repeated 6 times,
with a 10 s rest between each sprint. The mean power and the peak power were calculated (the child’s weight and running
time are factors in the formula) as outcomes. The test-retest reliability of the MPST is good (ICC 0.98) (Douma-van Riet
et al., 2012). The validity the MPST is good. In a comparison study (Verschuren, Bongers, Obeid, Ruyten, & Takken, 2013) in
children and adolescents with Cerebral palsy the MPST was highly correlated with the Wingate test (peak power r = 0,73,
mean power r = 0.90), which is regarded a gold standard for anaerobic capacity. (Bongers et al., 2015) compared the MPST
(renamed RAST) with the Wingate test in typically developing adolescents and children, and also found high correlations
(peak power 0.86, mean power 0.91).

2.2.2. Functional Strength Measure (FSM)

The FSM is a standardized norm-referenced test for functional strength in children aged 4–10 years old (Smits-Engelsman
& Verhoef-Aertssen, 2012). The FSM includes four RTF tests that assess muscle endurance, namely lateral step-up, sit to stand,
lifting a box and stair climbing where the number of repetitions in 30 s is measured. The FSM also includes four items that
assess muscle power, namely overarm throwing, underarm throwing, chest pass and standing long jump. In these items, distance
thrown or jumped in centimeters is measured.
118 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126

Fig. 1. Items of the Functional Strength Measurement.

The child performs three trials of each item and the best score is used for the analyses. Raw scores are converted to
standard scores with a standard score = 0 reflecting performance in upper normal range for that age (> 50th percentile),
standard score = 1 means lower normal range (between 16th and 50th percentile), standard score = 2 means at risk range
(between 5th and 15th percentile) and standard score 3 means impaired range ( < 5th percentile). The standard item scores
can summed into a Total Standard Score or can be combined and presented as cluster scores (a high scores means a worse
performance). The clusters include items of the upper extremities and items of the lower extremities, or items measuring
explosive power and items measuring muscular endurance. This test has good test-retest reliability (ICC 0.91-0.94) and good
construct validity (Aertssen, Ferguson, & Smits-Engelsman, 2016). Fig. 1 shows the different items of the FSM.

2.3. Procedure

All testing was conducted by nine pediatric physical therapists trained in the administration of the tests. All tests, including
anthropometric measures were conducted in a standardized manner, according to protocol and test manuals. The TD children
were tested individually at their school in two sessions with a 3-h break in between tests. The children with clin-DCD were
tested in two sessions in the physical therapy practices. The sessions took place on two different days within a period of two
weeks. On the first day the FSM was administrated, on the second day the MPST.

2.4. Statistical analyses

All statistical analyses were performed with SPSS, version 22. The Shapiro-Wilks test was used to determine whether
data were normally distributed. Independent t-tests were used to compare age, height and weight. The percentage of girls
was much lower in the clin-DCD-group compared to the TD- group. As this might influence the results, we used gender as a
factor in our analyses. Multi- (FSM-items) and univariate (MPST and Total standard score FSM) ANOVA’s in Generalized Linear
Model (GLM) were performed with 3 between subject factors (group: TD and clin-DCD; age: 4–6 and 7–10 years; gender:
boys and girls) to test if groups were different on anaerobic power and muscular endurance and if there was an interaction
between age, group and gender. Estimates of effect size (partial eta square) were calculated to evaluate the extent of the
differences. Small, medium, and large effects correspond to values of ␩2 of 0.01, 0.06, and 0.14, respectively (Cohen, 1988).
Alpha was set at 0.05.
 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126 119

Table 1
Group characteristics.

