Physical and sedentary activity in adolescents with cerebral palsy

Walking Performance, Physical Activity, and Validity of the Early Activity Scale for Endurance in Young Children with Cerebral Palsy

AIMS

To describe the walking performance and physical activity of children with cerebral palsy (CP) by Gross Motor Function Classification System (GMFCS) level, age, sex, and geographical location; and, to examine the concurrent validity of the 4-item Early Activity Scale for Endurance (EASE) to walking performance and physical activity scores.

METHODS

Seventy-nine children with CP participated. Parents completed the 4-item EASE. All children wore an Actigraph monitor (n = 79), and children in GMFCS levels I - III also wore a StepWatch monitor (n = 50), for seven days.

RESULTS

Only GMFCS level yielded significant differences in average strides taken per day, in strides per day taken faster than 30 strides per minute, in average physical activity counts per minute, and in minutes per day spent in moderate to vigorous physical activity. The 4-item EASE findings were moderately correlated with average physical activity counts per minute (.61, p< .001) and minutes per day spent in moderate to vigorous physical activity (.62, p < .001).

CONCLUSIONS

GMFCS level is predictive of both walking performance and physical activity in children with CP. The 4-item EASE may provide a quick and valid way to monitor physical activity in children with CP.

The effects of an individualized health-risk report intervention on changes in perceived inactivity-related disease risk in adults with cerebral palsy

BACKGROUND

To explore the effect of an individualized health-risk report intervention on changes in perceived disease risk in adults with cerebral palsy (CP).

HYPOTHESES

1. Perceived disease risk from those at risk for heart disease, obesity, and/or diabetes will be greater compared to those not at risk following receipt of health-risk information; 2. There will be a positive relationship between risk measures of inactivity-related diseases and post-intervention perceived disease risk; and increases in perceived disease risk will predict increases in physical activity (PA).

METHODS

An individualized health-risk report was delivered to each participant. Three brief telephone interviews were conducted over two weeks to measure perceptions of disease risk and PA. Two-way repeated measures ANOVA and regression analyses were performed to address the study objectives.

RESULTS

Thirty-one adults with CP (Gross Motor Function Classification System level I-V; age, 33.7 ± 13.1y) completed the study. The health-risk report did not change the perceived risk of any inactivity-related disease. We found significant main effects for hypertension (p = 0.02; 95% CI [-1.1, -0.5]) on perceived risk of heart disease, and for waist circumference (p < 0.01; 95% CI [-1.3, -0.3]) and BMI (p < 0.01; 95% CI [-1.3, -0.3]) on perceived risk of obesity. PA did not change following the intervention.

CONCLUSIONS

An individualized health-risk report intervention did not change perceived risk of inactivity-related disease or change PA behaviour. Blood pressure, waist circumference and BMI were salient measures of health that affected perceived disease risk in adults with CP; these health variables should be assessed and managed through clinical encounters.

Analysis for reliability and validity of gross motor function and health fitness tests for children with developmental disabilities

The aim of this study was to determine the reliability and validity of gross motor function and health fitness assessment tests for children with developmental disabilities. All 35 participants who took part in this study on a voluntary basis were male children (age, 10.31±1.25 years). All selected tests for gross motor function and health fitness assessments were used in previous studies to measure basic physical health and motor abilities, which include strength (grip strength test), muscular endurance (modified sit-ups test), flexibility (sit and reach test), and cardiopulmonary endurance (15-m shuttle run test). Reliability was analyzed using intraclass correlation coefficients in the pretest-posttest and Bland-Altman graphs study. Pearson correlation was used to analyze convergent validity and analysis of variance was used to analyze variations among age groups. Lastly, a correlation analysis was conducted between the tests in gross motor function and health fitness assessments. This study indicates that gross motor function and health fitness assessments have obtained adequate reliability parameters and are able to determine differences in children from 9 to 12 years of age. The tests performed were simple to use, safe, and suitable for children with developmental disabilities.

Instruments Measuring Physical Activity in Individuals Who Use a Wheelchair: A Systematic Review of Measurement Properties

OBJECTIVE

To systematically review the evidence evaluating validity or reliability of self-reported and device-based instruments, to measure physical activity (PA) in individuals who use a wheelchair, and to make recommendations for the selection of PA outcomes tools.

DATA SOURCES

PubMed, Embase, and CINAHL were systematically searched.

STUDY SELECTION

Studies reporting measurement properties of instruments to assess PA in individuals who use a wheelchair.

DATA EXTRACTION

The Consensus-Based Standards for the Selection of Health Status Measurement Instruments checklist was used to assess the methodological quality of the included studies. The measurement properties of instruments assessing PA were examined.

DATA SYNTHESIS

The search yielded 5341 records, 61 were considered relevant, 21 articles were included. A best evidence synthesis was performed on 9 studies including 4 self-reported instruments and 13 studies including 8 device-based instruments. One study evaluated both self-reported and device-based instruments. The overall methodological quality of all studies ranged from poor to excellent. Variable levels of evidence were found for both the validity and reliability for self-reported instruments and for criterion validity for device-based instruments.

CONCLUSIONS

The Physical Activity Scale for Individuals with Disabilities (PASIPD) and The Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) seem the most promising self-reported instruments for measuring the intensity of PA. Device-based instruments that can be used for measuring both the intensity and type of PA are the GENEActiv, Actigraph GT3X+, Actiheart, or the Physical Activity Monitor System (PAMS), showing moderate evidence for a positive rating of criterion validity. For measuring the type of PA, the PAMS and VitaMove are suitable, showing both good evidence for a positive rating of criterion validity.

Screen time among Spanish university students with disabilities: a self-organizing maps analysis

BACKGROUND

Screen time can play a significant role in the health and quality of life of people with disabilities. However, there is a lack of studies on this issue among people with disabilities, and even fewer in the university setting. Thus, the aim of our study was to explore the relationships between screen time, disability grade, body mass index (BMI), physical activity and sociodemographic variables (gender and socioeconomic status) in university students with different disabilities.

METHODS

A cross-sectional study was conducted on a sample of 1091 students with disabilities from 55 Spanish universities. Instruments used for data gathering were the Adolescent Sedentary Activity Questionnaire (ASAQ) and the International Physical Activity Questionnaire-Short Form (IPAQ-SF). A Self-Organizing Maps (SOM) analysis was carried out to explore the relationships between the variables under study.

