Physical and sedentary activity in adolescents with cerebral palsy

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.

Health-Promoting Physical Activity of Children Who Use Assistive Mobility Devices: A Scoping Review

Children with physical disabilities who use assistive mobility devices (AMDs) are at risk for obesity and other secondary health conditions. Habitual physical activity is one lifestyle factor that may prevent obesity and contribute to overall health, and an active lifestyle in childhood improves prospects for lifelong healthy behaviors. Child, family, and environmental facilitators and barriers influence health-promoting physical activity (HPPA) for children without disabilities, but comparable models and levels of understanding for children who use AMDs are lacking. In this scoping review, we identified a similar set of child, family, and environmental facilitators and barriers relevant to HPPA participation among children who use AMDs. Noted gaps in the literature included limited reporting of AMD use, inconsistent HPPA definitions, and inadequate measurement tools for children who are nonambulatory. The identified child, family, and environmental factors provide a framework for occupational therapy practitioners and interprofessional teams to develop HPPA opportunities and interventions for an underserved population.

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.

Correlates of physical activity in children and adolescents with physical disabilities: A systematic review

BACKGROUND

The benefits of physical activity (PA) for children with disabilities are well documented, and children with physical disabilities (PD) are often less active than peers with other disability types. Various correlates associated with PA in children with PD have been identified in separate studies, and a thorough analysis of these correlates could aid in understanding and designing interventions that promote children with PD to be more physically active. The purpose of this systematic review was to provide a comprehensive summary of the correlates of PA in children with PD.

METHOD

A systematic search using PubMed, CINAHL, Cochrane Library, PsychINFO, Eric, and EMbase was initiated in October 2014 to identify studies examining the correlates of PA in children with PD aged 6-18years. Two researchers independently screened studies, assessed their methodological quality, and extracted relevant data. The correlates were synthesized and further assessed semi-quantitatively.

RESULTS

A total of 45 articles were included in the detailed review. Several modifiable physical, psychological, and environmental correlates were consistently and positively associated with PA in children with PD. Some non-modifiable correlates (e.g., intellectual ability, parents' ethnicity) were found to be consistently and negatively associated with PA.

CONCLUSIONS

The correlates of PA in children with PD are multifaceted and along many dimensions. This review can have implications for future studies and these may confirm the consistency of variables related to PA. Insights derived from the outcomes may also foster the measurement of the magnitude of associations that could assist the development of future interventions.

Quantification of Physical Activity and Sedentary Time in Adults with Cerebral Palsy

PURPOSE

The purpose of this study was to determine objective and subjective quantification of habitual physical activity (HPA) and sedentary time in ambulatory and nonambulatory adults with cerebral palsy (CP).

METHODS

We recruited a clinical sample of adults with CP (N = 42; 21 women; mean (SD) age, 33.5 (12.3) yr; Gross Motor Function Classification System (GMFCS) distribution: level I (n = 5), level II (n = 9), level III (n = 10), level IV (n = 11), and level V (n = 7). Objective measures of HPA and sedentary time were obtained by using ActiGraph GT3X accelerometers at both hip and wrist sites. Three previously established cut-point values distinguishing light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) were evaluated across GMFCS levels. The concurrent validity of the self-report Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) was assessed for LPA and MVPA intensities in GMFCS levels II-V.

RESULTS

Participants showed little reluctance to wearing accelerometers; one participant reported discomfort. Nonambulatory adults (GMFCS levels IV-V) differed from ambulatory adults (GMFCS levels I-III) for recorded activity counts (hip and wrist sites), minutes of MVPA with each cut-point value, and breaks from sedentary time (all P < 0.05). For the same measures, adults in GMFCS level III also differed from GMFCS level I (all P < 0.05). The PARA-SCI correlated significantly with accelerometer-derived minutes of MVPA per day (r = 0.396; P = 0.014) and per hour of monitoring time (r = 0.356; P = 0.027).

CONCLUSIONS

Our findings support the use of accelerometers to objectively measure HPA and sedentary behavior in adults with CP across the severity spectrum, regardless of cut-point implementation. The PARA-SCI is a valid tool to capture subjectively reported patterns of MVPA in adults with CP who are GMFCS levels II-V.