TD 4–6 years Clin-DCD 4–6 TD 7–10 years Clin-DCD 7–10

N = 36 years N = 18 N = 74 years N = 29

Age (years) 5.25 (0.81) 4.78 (0.81) 8.46 (1.20) 8.48 (1.06)
mean (SD)
Gender n (%) Boys = 19 (53%) Boys = 13 (72%) Boys = 38 (51%) Boys = 23 (79%)
Girls = 17 (47%) Girls = 5 (28%) Girls = 36 (49%) Girls = 6 (21%)
Height (cm) 116.49 (7.99) 116.89 (8.20) 137.92 (8.99) 136.43 (6.78)
mean (SD)
Weight (kg) 21.22 (3.55) 23.88 (6.23) 31.35 (7.27) 34.35 (7.18)
mean (SD)
MABC-2 (total NT 3.61 (1.75) NT 3.83 (2.12)
SS) mean (SD)

TD = Typically Developing, Clin-DCD = Children with a clinical diagnosis of Developmental Coordination Disorder, cm = centimeters, kg = kg, SD = standard
deviation, SS = Standard Score, NT = not tested.

Table 2
The means and standard deviations (SD) of the Muscle Power Sprint test and the item, cluster and total score of the Functional Strength Measurement.

Items TD Total group TD 4–6 years TD 7–10 years Clin-DCD Clin-DCD Clin-DCD
(N = 110) (N = 36) (N = 74) Total group 4–6 years 7–10 years
(N = 47) (N = 18) (N = 29)

Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)

MPST mean powerb 116.24 (63.10) 62.51 (28.93) 142.74 (58.40) 73.15 (39.55) 37.21 (16.62) 95.45 (32.51)
MPST peak powerb 140.57 (72.48) 78.85 (35.16) 171.01 (66.60) 83.58 (47.17) 41.12(19.72) 109.93 (39.25)
Overarm throwinga 1.09 (0.90) 0.83 (0.81) 1.22 (0.93) 1.30 (0.98) 1.00 (1.08) 1.58 (0.87)
Standing long jumpa 0.63 (0.82) 0.67 (0.72) 0.61 (0.87) 1.81 (1.06) 1.94 (1.11) 1.72 (1.03)
Underarm throwinga 0.37 (0.69) 0.22 (0.54) 0.45 (0.74) 0.49 (0.75) 0.22 (0.43) 0.66 (0.86)
Lateral step-up Righta 0.35 (0.57) 0.50 (0.74) 0.28 (0.45) 1.74 (1.03) 1.33 (0.72) 2.00 (1.10)
Lateral step-up Lefta 0.34 (0.58) 0.53 (0.77) 0.24 (0.43) 1.57 (1.04) 1.11 (0.76) 1.86 (1.09)
Chest passa 0.85 (0.96) 0.94 (1.17) 0.80 (0.84) 0.96 (0.98) 0.61 (0.70) 1.17 (1.07)
Sit to standa 0.81 (0.91) 0.92 (0.91) 0.76 (0.92) 2.04 (0.81) 1.89 (0.90) 2.14 (0.74)
Lifting a boxa 0.52 (0.79) 0.39 (0.77) 0.58 (0.79) 1.51 (1.02) 1.17 (1.20) 1.72 (0.84)
Stairs climbinga 0.24 (0.45) 0.14 (0.35) 0.28 (0.48) 1.62 (0.95) 1.33 (1.08) 1.79 (0.82)
Cluster UEa 2.82 (2.33) 2.39 (2.22) 3.04 (2.37) 4.26 (2.87) 3.00 (2.79) 5.03 (2.68)
Cluster LEa 2.02 (1.98) 2.24 (1.99) 1.91 (1.98) 7.13 (2.50) 6.39 (2.58) 7.59 (2.38)
Cluster EXPLa 2.94 (2.28) 2.67 (2.34) 3.07 (2.25) 4.55 (2.44) 3.78 (2.49) 5.03 (2.32)
Cluster ENDUa 1.91 (1.78) 1.96 (1.80) 1.89 (1.78) 6.83 (2.48) 5.61 (2.58) 7.59 (2.13)
Total Score FSMa 4.85 (3.46) 4.63 (3.59) 4.95 (3.42) 11.38 (4.27) 9.39 (4.64) 12.62 (3.57)

UE = cluster upper extremities, LE = cluster lower extremities, ENDU = cluster muscle endurance, EXPL = cluster explosive power, TD = Typically Developing,
Clin-DCD = Children with a clinical diagnosis of Developmental Coordination Disorder.
a
standard scores.
b
watts.