RESULTS

Participants reported high values in overall screen time (5.45 h per day/week), with computers being the media most used (2.45 h per day/week). The SOM analysis showed slightly higher screen time values in women than men. People with a high disability grade spent less screen time than those with lower disability grade. Contradictory results exist when a group of men with the highest BMI had the highest screen time and the lowest physical activity (PA) while women with low BMI show the highest screen time and PA.

CONCLUSIONS

Gender and disability grade played a moderating role in screen time among people with disabilities while BMI and PA do not play such a role.

Physical activity patterns in children with cerebral palsy and typically developing peers

Objective: To compare physical activity level between children with cerebral palsy and typically developing peers using accelerometer and activity diary.Method: Twenty children with spastic cerebral palsy Level I and II according to Gross Motor Function Classification System, and 20 healthy age- and sex-matched typically developing peers were included. An activity diary was logged, and each child wore an accelerometer for 4 days, 2 weekdays and 2 weekend days.Results: Total and physical activity energy expenditure assessed using either accelerometer or activity diary was markedly lower in children with spastic cerebral palsy compared to typically developing peers. Moderate and vigorous physical activities and daily total energy expenditure assessed using activity diary were significantly lower in children with cerebral palsy than those of typically developing peers (p < .05). There was a significant relationship between accelerometer and activity diary in total energy expenditure for children with cerebral palsy (r = 0.752, p < .001) and typically developing peers (r = 0.732, p < .001) and a moderate significant relationship in physical activity energy expenditure for children with cerebral palsy (r = 0.463, p = .040).Conclusion: In this study, children with cerebral palsy had lower physical activity levels than their typically developing peers. The activity diary provided detailed information about physical activities and was correlated with accelerometer data. The activity diary could be a valid measure of physical activity levels in children with cerebral palsy.

Participation in leisure-time activities and the role of individual factors in children and adolescents with cerebral palsy

Background/Aims

This study evaluated the role of individual factors of children and adolescents with cerebral palsy in the prediction of leisure participation.

Methods

A cross-sectional study design was used. A group of children and adolescents with cerebral palsy were selected to complete the Children's Assessment of Participation and Enjoyment. Participants' cognitive levels were assessed based on the Study of Participation of Children with Cerebral Palsy Living in Europe estimated cognitive levels.

Findings

The models could best predict up to 31.8% of the variance in the participation rates, 28.4% of the variance in the frequency scores and 33.5% of the variance in the enjoyment scores of leisure domains. The type of cerebral palsy was one of the most significant predictive factors of leisure participation (β ranged from −0.177 to −0.525 for quadriplegia).

Conclusions

Therapists and rehabilitation specialists may consider individual factors to predict a proportion of leisure participation subscales before planning for interventions aimed at promoting the leisure participation of children and adolescents with cerebral palsy.

A qualitative study examining the validity and comprehensibility of physical activity items: developed and tested in children with juvenile idiopathic arthritis

BACKGROUND

Not all physical activity (PA) questionnaires (PAQ) gather information regarding PA intensity, duration, and modes and only a few were developed specifically for children. We assessed children's comprehensibility of items derived from two published PAQs used in children along with three items designed to ascertain PA intensity in order to assess comprehensibility of items and identify response errors. We modified items to create a new PAQ for children (ASCeND). We hypothesized that children would have comprehension difficulties with some original PAQ items and that ASCeND would be easier to comprehend, and would improve recall and reporting of PA.

METHODS

For this qualitative study, we recruited 30 Swedish children [ages 10-16 years; mean age = 13.0 (SD = 1.8)]; median disease activity score = 4.5 (IQR 2.2-9.0); median disease duration = 5.0 (IQR 2.6-10.8) with juvenile idiopathic arthritis (JIA) from a children's hospital-based rheumatology clinic. We conducted cognitive interviews to identify children's comprehension of PAQ items. Interviews were audiotaped, transcribed, and independently analyzed. In phase one, 10 children were interviewed and items modified based on feedback. In phase two, an additional 20 children were interviewed to gather more feedback and further refine the modified items, to create the ASCeND.

RESULTS

The median interview time was 41 min (IQR 36-56). In phase one, 219 comments were generated regarding directions for recording PA duration, and transportation use, walking, dancing, weight-bearing exercise and cardio fitness. Based on feedback we modified the survey layout, clarified directions and collapsed or defined items to reduce redundancy. In phase two, 95 comments were generated. Most comments related to aerobic fitness and strenuous PA. Children had difficulty recalling total walking and other activities per day. Children used the weather on a particular day, sports practice, or gym schedules to recall time performing activities. The most comments regarding comprehension were generated about the 3-item PA intensity survey, suggesting children had problems responding to intensity items.

CONCLUSIONS

The newer layout facilitated recall of directions or efficiency in answering items. The 3-item intensity survey was difficult to answer. Sports-specific items helped children more accurately recall the amount of daily PA. The ASCeND appeared to be easy to answer and to comprehend.

Novel approaches to measuring community integration in adults with cerebral palsy

Purpose: Rehabilitation goals often focus on increasing community integration for adults with disabilities and are measured by objective assessments. Research methods have lagged behind in capturing current conceptualizations of community integration as a multidimensional construct that incorporates participation, social supports, and feelings of belonging in the community. This paper addresses this challenge by describing a multi-method approach to assessing community integration for adults with cerebral palsy.Methods: Measures include standardized questionnaires, qualitative methods, measures of function and physical activity, and geospatial measures using Geographic Information System mapping and Global Positioning System tracking. These objective and subjective data are used to determine where adults spend time and are most active, and which activities and social connections are associated with feeling integrated into the community.Results: Two case examples highlight the importance of using a multi-method approach to assess community integration for adults with cerebral palsy. Results of objective clinical measures were comparable among case examples; however, actual experiences of feeling connected to the community were vastly different.Conclusions: Multiple measures are required to capture the complexity of community integration. Relying solely on objective measures may not provide a complete picture of community integration.IMPLICATIONS FOR REHABILITATIONCommunity integration is a complex construct that incorporates participation, socialization, and feelings of belonging in the community.New methods and measures are needed to assess the many aspects of community integration in adults with disabilities.A multi-method approach is recommended to provide a richer characterization of community integration in individuals with disabilities.A combination of quantitative and qualitative measures addressing the physical, social and psychological aspects of community integration should be used.