Comparing participation in physical recreation activities between children with disability and children with typical development: A secondary analysis of matched data

BACKGROUND

Facilitating participation in physical recreation among children with disability is an increasingly important aim of paediatric rehabilitation.

AIM

To compare the extent (diversity and frequency), context (where and companionship), experience (enjoyment) and preference for participation in physical recreation activities outside-of-school between children with disability and children with typical development.

METHODS AND PROCEDURES

One hundred and sixty-three children with physical, intellectual, sensory or multiple disabilities (67 girls; mean age 10.8 yr) were matched with 163 children with typical development for age, sex, geographical location and socioeconomic status. Participation in 16 physical recreation activities (including walking, cycling, team sports) was compared between these two groups using non-parametric statistics and relative risk ratios.

OUTCOMES AND RESULTS

There were significant differences between the groups in 14 activities. A lower percentage of children with disability reported participating in 5 physical recreation activities. A higher percentage of children with disability reported not participating in their preferred activities. Children with disability were less likely to participate on their own in some day-to-day physical recreation activities such as walking and cycling.

CONCLUSIONS AND IMPLICATIONS

Differences between the groups related to the context (companionship) and preference for participation. Understanding and addressing these differences may enhance participation among children with disability.

Validity and reliability of a modified english version of the physical activity questionnaire for adolescents

Background

Adaptation of physical activity self-report questionnaires is sometimes required to reflect the activity behaviours of diverse populations. The processes used to modify self-report questionnaires though are typically underreported. This two-phased study used a formative approach to investigate the validity and reliability of the Physical Activity Questionnaire for Adolescents (PAQ-A) in English youth. Phase one examined test content and response process validity and subsequently informed a modified version of the PAQ-A. Phase two assessed the validity and reliability of the modified PAQ-A.

Methods

In phase one, focus groups (n = 5) were conducted with adolescents (n = 20) to investigate test content and response processes of the original PAQ-A. Based on evidence gathered in phase one, a modified version of the questionnaire was administered to participants (n = 169, 14.5 ± 1.7 years) in phase two. Internal consistency and test-retest reliability were assessed using Cronbach’s alpha and intra-class correlations, respectively. Spearman correlations were used to assess associations between modified PAQ-A scores and accelerometer-derived physical activity, self-reported fitness and physical activity self-efficacy.

Results

Phase one revealed that the original PAQ-A was unrepresentative for English youth and that item comprehension varied. Contextual and population/cultural-specific modifications were made to the PAQ-A for use in the subsequent phase. In phase two, modified PAQ-A scores had acceptable internal consistency (α = 0.72) and test-retest reliability (ICC = 0.78). Modified PAQ-A scores were significantly associated with objectively assessed moderate-to-vigorous physical activity (r = 0.39), total physical activity (r = 0.42), self-reported fitness (r = 0.35), and physical activity self-efficacy (r = 0.32) (p ≤ 0.01).

Conclusions

The modified PAQ-A had acceptable internal consistency and test-retest reliability. Modified PAQ-A scores displayed weak-to-moderate correlations with objectively measured physical activity, self-reported fitness, and self-efficacy providing evidence of satisfactory criterion and construct validity, respectively. Further testing with more diverse English samples is recommended to provide a more complete assessment of the tool.

Electronic supplementary material

The online version of this article (doi:10.1186/s13690-016-0115-2) contains supplementary material, which is available to authorized users.

Reliability and Validity of Objective Measures of Physical Activity in Youth With Cerebral Palsy Who Are Ambulatory

BACKGROUND

Physical therapy for youth with cerebral palsy (CP) who are ambulatory includes interventions to increase functional mobility and participation in physical activity (PA). Thus, reliable and valid measures are needed to document PA in youth with CP.

OBJECTIVE

The purpose of this study was to evaluate the inter-instrument reliability and concurrent validity of 3 accelerometer-based motion sensors with indirect calorimetry as the criterion for measuring PA intensity in youth with CP.