3. Results

3.1. Group characteristics

The TD group consisted of 110 children (mean age 7y 5mo, SD 1y 10mo) and clin-DCD group of 47 children (mean age
7y 1mo, range, SD 2y 1mo). The TD and clin-DCD group were not significantly different in age (t = 1.03, p = 0.30), height
(t = 0.87, p = 0.39) and weight (t = 0.15, p = 0.10). The distribution of gender was significantly different between the TD and
clin-DCD group (chi square 8.37, p = 0.04). There were more boys in the clin-DCD group (77%) than in the TD group (52%).
The characteristics of the participants per group are shown in Table 1.

3.2. Outcome analyses

MPST and FSM data showed a normal distribution. Table 2 shows the scores of the MPST and the FSM and Table 3 shows
the results of the GLM analysis (main effect group, age and gender and their interaction) and the different effect sizes.

3.2.1. Muscle Power Sprint Test

The mean scores of the MPST (peak and mean power) were significant lower in children with clin-DCD and showed large
effect sizes (2 = 0.13–0.17). There was a significant age effect, which had a large effect size (2 = 0.28). The mean of effect of
gender was significant and had small effect sizes (2 0.04–0.05). The interactions between group and age, group and gender,
and group by age by gender were not significant.
 120
Table 3

W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126

Results of the GLM with 3 between subject factors (participant groups TD and clin-DCD; age 4–6 and 7–10 years and gender) on the Muscle Power Sprint Test (MPST) and the Functional Strength Measurement
(FSM).

Age group (4–6 Participant Gender Age group x Participant Participant

and 7–10 group (TD and Gender group x Gender group x Age
years) clin-DCD) group

MPST F p Partial 2 F p Partial ␩2 F p Partial ␩2 F p Partial ␩2 F p Partial ␩2 F p Partial ␩2

Mean power 58.84 <0.01 0.28 22.48 <0.01 0.13 7.46 <0.01 0.05 0.14 0.71 <0.01 < 0.01 0.93 <0.01 2.02 0.16 0.01
Peak power 58.35 <0.01 0.28 29.35 <0.01 0.17 6.50 0.01 0.04 0.32 0.57 <0.01 0.01 0.91 <0.01 1.89 0.17 0.01
FSM F p Partial 2 F p Partial ␩2 F p Partial ␩2 F p Partial ␩2 F p Partial ␩2 F p Partial ␩2
Overarm throwing 6.05 0.02 0.04 0.75 0.39 <0.01 <0.01 0.93 <0.01 1.50 0.22 0.01 1.92 0.17 0.01 0.07 0.80 <0.01
Standing long jump 0.03 0.87 <0.01 62.29 <0.01 0.30 6.93 <0.01 0.04 4.19 0.04 0.03 1.40 0.24 <0.01 < 0.01 0.92 <0.01
Underarm throwing 5.49 0.02 0.04 1.32 0.25 <0.01 1.34 0.25 <0.01 0.04 0.85 <0.01 0.25 0.62 <0.01 0.62 0.43 <0.01
Lateral step-up R 3.74 0.06 0.02 71.99 <0.01 0.33 1.94 0.17 0.01 1.36 0.25 <0.01 0.04 0.84 <0.01 11.43 <0.01 0.07
Lateral step-up L 2.34 0.13 0.02 54.31 <0.01 0.27 3.34 0.07 0.02 0.07 0.80 <0.01 0.18 0.67 <0.01 11.90 <0.01 0.07
Chest pass 1.53 0.22 0.01 0.33 0.57 <0.01 0.76 0.38 <0.01 0.26 0.62 <0.01 0.73 0.39 <0.01 3.87 0.05 0.03
Sit to stand 0.05 0.82 <0.01 56.08 <0.01 0.27 1.87 0.17 0.01 0.25 0.62 <0.01 3.69 0.06 0.02 1.10 0.30 <0.01
Lifting a box 5.25 0.02 0.03 33.11 <0.01 0.18 1.92 0.17 0.01 0.22 0.64 <0.01 0.71 0.40 <0.01 1.36 0.25 <0.01
Stairs climbing# 4.64 0.03 0.03 204.76 <0.01 0.58 28.91 <0.01 0.16 0.24 0.62 <0.01 17.50 <0.01 0.11 0.61 0.44 <0.01
Cluster UE 8.20 <0.01 0.05 8.24 <0.01 0.05 1.43 0.23 < 0.01 0.57 0.45 <0.01 0.10 0.75 <0.01 2.27 0.13 0.02
Cluster LE 1.48 0.23 0.01 174.25 <0.01 0.54 6.78 0.01 0.04 1.41 0.24 <0.01 6.26 0.01 0.04 3.58 0.06 0.02
Cluster EXPL 4.64 0.03 0.03 15.57 <0.01 0.10 3.14 0.08 0.02 2.00 0.16 <0.01 0.18 0.67 <0.01 1.49 0.23 0.01
Cluster ENDU 5.70 0.02 0.04 171.87 <0.01 0.54 4.88 0.03 0.03 0.31 0.58 <0.01 3.15 0.08 0.02 6.23 0.01 0.04
Total score FSM 7.18 <0.01 0.05 93.02 <0.01 0.38 5.46 0.02 0.04 1.47 0.23 0.01 1.53 0.22 0.01 4.57 0.03 0.03