The impact of breathing rate on the cardiac autonomic dynamics among children with cerebral palsy compared to typically developed controls

PURPOSE

To describe the immediate effect of breathing rate on heart rate (HR) and heart rate variability (HRV) in children with cerebral palsy (CP) and a control group of typically developed (TD) age and gender-matched children.

METHODS

Twenty children with CP at gross motor function classification system levels I-III and 20 TD children aged 6-11 participated in the study. HR was monitored at rest and during paced breathing with biofeedback. Respiratory measures were assessed by KoKo spirometry.

RESULTS

Children with CP have lower spirometry and HRV values at rest compared to TD children. The mean reduction of breathing rate during paced breathing among children with CP was significantly smaller. Nonetheless, while practicing paced breathing, both groups reduced their breathing rate and increased their HRV.

CONCLUSIONS

The results of the current work present the immediate effect of paced breathing on HRV parameters in CP and TD children. Further studies are needed to investigate the effect of long-term treatment focusing on paced breathing for children with CP.

Longitudinal trajectories of physical activity and walking performance by gross motor function classification system level for children with cerebral palsy

Purpose: This study aims to present developmental trajectories for physical activity (PA) and walking performance for children with cerebral palsy (CP).Materials and methods: Seventy-nine children with CP, 39 (49%) female, Gross Motor Functional Classification System levels I-V, and mean age 91.3 months (+/-27.7 SD) participated. Participants in levels I-V wore the Actigraph to capture PA and children in levels I-II also wore a StepWatch (SW) (n = 43) to measure walking performance. Trajectories for average PA counts/minute and number of minutes of moderate to vigorous PA were generated for levels I, II, and III/IV/V (aggregate). Single leg strides/day and average strides faster than 30 strides/min trajectories were generated for levels I-II.Results: Participants did not display plateaus in PA or walking performance based on functional level. Children in all levels showed a decrease in amount and intensity of PA from 3.0 to 12 years old, with participants in level I demonstrating the steepest decline. Children in level I decreased slightly, and level II increased slightly in both walking performance measures from 3.0 to 12 years old.Conclusions: Longitudinal curves demonstrate variations in PA and walking performance by functional level and provide prognostic information as to what changes may be anticipated for children with CP.Implications for rehabilitationLongitudinal developmental trajectories for physical activity and walking performance for children with cerebral palsy across functional levels are documented.Trajectories have potential to support collaborative intervention planning between therapists and families relative to physical activity and walking performance.

Meta-Analysis of Physical Activity Levels in Youth With and Without Disabilities

The purpose of this study was to explore the current levels of physical activity among youth with disabilities using meta-analysis. The search identified 11 publications including 729 participants (age 4-20 yr). The overall effect size for 11 studies was Hedges g = 0.60 (SE = 0.18, 95% confidence interval [CI] [0.24, 0.96], p < .05, k = 11) using a random-effects model. The findings suggest that differences in physical activity levels between youth with and without disabilities are complex. Results indicated that youth without disabilities engaged in higher levels of physical activity of moderate to vigorous intensity (g = 0.66, SE = 0.18, p < .05). However, no differences were found in light-intensity physical activity (g = -0.03, SE = 0.16, p > .85). Results also suggested that the differences in physical activity between youth with and without disabilities were affected by age (<12 yr, g = 0.83, SE = 0.24, 95% CI [0.37, 1.29], p < .05, and >13 yr, g = 0.37, SE = 0.10, 95% CI [0.18, 0.57], p < .05; Q value = 3.20, df = 1, p < .05), with children with disabilities engaging in less physical activity than children without disabilities in younger ages. Differences in physical activity level between youth with and without disabilities are functions of intensity of physical activity and age but may not be of type of disability (Q value = 0.22, df = 1, p > .6).

Current evidence does not support whole body vibration in clinical practice in children and adolescents with disabilities: a systematic review of randomized controlled trial

BACKGROUND

Whole body vibration has been used alone or combined with other interventions in rehabilitation of children and adolescents with disabilities; however, there is limited evidence to support this approach.

OBJECTIVES

To review the strength, quality, and conclusiveness of evidence supporting the use of whole body vibration in children and adolescents with disabilities.

METHODS

Electronic database search included Medline, AMED, Embase, Cochrane, SportDiscus, CINAHL and PEDro from the inception to June 2018. Studies investigating the effects of whole body vibration, alone or combined with other interventions, compared to minimal intervention or other interventions were included. The outcomes measured were: body structure and function (lean body mass, bone mineral density, knee muscle strength and overall stability) and activity and participation (gait speed, walking distance, gross motor function, self-care and mobility).

RESULTS

Fifteen randomized trials involving 403 participants were included. Methodological quality of eligible trials was moderate (mean of 5.5 points on the 10-point PEDro scale). Overall, whole body vibration was no better than minimal intervention. In all comparisons where additional effect of whole body vibration was better than other interventions, the effect size ranged from low to high in the trials, but ranged from very-low to low quality at short and medium-term follow-up. Sensitivity analysis for health condition and low-quality studies showed impact on trunk bone mineral density of additional effect of whole body vibration at medium-term compared to other interventions.

CONCLUSION

The low to very-low quality of evidence suggests caution in recommending the use of this approach. New studies could change the findings of this review. PROSPERO registration: CRD42017060704.

The risk, burden, and management of non-communicable diseases in cerebral palsy: a scoping review

AIM

To examine the risk, burden, and management of non-communicable diseases (NCDs) among people with cerebral palsy (CP).

METHOD

Databases (Ovid MEDLINE, Embase Ovid, CINAHL Plus) were systematically searched up to August 2017. Data on the prevalence of risk factors for, and the burden and management of, cardiovascular diseases, diabetes, cancers, and respiratory diseases were extracted.

RESULTS

Thirty-six studies that examined the prevalence of risk factors among people with CP were identified. There was inconsistent evidence that people with CP had higher prevalence of metabolic risk factors such as hypertension, hyperlipidaemia, and obesity, but strong evidence that they participated in low levels of physical activity, compared with people without CP. Seven studies reported on the burden of NCDs. Adults with CP had a higher risk of NCDs, including stroke, chronic obstructive pulmonary disease, and other heart conditions, and death due to NCDs, including cancers, chronic obstructive pulmonary disease, stroke, and ischaemic heart disease, compared with the general population. Only one study reported on the management of NCD, specifically the uptake of breast cancer screening among females.

INTERPRETATION

The burden of NCDs is higher among adults with CP compared with the general population. Further research is required to determine the prevalence of metabolic risk factors and management of NCDs among people with CP.