METHODS

Fifty-seven youth with CP (mean age=12.5 years, SD=3.3; 51% female; 49.1% with spastic hemiplegia) participated. Inclusion criteria were: aged 6 to 20 years, ambulatory, Gross Motor Function Classification System (GMFCS) levels I through III, able to follow directions, and able to complete the full PA protocol. Protocol activities included standardized activity trials with increasing PA intensity (resting, writing, household chores, active video games, and walking at 3 self-selected speeds), as measured by weight-relative oxygen uptake (in mL/kg/min). During each trial, participants wore bilateral accelerometers on the upper arms, waist/hip, and ankle and a portable indirect calorimeter. Intraclass coefficient correlations (ICCs) were calculated to evaluate inter-instrument reliability (left-to-right accelerometer placement). Spearman correlations were used to examine concurrent validity between accelerometer output (activity and step counts) and indirect calorimetry. Friedman analyses of variance with post hoc pair-wise analyses were conducted to examine the validity of accelerometers to discriminate PA intensity across activity trials.

RESULTS

All accelerometers exhibited excellent inter-instrument reliability (ICC=.94-.99) and good concurrent validity (rho=.70-.85). All accelerometers discriminated PA intensity across most activity trials.

LIMITATIONS

This PA protocol consisted of controlled activity trials.

CONCLUSIONS

Accelerometers provide valid and reliable measures of PA intensity among youth with CP.

Children with cerebral palsy do not achieve healthy physical activity levels

AIM

This study compared daily activity energy expenditure (AEE) in children with cerebral palsy with a control group and investigated whether the children achieved healthy levels of physical activity.

METHODS

We enrolled eight children with bilateral cerebral palsy, from eight to 10 years of age, and a group of controls matched for age and gender. For three days, physical activity was simultaneously measured by accelerometers and self-reports using a diary. The daily AEE results were compared between groups and methods. The number of children that achieved healthy physical activity levels in each group was explored.

RESULTS

Children with cerebral palsy had significantly lower daily AEE, as measured by accelerometers, than the controls, and they did not achieve the healthy moderate to heavy physical activity level defined in the Nordic Nutrition Recommendations. Self-reports using the diaries resulted in an overestimation of physical activity compared with the ankle accelerometer measurements in both groups.

CONCLUSION

Our investigation of physical activity in children with cerebral palsy and controls using accelerometers and a diary found low levels of daily AEE and physical activity, and these results were most prominent in the group with cerebral palsy. The diaries overestimated physical activity in both groups.

Moderating effect of the environment in the relationship between mobility and school participation in children and adolescents with cerebral palsy

BACKGROUND:

The literature demonstrates that the social participation of children with disabilities is influenced by both their functional skills repertoire and environmental factors. However, it is not yet known whether the effect of functional limitations on social participation is minimized or enhanced by the environmental facilitators and barriers. This study aimed to test this hypothesis.

OBJECTIVE:

To investigate the moderating effect of environmental factors in the relationship between mobility and school participation of children and adolescents with cerebral palsy (CP).

METHOD:

Participants were 102 elementary school children and adolescents with CP, aged 6 to 17 years, classified as levels I, II, and III according to the Gross Motor Classification System, along with their parents or caregivers and teachers. School participation and parents' perceptions of barriers were evaluated using the School Function Assessment and the Craig Hospital Inventory of Environmental Factors (CHIEF), respectively.

RESULTS:

The regression model failed to reveal a moderating effect of environmental factors in the relationship between mobility and school participation. While mobility was a strong predictor of participation, environmental factors demonstrated a weak predictive effect on the latter. The CHIEF subscale school/work showed the factors which were greatest barrier to children's participation, while the subscale attitude/support had the least impact.

CONCLUSION:

The absence of moderation on the tested relationship suggests that, when investigated under the negative perspective of environmental barriers, the contextual factors do not modify the relationship between mobility and school participation. Factors specific to the school environment might add to the present study's results regarding the effect of school participation in this population.

Physical Activity Among Adolescents with Cerebral Palsy: An Integrative Review

PROBLEM

Physical activity is necessary for optimum physical and psychosocial health in the general population. It is even more important for adolescents who struggle with impairments that limit motor function. Recommendations for best practice are needed as adolescents transition into adulthood.

PURPOSE

An integrative review was performed to determine the state of the science regarding 1) what factors impact physical activity in adolescents with cerebral palsy, and 2) how the needs of this population have been addressed regarding physical activity.