L = left, R = right, UE = cluster upper extremities, LE = cluster lower extremities, ENDU = cluster muscle endurance, EXPL = cluster explosive power, TD = typically developing, DCD = Developmental Coordination
Disorder, #Only item with 3-way interaction see Fig. 2.
 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126 121

stair climbing
3

2.5

2
standard score
1.5

0.5

0 DCD girls 4-6 years

TD boys 4-6 years

DCD boys 4-6 years

DCD girls 7-10 years

TD girls 7-10 years

TD boys 7-10 years

DCD boys 7-10 years

TD girls 4-6 years

Fig. 2. Standard scores of stair climbing (Functional Strength Measurement) in the different age groups, participant groups and gender.

3.2.2. Functional Strength Measurement

Six out of the nine standard scores of the FSM items were significantly poorer in the clin-DCD group compared to the
TD group and yielded large effect sizes (2 = 0.18-0.58), The items overarm throwing (p = 0.39 2 < 0.01), underarm throwing
(p = 0.25 2 < 0.01) and chest pass (p = 0.57 2 < 0.01) were not significantly different between the TD and clin-DCD group.
There was a significant effect of gender on the items standing long jump (2 = 0.04) and stair climbing (2 = 0.16). Boys outper-
formed the girls on both items. An interaction between age and group was found on the items lateral step-up right and left,
indicating that difference between the TD and the clin-DCD group was larger in the older children. The item stairs climbing
was the only item with an interaction between group, gender and age (2 = 0.06). Fig. 2 shows the standard scores of the
item stair climbing and depicts a clear difference between groups and gender. DCD children are slower running up and down
the stairs, and girls are generally slower. However, young boys with DCD are closer to normal performance while the older
boys are clearly worse than their TD counterparts. Girls with DCD are already slow at climbing stair in the younger ages.
Next we looked at the cluster scores of the FSM. Children with clin-DCD had significantly lower scores on all clusters
(upper extremities, lower extremities, explosive power and muscle endurance) and on the total score FSM and yielded
medium to large effect sizes (2 0.05–0.54). There was a significant effect of gender on the cluster lower extremities, cluster
muscle endurance and the total score FSM (2 = 0.02–0.04). Additionally, an interaction between age and group emerged
on the cluster lower extremities, cluster muscle endurance and the total score FSM. The means showed that the differences
between groups were larger in the older age group. Lastly, the gender differences on the cluster lower extremities were
different between the DCD and TD group, confirmed by a significant interaction between group and gender (2 = 0.04). The
clin-DCD group (7.53[SD 2.45]) performed worse than TD group (2.07[SD 2.18]). Overall, the girls (5.34 [SD 2.76]) had lower
performance on the cluster lower extremities than the boys (4.26 [SD 2.21]). However, this difference was merely caused by
the lower performance of the girls with DCD (8.58 [SD 2.06]) in comparison with the clin-DCD boys (6.47 [SD 2.13]). In the
TD group boys (2.05 [SD 2.17]) and girls (2.09 [SD 2.19]) had comparable scores.
Fig. 3 and 4 depicts the results of the MPST and the different clusters of the FSM for age and group.
More than 50% of the children with clin-DCD scored below the 15th percentile on the items lateral step up, sit to stand,
lifting a box and stair climbing. Among the TD children, 19% or less scored below the 15th percentile on these items. Fig. 4
shows the percentage of children in the impaired, at risk, lower normal range and upper normal range (Fig. 5).