WHAT THIS PAPER ADDS

Adults with cerebral palsy (CP) have an increased risk of non-communicable diseases (NCDs) and increased risk of death because of NCDs. Evidence is inconsistent about the elevated prevalence of metabolic risk factors for NCDs. Evidence is consistent that people with CP participate in reduced physical activity. Only one study reported on management of NCD among people with CP. Available evidence suggests people with CP are less likely to receive preventive medicine.

Enabling physical activity participation for children and youth with disabilities following a goal-directed, family-centred intervention

BACKGROUND

There is a paucity of research demonstrating the optimisation and maintenance of participation outcomes following physical activity interventions for children and youth with disabilities.

AIM

To evaluate changes in physical activity participation in children with disabilities following a goal-directed, family-centred intervention at a healthsports centre, and to identify factors influencing participation following the intervention.

METHODS AND PROCEDURES

A mixed methods pre-test post-test cohort design was applied. Recruitment occurred over a 12 month period during standard clinical service provision. The Canadian Occupational Performance Measure (COPM) was administered to children and parents pre (T1) and post-intervention (T2), and at 12 weeks follow-up (T3). Goal Attainment Scaling (GAS) was applied to assess outcomes at 12 weeks follow-up (T2-T3). Qualitative inquiry described barriers to goal attainment at T3.

OUTCOMES AND RESULTS

Ninety two children with a range of disabilities (mean age 11.1yr; 49 males) were included in the study. Statistically significant and clinically meaningful improvements in parent ratings of COPM performance and satisfaction of participation goals were observed following intervention. Ratings at 12 weeks follow-up remained significantly higher than baseline, and 32% of children attained their COPM-derived GAS goal. Environmental factors were the most frequent barrier to goal attainment following intervention.

CONCLUSION AND IMPLICATIONS

These results provide preliminary evidence for goal-directed, family-centred interventions to optimise physical activity participation outcomes for children with disabilities.

Barriers and facilitators to physical activity participation for children with physical disability: comparing and contrasting the views of children, young people, and their clinicians

PURPOSE

Existing research has explored the barriers and facilitators of physical activity participation for young people with disability from the perspective of young people and their families. However, little research has investigated the views of clinicians who facilitate access to physical activity programs and compared this with their child client's perspectives.

METHOD

Interviews were conducted with six allied health and sports development professionals associated with a programme which supports access to recreation and sporting activities. Interviews explored facilitators and barriers to physical activity experienced by their clients. Open-ended survey questions investigating barriers and facilitators of physical activity participation were also completed by 28 young people with disability aged 10-17 years who were clients of this programme.

RESULTS

The most salient facilitator of participation described by clinicians was "planning programs to promote success and inclusion." Young people described two main facilitators; "the right people make physical activity fun!" and, similar to clinicians, "appropriate and inclusive opportunities to be active." The most salient barriers identified by clinicians were "practical limitations" and "time constraints and priorities," and a novel barrier raised was "whose choice?" The "lack of accessible and inclusive opportunities" was the most pertinent barrier for young people.

CONCLUSIONS

Clinicians should determine both parent and young person commitment to a physical activity before enrolment. Lack of commitment can act as a barrier to physical activity and a more appropriate intervention could focus on increasing awareness of the benefits of being active, drawing on a Stages of Change based model of service delivery. Implications for rehabilitation Rehabilitation professionals seeking to increase physical activity participation for young people with physical disability should discuss readiness and motivation to change prior to any activity/sports referral. Different behaviour change processes are required for young people and for their parents and both are important to achieve physical activity participation. Regular monitoring is important to identify on-going physical and psychological barriers to participation, even for those who were already active. Clinicians should be aware that teenagers may be more ready to be active as they develop greater independence and should raise awareness of the benefits of physical activity.

Effects of a School-Based Sports Program on Physical Fitness, Physical Activity, and Cardiometabolic Health in Youth With Physical Disabilities: Data From the Sport-2-Stay-Fit Study

OBJECTIVE

To investigate the effects of a school-based once-a-week sports program on physical fitness, physical activity, and cardiometabolic health in children and adolescents with a physical disability.

METHODS

This controlled clinical trial included 71 children and adolescents from four schools for special education [mean age 13.7 (2.9) years, range 8-19, 55% boys]. Participants had various chronic health conditions including cerebral palsy (37%), other neuromuscular (44%), metabolic (8%), musculoskeletal (7%), and cardiovascular (4%) disorders. Before recruitment and based on the presence of school-based sports, schools were assigned as sport or control group. School-based sports were initiated and provided by motivated experienced physical educators. The sport group (n = 31) participated in a once-a-week school-based sports program for 6 months, which included team sports. The control group (n = 40) followed the regular curriculum. Anaerobic performance was assessed by the Muscle Power Sprint Test. Secondary outcome measures included aerobic performance, VO₂ peak, strength, physical activity, blood pressure, arterial stiffness, body composition, and the metabolic profile.

RESULTS

A significant improvement of 16% in favor of the sport group was found for anaerobic performance (p = 0.003). In addition, the sport group lost 2.8% more fat mass compared to the control group (p = 0.007). No changes were found for aerobic performance, VO₂ peak, physical activity, blood pressure, arterial stiffness, and the metabolic profile.

CONCLUSION

Anaerobic performance and fat mass improved following a school-based sports program. These effects are promising for long-term fitness and health promotion, because sports sessions at school eliminate certain barriers for sports participation and adding a once-a-week sports session showed already positive effects for 6 months.

CLINICAL TRIAL REGISTRATION

This trial was registered with the Dutch Trial Registry (NTR4698).

Physical Activity in Adolescents and Young Adults with Cerebral Palsy

The aim of this study was to examine the level of physical activity in adults with cerebral palsy (CP) and to analyse its relationship with physical activity as adolescents, pain, and gross motor function. A prospective cohort study was performed using data from the Swedish National CP Registry (CPUP) for all 129 individuals born in 1991–1993 living in Skåne and Blekinge who reported to CPUP at 14–16 years of age. Physical activity as adult was analysed relative to physical activity as adolescents, pain, and the Gross Motor Function Classification System (GMFCS). Seventy-one individuals at GMFCS I–V were followed up as adults and included in the analyses. Of these, 65% were physically active, but only 56% performed physical activity at least once a week. Their physical activity as adults differed relative to their physical activity as adolescents (p = 0.011) but not to pain or GMFCS. Being physically active as an adolescent doubled the probability of being active as an adult (OR 2.1; p = 0.054), indicating that physical activity in adults with CP is related to their physical activity as adolescents. Therefore, interventions to increase physical activity among adolescents with CP are likely also to improve physical activity in adulthood.

Exploring factors that impact activity participation of children and adolescents with severe developmental disabilities

BACKGROUND

Despite the benefits of social participation, children and adolescents with developmental disabilities (DD) are often excluded from taking part in social activities. There is a gap in the literature about the factors that contribute to adequate participation of children with severe DD in particular and the barriers to their participation. Taking an ecological perspective, the purpose of this study was to examine child, family and community variables that may impact the activity participation of children and adolescents with severe DD.

METHODS

A total of 197 parents of children with severe DD (4-19 years) completed a survey, addressing a wide range of child, family and community related variables, as well as a measure of activity participation.

RESULTS

Overall, the final model significantly accounted for 30% of the variance in activity participation. Higher adaptive behaviour, greater parental socialisation and placement in an integrated school programme were significant predictors of greater activity participation.

CONCLUSION

Child, family and community factors were all important in understanding the activity participation of children with severe DD, thus supporting the value of an ecological approach. Suggestions for future research and clinical implications are discussed.

Participation in physical activities for children with cerebral palsy: feasibility and effectiveness of physical activity on prescription

Background

Children with cerebral palsy (CP) are less physically active and more sedentary than other children which implies risk factors for their physical and mental health. Physical activity on prescription (PAP) is an effective intervention to promote a lifestyle change towards increased physical activity in adults in general. Knowledge is lacking about the use of PAP in children with CP. Therefore, the aim of this study was to evaluate the feasibility of PAP for children with CP and its effectiveness on participation in physical activity and sedentary behaviour.

Methods

Eleven children with CP, aged 7-11 years, participated in PAP, consisting of a written agreement between each child, their parents and the physiotherapist and based on Motivational Interviewing (MI), Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS). Individual goals, gross motor function and physical activity were assessed at baseline, at 8 and/or 11 months using COPM, GAS, logbooks, Gross Motor Function Measure (GMFM-66), physical activity questionnaires, physical activity and heart rate monitors and time-use diaries. At 8 and 11 months the feasibility of the intervention and costs and time spent for the families and the physiotherapist were evaluated by questionnaires.

Results

The intervention was feasible according to the feasibility questionnaire. Each child participated in 1-3 self-selected physical activities during 3-6 months with support from the physiotherapist, and clinically meaningful increases from baseline of COPM and GAS scores were recorded. Being physically active at moderate-vigorous levels varied between less than 30 and more than 240 minutes/day, and the median for the whole group was 84 minutes/day at baseline and 106 minutes/day at 8 months.

Conclusions

The intervention PAP seems to be feasible and effective for children with CP, involving both every day and organised physical activities to promote an active lifestyle through increased participation, motivation, and engagement in physical activities. Further research of PAP is needed, preferably in a long term randomised controlled trial and including health economic analysis to show costs and benefits.

Trial Registration

ISRCTN76366356, retrospectively registered.

Having Fun and Staying Active! Children with Disabilities and Participation in Physical Activity: A Follow-Up Study

AIM

This study investigated change in the participation profile of physical activity over 15 months after a three-week intensive rehabilitation that used physical activity as the main intervention.

METHODS

The Children's Assessment of Participation and Enjoyment (CAPE) was used in a longitudinal prospective study (pre- and post-design) with three measurements over 15 months. Eighty children with physical disabilities (6-17 years old; mean score 11.1; SD 2.4), some with additional cognitive challenges, completed all three measurements.

RESULTS

Participation diversity and intensity of all 55 leisure activities declined significantly over the 15-month period. The largest decline was for children aged between 10 and 13 years. Among physical activities, there was a stable level of participation of the total group, and sub-groups. Boys preferred "active physical activities" to a greater extent, while girls preferred "skill-based activities." Both genders expressed a higher level of enjoyment in their preferred activities according to the Preferences for Activities of Children.

CONCLUSIONS

This intervention may have the potential to maintain the level of physical activity among children and youths with disabilities, yet further controlled studies are needed. Gender differences should be taken into consideration to facilitate stable participation in physical activities with a high level of enjoyment.

Psychometric properties of measures of gait quality and walking performance in young people with Cerebral Palsy: A systematic review

Availability of outcome measures (OMs) with robust psychometric properties is an essential prerequisite for the evaluation of interventions designed to address gait deterioration in young people with Cerebral Palsy (CP). This review evaluates evidence for the reliability, validity and responsiveness of outcome measures of gait quality and walking performance in young people with CP. A systematic search was performed in MEDLINE, CINAHL, PubMed and Scopus. Articles that met the eligibility criteria were selected. Methodological quality of studies was independently rated by two raters using the modified COnsensus-based Standard for the selection of health status Measurement INstruments checklist. Strength of evidence was rated using standardised guidelines. Best evidence synthesis was scored according to Cochrane criteria. Fifty-one articles reporting on 18 distinct OMs were included for review. Best evidence synthesis indicated a moderate to strong evidence for the reliability for OMs of walking performance but conflicting evidence for the reliability of OMs of gait quality. The evidence for responsiveness for all OMs included in this review was rated as 'unknown'. The limitations of using the modified COSMIN scoring for small sample sizes are acknowledged. Future studies of high methodological quality are needed to explore the responsiveness of OMs assessing gait quality and walking performance in young people with CP.

Evidence for increasing physical activity in children with physical disabilities: a systematic review

AIM

To summarize the best evidence of interventions for increasing physical activity in children with physical disabilities.

METHOD

A systematic review was conducted using an electronic search executed in Academic Search Elite, Academic Search Premier, CINAHL, Embase, MEDLINE, PEDro, PsychINFO, and SPORTDiscus up to February 2016. The selection of articles was performed independently by two researchers according to predetermined eligibility criteria. Data extraction, methodological quality, and levels of evidence were independently assessed by two researchers using a data-collection form from the Cochrane Collaboration and according to the guidelines of the American Academy for Cerebral Palsy and Developmental Medicine.

RESULTS

Seven studies were included. Five randomized controlled trials ranged from strong level I to weak level II studies, and two pre-post design studies were classified as level IV. There is level I evidence for no effect of physical training on objectively measured physical activity, conflicting level II evidence for interventions with a behavioural component on the increase of objectively measured physical activity directly after the intervention, and level II evidence for no effect during follow-up. Results are limited to children with cerebral palsy as no other diagnoses were included.