4. Discussion

In this study we examined anaerobic capacity and functional strength in a group of children with a clinical diagnosis of
DCD.

4.1. Differences between TD and clin-DCD group on anaerobic capacity measured with the MPST and FSM

The data in this study clearly show that children with clin-DCD have lower anaerobic capacity. The MPST, the most general
test of anaerobic capacity in this study, revealed significantly poorer performance in the clin-DCD group.
Children with clin-DCD also presented lower levels of explosive power in the lower extremities, as measured by the FSM.
Our findings are comparable with the results of (Farhat et al., 2015), and similar to (Ferguson et al., 2014) who also found
differences in explosive power as measured by the standing long jump item of the FSM.
122 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126

Fig. 3. Standard scores of the different clusters of the FSM in two age groups in TD children and children with DCD (higher score indicates worse performance)
TD = typically developing children, clin-DCD = Developmental Coordination Disorder UE = upper extremities, LE = lower extremities, Explosive = muscle
power items, Endurance = muscle endurance items.

Fig. 4. Differences of the scores on the Functional Strength Measurement (FSM) and Muscle Power Sprint Test (MPST) in two age groups (4–6years, 7–10
years) and two participant groups (TD and clin-DCD).
Significant age x group effect.
 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126 123

100%
90%
80%
70%
60%
50%
40%
upper normal range (ss 0)
30%
lower normal range (ss 1)
20%
At risk (ss 2)
10%
Impaired (ss 3)
0%
Overarm throwing

Overarm throwing
Chest pass

Liing a box

Underarm throwwing

Chest pass
Underarm throwing
Lateral step up rigth

Sit to stand

Stairs climbing

Lateral step up rigth

Sit to stand
Liing a box
Standing long jump

Standing long jump

Stairs climbing
Lateral step up le

Lateral step up le

TD DCD

Fig. 5. Percentage of clin-DCD and TD children that scored on the different ranges of the FSM standard scores.