INTERPRETATION

Increasing physical activity in children with physical disabilities is very complex and demands further development and research.

Self-efficacy of physical education teachers in including students with cerebral palsy in their classes

Children with cerebral palsy (CP) are often mainstreamed into the general education system, but are likely to be excluded from physical education (PE) classes. A questionnaire was constructed and utilized to measure PE teachers' self-efficacy (SE) toward inclusion of students with CP in each of three mobility categories (independent, using assistive devices, using wheelchair mobility) and the impact of experience and training on teachers' SE. Participants in the study were 121 PE teachers from different parts of Israel (mean age: 41.02±9.33 years; range: 25.00-59.00 years). Exploratory factor analysis was used to determine the structure of the sub-scales' factors' structure and Cronbach's Alpha reliability was satisfactory (range 0.872-0.941). Independent t-tests were calculated in order to compare the SE of teachers with and without adapted PE experience. Repeated Analysis of Variance was performed to measure within-group differences in SE. Results revealed that the PE teachers' SE in teaching students who use mobility assistive devices or wheelchairs was significantly lower compared to teaching those who walk and run unaided (F=19.11; p<0.001). The teachers' SE towards including CP children who independently ambulate was influenced (p<0.05; d=0.94) by the teacher's experience (elementary school practicum). SE in the mobility with assistive device group was also significantly influenced (p<0.05; d=0.1) by teaching experience (previous experience and having a specialization in adapted PE). Finally, SE when teaching the wheelchair mobility group was influenced by having an adapted PE specialization (p<0.05; d=0.82). Specialized training in this particular area should be enhanced to increase teachers' SE and enable greater participation of children with CP in general physical education classes.

From Disease to Health: Physical Therapy Health Promotion Practices for Secondary Prevention in Adult and Pediatric Neurologic Populations

BACKGROUND AND PURPOSE

Over the last decade there has been a substantial increase in efforts to better understand how targeted physical activity and exercise interventions can be used to minimize secondary consequences arising from neurological damage in both adult and pediatric populations. This article offers an overview of contemporary research that addresses mediators of functional and neuroplastic adaptations associated with physical activity and exercise. We emphasize the important role that physical therapists can play to increase participation and improve well-being in adults and children with neurological disorders. We further highlight potential strategies to foster translation of evidence-based findings for use by clinicians and consumers.

SUMMARY OF KEY POINTS

Engagement in physical activity can serve as a powerful promoter of health and well-being in adults and youth with neurologic disease, and has the potential to alter the course of disease processes. Physical therapists can play a key role in promoting fitness and wellness by encouraging active living, providing early diagnosis of disease and prescribing targeted activity interventions to improve fitness and participation, and helping individuals overcome personal and environmental barriers to an active lifestyle.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Physical therapists must adopt a model of rehabilitation that emphasizes secondary prevention in adults and youth with neurologic diseases. Physical therapists have a unique role in developing forward-thinking approaches in using innovative health and wellness strategies to promote positive changes in activity and exercise behaviors.

Parental perspectives on physical activity of adolescents with cerebral palsy: a pilot study

As adolescents with cerebral palsy (CP) move into adulthood, physical activity tends to decline and they are three times more likely to develop heart disease, stroke or cancer than their able-bodied peers. While their motor function may never reach the level of able-bodied teens, improving physical activity of adolescents with CP may help them reach more optimal physical and psychosocial health. The purpose of this qualitative study was to understand physical activity of adolescents with cerebral palsy from the viewpoint of their parents ( n = 5). The research question was ‘How do parents of adolescents with cerebral palsy view physical activity?’. The study resulted in five themes: 1) ‘My child is unique’; 2) ‘It is not about winning, it is about being able to participate’; 3) ‘Friends motivate my child’; 4) ‘We can figure it out’; and 5) ‘I wish I could do more with my teen.’ Parents expressed powerlessness over their teen’s opportunities for physical activity. They reported that friends’ participation and social interaction are motivating factors for their child’s participation in physical activity. Another motivator would be linking movement to individual interests, focusing on abilities, not disabilities. An implication for practice would be to include parents in the development of physical activity programmes. Increasing empirical evidence from the viewpoint of these parents could inform nurses involved in public health, family medicine and rehabilitation about the development of programmes that would better anticipate and meet adolescent needs.

Family Dog-Assisted Adapted Physical Activity: A Case Study

Purpose: The aim of this case study was to examine the individual effects of an adapted physical activity, animal-assisted intervention (APA-AAI) with the family dog on motor skills, physical activity, and quality of life of a child with cerebral palsy (CP). Method: This study used an A-B-A single-subject design. The assessment phase (phase A) occurred pre- and post-intervention. This consisted of standardized assessments of motor skills, quality of life questionnaires, physical activity (measured using the GT3X+ accelerometer) and the human-animal bond. The intervention (phase B) lasted 8 weeks and consisted of adapted physical activities performed with the family dog once a week for 60 min in a lab setting. In addition, the participant had at-home daily activities to complete with the family dog. Results: Visual analysis was used to analyze the data. Motor skill performance, physical activity, quality of life and human animal interaction gains were observed in each case. Conclusions: These preliminary results provided initial evidence that the family-dog can play a role in healthy lifestyles through APA-AAI in children with CP.

Cardiac Autonomic System Response to Submaximal Test in Children With Cerebral Palsy

AIM

To describe the heart rate (HR) and heart rate variability at rest, during a submaximal treadmill test and at rest posttreadmill in children with cerebral palsy (CP).

METHODS

Twenty children (6-11 years) with CP participated, who had Gross Motor Function Classification System levels I to III. The HR was monitored for 5 minutes seated, during a submaximal treadmill test, and after 5 minutes rest posttreadmill. Outcome variables were HR and the square root of the mean squared differences of successive differences between adjacent heart beats (RMSSD).

RESULTS

HR increased during the last stage of the treadmill test compared with rest. RMSSD was reduced during the last 2 minutes of the treadmill test compared with rest. The HR and RMSSD mean value at the second minute posttest were not significantly different from the pretreadmill rest value.

INTERPRETATION

The cardiac system in children with CP responded to the submaximal testing.