Children usually develop their anaerobic power by participating in short bursts of high intensity activity while playing
outdoor games or in sport activities that require high force and velocity (e.g. jumping, sprinting and throwing). It is likely that
children with DCD participate less in these types of activities, either because they are not motivated to participate, do not
feel competent to participate or because they are excluded by their peers due to their poor motor skills (Magalhaes, Cardoso,
& Missiuna, 2011; Cairney et al., 2006). The relationship between reduced levels of participation and lower anaerobic power
were also confirmed by one of our earlier studies conducted in a low socio-economic area in South Africa (Ferguson et al.,
2014). In that study setting, opportunities for outside play and sport were very limited, and we reported no differences in
the MPST scores between children with and without DCD. When comparing the MPST scores of TD children in the current
study to a similar age group (6–10 years) of TD children in the South African study, it is clear that the scores of the South
African children (mean power: 108.5 [SD 39.6]) were considerably lower than in the present study sample of TD children
(mean power: 131.06 [SD 58.95]). Thus, lack of opportunities to participate in physical activity is most likely causing the
lower anaerobic capacity in that group of children with normal levels of coordination. We suspect that the poorer outcome
in the MSPT in the current study is most likely caused by less optimal levels of fitness in the DCD group. Still, this result
might also be partly explained by a less efficient running style resulting in low speed (Diamond, Downs, & Morris, 2014).
We found no significant differences in the explosive power items of the upper extremities (overarm throwing, underarm
throwing and chest pass). Our findings are comparable to the study of (Ferguson et al., 2014) who found significant differences
on all items of the FSM except for overarm throwing and chest pass. (Hands & Larkin, 2006) also found no significant differences
on the item chest pass and (Schott et al., 2007) found no differences on the medicine ball throwing. In contrast to the explosive
lower limb item, standing long jump, whole body displacement is not required in the explosive upper extremity item. Why
the differences are more prominent in the lower extremity is not obvious at first sight. It could be that moving the whole
body requires more balance and interlimb coordination than throwing or pushing a ball or heavy bag in sitting or standing
position.
In the present study, children with clin-DCD exhibited lower levels of muscle endurance, showing large effect sizes.
Here, the impact of poor coordination seems stronger. The poor control of the timing between agonists and antagonists
could account for these results (Geuze, 2003; Wilson, Ruddock, Smits-Engelsman, Polatajko, & Blank, 2013). The effect size
for stair climbing was the highest (2 = 0.58) of all items tested. The stair climbing item of the FSM requires children to run
up and down a flight of six steps, turn around and repeat this as many times as possible in 30 s while making accurate
foot placements on each step. Besides muscular endurance, this item also requires the performer to quickly and efficiently
change direction (agility) between successive ascents, known to be poor in children with DCD (Zaino, Marchese, & Westcott,
2004). The items lateral step-up and sit to stand also showed large effect sizes (2 = 0.27–0.33). In the lateral step-up children
are required to stand on one leg and perform rapid alternating flexion and extension movements of the hip and knee joint,
switching from concentric to eccentric muscle action as many times as possible in 30 s. Importantly, this test mainly evaluates
localized endurance of the hip and knee extensors of the weight-bearing leg. Thus, lack of muscle endurance and inability
to rapidly alternate contractions both influence task performance. Sit to stand, besides endurance, also involves transferring
the center of mass by moving the trunk forward over the new base of support and is thus commonly used to assess both
lower extremity strength and postural control (Whitney et al., 2005). Children with DCD are known to have lower levels
of postural control, especially if it concerns anticipatory postural adaptations (APA) (Geuze, 2003; Kane & Barden, 2012).
Studies using functional tasks have shown that children with DCD have more variable postural sway and depend more on
124 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126

reactive postural adjustments (RPAs) than controls (Kane & Barden, 2014). The item lifting a box, showed a large difference
between the TD and clin-DCD group (2 = 0.18). During this item, children have to lift a box from the table to another 22 cm
high box at about arm-length distance. The number of times this can be repeated in 30 s is counted. Fast APA’s are needed to
lift the heavy box in synchrony with fast reversal of the upper extremity movements. Poorly coordinated APA’s in DCD were
observed in a number of studies (Fong et al., 2016), also when making arm movements (Jover, Schmitz, Centelles, Chabrol,
& Assaiante, 2010). Moreover children with DCD are also less able to complete a dual task while maintaining stability as
desired in this item (Chen et al., 2012).