Fatigue and its relationship with physical activity, age, and body composition in adults with cerebral palsy

AIM

The objectives of this exploratory study were (1) to describe the experience of fatigue in adults with cerebral palsy (CP) inclusive of all levels of the Gross Motor Function Classification System (GMFCS); and (2) to determine if physical activity level, sedentary time, age, or body composition can predict fatigue in adults with CP.

METHOD

An observational study was conducted in an outpatient setting in Ontario, Canada. Participants included adults with CP (n=41; GMFCS levels I-V; mean age 33.7y, standard deviation [SD] 12.3y). Fatigue was measured using the Fatigue Impact and Severity Self-Assessment (FISSA) questionnaire. Habitual physical activity and sedentary time were measured using accelerometry. Body mass index (BMI) and waist circumference were reported as measures of body composition.

RESULTS

The mean (SD) FISSA score for all participants was 84.5 (30.6), ranging from 54.0 (18.3) (GMFCS level I) to 93.6 (21.9) (GMFCS level V). Significant positive relationships (regression coefficient β [95% confidence intervals]) were observed between BMI and FISSA scores (1.9 [0.73-3.1]), waist circumference and FISSA scores (0.71 [0.19-1.2]), and age and FISSA scores (0.99 [0.26-1.7]). A significant negative relationship was observed between moderate-to-vigorous physical activity (MVPA) per hour and FISSA scores -6.4 [-12 to -0.83]). Backwards stepwise regression analysis revealed BMI (1.8 [0.61-2.9]) and MVPA per hour (-5.4 [-10 to -0.30]) were significant predictors of FISSA scores.

INTERPRETATION

Health care providers should consider the importance of weight management and physical activity to prevent and treat fatigue in this population.

The WE-Study: does botulinum toxin A make walking easier in children with cerebral palsy?: Study protocol for a randomized controlled trial

BACKGROUND

Intramuscular injections of botulinum toxin A (BoNT-A) have been a cornerstone in the treatment of spasticity for the last 20 years. In Norway, the treatment is now offered to two out of three children with spastic cerebral palsy (CP). However, despite its common use, the evidence for its functional effects is limited and inconclusive. The objective of this study is to determine whether BoNT-A makes walking easier in children with CP. We hypothesize that injections with BoNT-A in the calf muscles will reduce energy cost during walking, improve walking capacity, increase habitual physical activity, reduce pain and improve self-perceived performance and satisfaction.

METHODS/DESIGN

This randomized, double-blinded, placebo-controlled, multicenter trial is conducted in a clinical setting involving three health regions in Norway. Ninety-six children with spastic CP, referred for single-level injections with BoNT-A in the calf muscles, will be invited to participate. Those who are enrolled will be randomized to receive either injections with BoNT-A (Botox®) or 0.9% saline in the calf muscles. Stratification according to age and study center will be made. The allocation ratio will be 1:1. Main inclusion criteria are (1) age 4 - 17.5 years, (2) Gross Motor Function Classification System levels I and II, (3) no BoNT-A injections in the lower limbs during the past 6 months and (4) no orthopedic surgery to the lower limbs during the past 2 years. The outcome measures will be made at baseline and 4, 12 (primary endpoint) and 24 weeks after injections. Primary outcome is change in energy cost during walking. Secondary outcomes are change in walking capacity, change in activity, perceived change in performance and satisfaction in mobility tasks, and pain. The primary analysis will use a linear mixed model to test for difference in change in the outcome measures between the groups. The study is approved by the Regional Ethical Committee and The Norwegian Medicines Agency. Recruitment started in September 2015.

DISCUSSION

The evaluation of effect is comprehensive and includes objective standardized tests and measures on both impairment and activity level. Results are to be expected by spring 2019.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02546999 . Registered on 9 September 2015.

Consensus Planning Toward a Community-Based Approach to Promote Physical Activity in Youth with Cerebral Palsy

AIMS

To engage researchers and knowledge-users in six Ontario communities in knowledge translation initiatives to identify community-informed elements to guide the development of an optimal physical activity program for youth with cerebral palsy (CP) and to support research efforts.

METHODS

The project included three iterative steps, i.e., an environmental scan of five communities, six regional planning meetings, and a member-checking survey, followed by a Delphi survey to reach consensus on the elements deemed most important.

RESULTS

Twenty-four elements were identified to include in programs promoting physical activity in youth with CP, which were organized in five categories: raise awareness of the options and opportunities (n = 4); pique interest and motivate youth to become and stay active (n = 9); ensure community programs are ready for youth with a disability (n = 2); be fit, fit in, and finding the best fit (n = 5); and explore the layers of physical activity and how they interact (n = 4).

CONCLUSIONS

The 24 elements established characterize the key concepts that families and community stakeholders value when developing physical activity programs for youth with CP. When incorporated into clinical practice, each of the elements may be used to evaluate key aspects of outcome for individuals with CP.

Systematic review of physical activity and exercise interventions to improve health, fitness and well-being of children and young people who use wheelchairs

AIM

To perform a systematic review establishing the current evidence base for physical activity and exercise interventions that promote health, fitness and well-being, rather than specific functional improvements, for children who use wheelchairs.

DESIGN

A systematic review using a mixed methods design.

DATA SOURCES

A wide range of databases, including Web of Science, PubMed, BMJ Best Practice, NHS EED, CINAHL, AMED, NICAN, PsychINFO, were searched for quantitative, qualitative and health economics evidence.

ELIGIBILITY

participants: children/young people aged >25 years who use a wheelchair, or parents and therapists/carers. Intervention: home-based or community-based physical activity to improve health, fitness and well-being.

RESULTS

Thirty quantitative studies that measured indicators of health, fitness and well-being and one qualitative study were included. Studies were very heterogeneous preventing a meta-analysis, and the risk of bias was generally high. Most studies focused on children with cerebral palsy and used an outcome measure of walking or standing, indicating that they were generally designed for children with already good motor function and mobility. Improvements in health, fitness and well-being were found across the range of outcome types. There were no reports of negative changes. No economics evidence was found.

CONCLUSIONS

It was found that children who use wheelchairs can participate in physical activity interventions safely. The paucity of robust studies evaluating interventions to improve health and fitness is concerning. This hinders adequate policymaking and guidance for practitioners, and requires urgent attention. However, the evidence that does exist suggests that children who use wheelchairs are able to experience the positive benefits associated with appropriately designed exercise.

TRIAL REGISTRATION NUMBER

CRD42013003939.