4.2. Interaction between group and age on the measures MPST and FSM

The results of the MPST showed an age effect, which was expected because the weight of the child is used in the formula
calculating the power (watts). Weight is not different between the groups, hence it can be concluded that the differences
in scores are due to running speed. These results are similar to the studies of (O’Beirne et al., 1994) and Haga (2008). Both
studies found that differences between children with and without motor coordination problems increased over time on the
50 and 20 m run respectively.
The total score of the FSM and the cluster muscle endurance showed a significant interaction between age and group and
for the cluster lower extremities there was a trend (p = 0.06). Means indicate that the differences between the children with
clin-DCD and TD children are significantly larger in the older age group. (Hands, 2008) also found that the differences become
larger on the standing broad jump. The fact that older children with DCD participate less in sports and outdoor activities could
be a reason for this.
The cluster upper extremities and cluster explosive power showed a group and an age effect but the interaction between
age and group was not significant. On closer examination of the graphs (Fig. 4), we see the lines (representing the TD and
clin-DCD group) diverge; the same pattern as in the cluster lower extremities and cluster muscle endurance. The differences
between the groups however, have small effect sizes.
Fig. 4 shows that, children with clin-DCD score poorer than the children in the TD group on all variables depicted but that
the difference in cluster upper extremities and cluster explosive power behave comparably poor in younger and older TD and
clin-DCD. For the cluster muscle endurance and cluster lower extremities the two TD age groups perform comparably, while
the older DCD group scores worse than the younger group.

4.3. Interaction between gender, group and age on the FSM

Interactions between gender and group emerged on the cluster lower extremities. This is in contrast with the study of
(Lifshitz et al., 2014), who found no interaction between group and gender on subscale strength of the Bruininks Oseretsky
test of motor proficiency (BOT-2). The most likely explanation for the lack of differences between boys and girls is that
(Lifshitz et al., 2014) used the gender specific scale scores of the BOT-2. Another important point to take into consideration
when comparing gender differences, is that multiple studies have shown that strength and BMI is positively related (Thivel,
Ring-Dimitriou, Weghuber, Frelut, & O’Malley, 2016) and girls with DCD are more frequently overweight than boys (Lifshitz
et al., 2014). Since sample sizes in both studies were small (n = 6 and 11) generalizability of these findings requires studies
with larger sample sizes.
Only on the item stair climbing, a 3-way interaction between group, age and gender was found. Girls with DCD are poor
in both age groups, while boys with DCD only performed worse in the older age group. However, this effect in the girls is
again based on very small sample size and should be interpreted with extra care.

4.4. Results on standard scores of the FSM items

Studies in various countries have reported that children with DCD have inadequate (an)aerobic fitness, strength, and
agility. However, these results are mostly based on group differences and not in comparison to age referenced norm scores.
Our study results reveal that a large percentage of children with clin-DCD scored in the at risk and impaired range of the FSM.
For example, on the item sit to stand, 79% of the children with DCD scored below the 15th percentile, while 19% of the TD
children scored in this range.
One of the core criteria for DCD is impairment of motor coordination. Looking at the scores of the FSM, it is clear that
children with DCD also have problems in activities where functional strength plays an important role. One explanation
could be that there is in fact reduced strength in different muscle groups. Studies investigating isometric muscle strength
in DCD, report inconclusive or contradictory results. Some studies found lower levels of knee extension strength in children
with DCD measured with hand held dynamometry (Ferguson et al., 2014) while other studies did not (Hoek et al., 2012).
(Ferguson et al., 2014) found differences in handgrip, while other studies did not (Hoek et al., 2012; Hands & Larkin, 2006).
(Hoek et al., 2012) found lower levels of strength in the elbow extensors and flexors in children with DCD, while in the study
of (Ferguson et al., 2014) this was not the case.
Another explanation for lower levels of functional strength refers to the fact that children with DCD participate less in
physical activities (Magalhaes et al., 2011; Cairney et al., 2006). This could be the reason that in some studies, no differences
in performance were found in younger children with DCD, while older children exhibited lower levels of strength as they had
 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126 125