An innovative cycling exergame to promote cardiovascular fitness in youth with cerebral palsy

OBJECTIVE

To evaluate the effects of an internet-platform exergame cycling programme on cardiovascular fitness of youth with cerebral palsy (CP).

METHODS

In this pilot prospective case series, eight youth with bilateral spastic CP, Gross Motor Functional Classification System (GMFCS) level III, completed a six-week exergame programme. Outcomes were obtained at baseline and post-intervention. The primary outcome measure was the GMFCS III-specific shuttle run test (SRT-III). Secondary outcomes included health-related quality of life (HQL) as measured by the KIDSCREEN-52 questionnaire, six-minute walk test, Wingate arm cranking test and anthropomorphic measurements.

RESULTS

There were significant improvements in the SRT-III (t = -2.5, p = 0.04, d = 0.88) post-intervention. There were no significant changes in secondary outcomes.

CONCLUSION

An exergame cycling programme may lead to improvement in cardiovascular fitness in youth with CP. This study was limited by small sample size and lack of a comparison group. Future research is warranted.

Skeletal muscle fiber-type specific succinate dehydrogenase activity in cerebral palsy

INTRODUCTION

Children with cerebral palsy (CP) exhibit increased energy expenditure during movement, but whether this is due in part to decrements in skeletal muscle mitochondrial oxidative capacity is unknown. Accordingly, we compared fiber-type specific succinate dehydrogenase (SDH) activity in children with CP with typically developing (TD) children.

METHODS

SDH activity and myofiber areas of type 1 and 2A fibers were measured in semitendinosus biopsies of both groups (n = 5/group).

RESULTS

SDH activity was ∼35% higher in type 1 compared with type 2A fibers, but there were no differences between groups. Average myofiber area was 45% smaller in CP versus TD (P < 0.05), and type 2A fibers were 32% larger than type 1 fibers (P < 0.05) only in TD children.

CONCLUSIONS

Fiber-type specific SDH activity is similar between TD children and children with CP. This suggests that increased energy expenditure in children with CP is not related to impaired mitochondrial oxidative capacity. Muscle Nerve, 2016 Muscle Nerve 55: 122-124, 2017.

Physical Activity Participation of Disabled Children: A Systematic Review of Conceptual and Methodological Approaches in Health Research

Physical activity (PA) participation is widely recognized as a critical component of health and development for disabled and non-disabled children. Emergent literature reflects a paradigm shift in the conceptualization of childhood PA as a multi-dimensional construct, encompassing aspects of physical performance, and self-perceived engagement. However, ambiguity remains around how participation as a health construct is integrated into PA research. The primary objective of the present mini-review is to critically examine current conceptual and methodological approaches to evaluating PA participation among disabled children. We conducted a systematic review of contemporary literature (published between 2000 and 2016). Seventeen articles met inclusion criteria, and their research approach was classified into guiding framework, definition of the key construct, and measurement used. The primary guiding framework was the international classification of functioning, disability and health. An explicit definition of PA participation was absent from all studies. Eight studies (47%) operationalized PA and participation as independent constructs. Measurements included traditional performance-based aspects of PA (frequency, duration, and intensity), and alternative participation measures (subjective perception of involvement, inclusion, or enjoyment). Approximately 64% of included articles were published in the past 2 years (2014-2016) indicating a rising interest in the topic of PA participation. Drawing from the broader discussion of participation in the literature, we offer a working definition of PA participation as it pertains to active, health-associated behaviors. Further description of alternative approaches to framing and measuring PA participation are offered to support effective assessment of health status among disabled children.

Pilot study of a targeted dance class for physical rehabilitation in children with cerebral palsy

Introduction:

This pilot study evaluates the effects of a targeted dance class utilizing classical ballet principles for rehabilitation of children with cerebral palsy on balance and upper extremity control.

Methods:

Twelve children with cerebral palsy (ages 7–15 years) with Gross Motor Function Classification scores II–IV participated in this study and were assigned to either a control group or targeted dance class group. Targeted dance class group participated in 1-h classes three times per week in a 4-week period. The Pediatric Balance Scale and the Quality of Upper Extremity Skills Test were administered before, after, and 1 month after the targeted dance class.

Results:

Improvements in the Pediatric Balance Scale were present in the targeted dance class group in before versus after and before versus 1 month follow-up comparisons (p-value = 0.0088 and p-value = 0.019, respectively). The Pediatric Balance Scale changes were not significant in the control group. The Quality of Upper Extremity Skills Test did not reach statistical differences in either group.

Conclusion:

Classical ballet as an art form involves physical training, musical accompaniment, social interactions, and emotional expression that could serve as adjunct to traditional physical therapy. This pilot study demonstrated improvements in balance control. A larger study with a more homogeneous sample is warranted.

Variability of total step activity in children with cerebral palsy: influence of definition of a day on participant retention within the study

BACKGROUND

Activity monitoring is important to establish accurate daily physical activity levels in children with cerebral palsy (CP). However, few studies address issues around inclusion or exclusion of step count data; in particular, how a valid day should be defined and what impact different lengths of monitoring have on retention of participant data within a study. This study assessed how different 'valid day' definitions influenced inclusion of participant data in final analyses and the subsequent variability of the data.

RESULTS

Sixty-nine children with CP were fitted with a StepWatch™ Activity Monitor and instructed to wear it for a week. Data analysis used two broad definitions of a day, based on either number of steps in a 24 h monitoring period or the number of hours of recorded activity in a 24 h monitoring period. Eight children either did not use the monitor, or used it for only 1 day. The remaining 61 children provided 2 valid days of monitoring defined as >100 recorded steps per 24 h period and 55 (90 %) completed 2 valid days of monitoring with ≥10 h recorded activity per 24 h period. Performance variability in daily step count was lower across 2 days of monitoring when a valid day was defined as ≥10 h recorded activity per 24 h period (ICC = 0.765) and, higher when the definition >100 recorded steps per 24 h period (ICC = 0.62). Only 46 participants (75 %) completed 5 days of monitoring with >100 recorded steps per 24 h period and only 23 (38 %) achieved 5 days of monitoring with ≥10 h recorded activity per 24 h period. Datasets of participants who functioned at GMFCS level II were differentially excluded when the criteria for inclusion in final analysis was 5 valid days of ≥10 h recorded activity per 24 h period, leaving datasets available for only 8 of 32 participant datasets retained in the study.

CONCLUSION

We conclude that changes in definition of a valid day have significant impacts on both inclusion of participant data in final analysis and measured variability of total step count.