likely decreased their level of participation in active outdoor games. In our study, 4–6 year old children with clin-DCD showed
lower levels of anaerobic capacity. Notably, the older children with clin-DCD performed even worse on total standard score
and the cluster muscle endurance of the FSM. Thus, a possible explanation could be that initially neuromuscular differences
typical to DCD explain poor performance in the younger children as shown by the large effect size in tests with higher
coordination demands but that in older children there is an additional non-use deficit.
Identification of children with DCD in the majority of studies has been based on a standardized instrument rather than
clinical diagnosis, which may have led to some selection bias. (Geuze et al., 2015) stated that research is needed that compares
clinical groups and groups selected for research purposes to know if knowledge gained in one group can be generalized to
the other. The best way to find out if the clinical group is different from a group of children with DCD selected for research
purposes would be to directly compare these groups on the same measures. In our case, we can only compare the results
of our clinical sample to the literature published so far (primarily based on research samples). The results are largely in
agreement with the literature. Children with DCD are clearly poorer on anaerobic performance and functional strength and
this difference is larger in older children.
It is difficult to compare findings from the literature where clinical and research samples were used, as many studies did
not use norm-referenced tests and those who did, did not compare their results with the existing norms.
Our results imply that it is important that children with DCD are stimulated to participate in playground activities and
sports. This is especially true as children grow older the difference in performance in comparison to TD children becomes
larger. In therapy situations, anaerobic capacity activities especially ones requiring fast direction changes must be practiced
in skills that are needed to take part in daily recreational activities; improving their motor abilities will make it easier for
them to be physically active.

4.5. Limitations

The TD children had no known motor problems according to their teachers and parents but since they were not formally
assessed for motor problems, it might be possible that some children had scores ≤16th percentile on MABC-2.
We chose to use the Muscle Power Sprint Test as a measure for anaerobic performance, even though the Wingate test
is recognized as the gold standard. However, the MPST seems ecological valid for younger children because they are more
frequently observed to be sprinting at maximum speed for short distances than sprinting on a bicycle Douma et al., 2012.
Nevertheless, it would be interesting to include the Wingate test in future studies in children with DCD to make a comparison
between the two tests and the FSM in children with DCD.
The group size of the TD and clin-DCD group was not equal. We found an age effect on the MPST, cluster upper extremities,
cluster explosive power, cluster muscle endurance and the total score FSM. The percentage of children with clin-DCD in the
younger age group was higher (50%) than in the older age group (39%), and this may have influenced the mean values of the
age group (clin-DCD and TD together).
In our study, attitudes and psychological factors were not measured and could not be taken into account. (Cairney et al.,
2006) reported that children with DCD have a negative expectation of their own performance; consequently even though
maximally motivated by the trained assessors. So it might be that, some children have lacked motivation to give their best
performance. It would be interesting to evaluate the influence of these factors in future research.

5. Conclusion

Children with a clinical diagnosis of DCD had poorer performance on anaerobic capacity, anaerobic muscle endurance and
explosive muscle power tests compared to their TD peers as measured with the MPST and the FSM. The differences between
groups were larger in items that required more coordination especially in the items requiring fast reversals within a 30 s
timeframe. The scores on the FSM were lower in the older age group in comparison with the younger group suggesting that
age is an interfering factor in anaerobic capacity. More than 50% of children with clin-DCD scored below the 15th percentile
on these repetitive movement items of the FSM. Further studies are needed to determine whether these results are due to
less adequate coordination or if less participation in sports or decreased motivation is responsible.
In summary, results from the present study, which included children with a clinical diagnosis of DCD, are not at odds
with the current literature in which children with DCD are included based on scores on a motor performance test and well
defined operational definitions of the other DSM-5 criteria. Nonetheless, including a clinical group is important when the
research question is concerned with a specific condition in children with DCD such as anaerobic capacity in functional tasks.
Including a clinical group is clinically more relevant since these are the children intervention programs are developed for.

Acknowledgements

We would like to thank all children and their parents for participating in this study. We also would like to thank the
students of Avans+ for helping with the data collection.
126 W.F.M. Aertssen et al. / Research in Developmental Disabilities 59 (2016) 115–126

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