SEARCH STRATEGY

A literature search of MEDLINE, CINAHL, and PubMed was conducted using the terms cerebral palsy, mobility or activity, and adolescents. Exclusion criteria were surgical or pharmacological interventions.

RESULTS OF THE LITERATURE SEARCH

Descriptive and intervention studies were included and evaluated for purpose, design, and key findings.

SYNTHESIS OF EVIDENCE

Correcting the decline of physical activity in adolescents with CP may carry benefits over into adulthood. There are few studies that adapt physical activity to age and level of impairment. Several studies support approaching physical activity from a social model, focusing on participation of the person in the context of environment. There is a lack of research incorporating family-centered care. Many study designs are shallow and lack the proper instruments for assessing outcomes.

IMPLICATIONS FOR PRACTICE

Home and community based interventions need to be developed that are individualized. More studies are needed with stronger research designs and better instruments in order to generalize results for practice.

Validity of the OMNI rating of perceived exertion scale for children and adolescents with cerebral palsy

AIM

This study evaluated the validity of the OMNI Walk/Run Rating of Perceived Exertion (OMNI-RPE) scores with heart rate and oxygen consumption (VO₂) for children and adolescents with cerebral palsy (CP).

METHOD

Children and adolescents with CP, aged 6 to 18 years and Gross Motor Function Classification System (GMFCS) levels I to III completed a physical activity protocol with seven trials ranging in intensity from sedentary to moderate-to-vigorous. VO₂ and heart rate were recorded during the physical activity trials using a portable indirect calorimeter and heart rate monitor. Participants reported OMNI-RPE scores for each trial. Concurrent validity was assessed by calculating the average within-subject correlation between OMNI-RPE ratings and the two physiological indices.

RESULTS

For the correlational analyses, 48 participants (22 males, 26 females; age 12y 6mo, SD 3y 4mo) had valid bivariate data for VO₂ and OMNI-RPE, while 40 participants (21 males, 19 females; age 12y 5mo, SD 2y 9mo) had valid bivariate data for heart rate and OMNI-RPE. VO₂ (r=0.80; 95% CI 0.66-0.88) and heart rate (r=0.83; 95% CI 0.70-0.91) were moderately to highly correlated to OMNI-RPE scores. No difference was found for the correlation of physiological data and OMNI-RPE scores across the three GMFCS levels. The OMNI-RPE scores increased significantly in a dose-response manner (F(6,258) =116.1, p<0.001) as exercise intensity increased from sedentary to moderate-to-vigorous.

INTERPRETATION

OMNI-RPE is a clinically feasible option to monitor exercise intensity in ambulatory children and adolescents with CP.

Fatigue is a major issue for children and adolescents with physical disabilities

AIM

This study aimed to investigate fatigue, and its correlates, in children and adolescents with physical disabilities.

METHOD

Sixty-five young people aged 8 to 17 years (35 males, 30 females; mean age 13y 2mo, SD 2y 8mo) with mild to moderate physical disabilities (Gillette Functional Assessment Questionnaire levels 7-10) were recruited. Self-reported fatigue was measured using the PedsQL Multidimensional Fatigue Scale. Physical activity was measured using 7-day hip-worn accelerometer. Associations between fatigue, physical activity, and socio-demographic characteristics were examined using analysis of covariance, with significance (α) set at 0.05. Results were compared with normative data from other paediatric populations.

RESULTS

Among children with physical disabilities, fatigue was associated with being physically inactive (F-statistic=4.42, p=0.040), female (F=4.37, p=0.042), and of low socio-economic status (F=3.94, p=0.050). Fatigue was not associated with age, weight status, or functional impairment. Young people with physical disabilities experienced high levels of fatigue compared with other paediatric health populations, and comparable to the paediatric cancer population.

INTERPRETATION

Fatigue is an important issue for young people with physical disabilities. Clinicians and researchers working with this group should be mindful that fatigue is likely to impact on an individual's ability to undertake new treatment regimens or interventions. Interventions aimed at reducing fatigue are warranted. Increasing physical activity might play a role in reducing fatigue.

Physical activity predicts quality of life and happiness in children and adolescents with cerebral palsy

PURPOSE

To examine the associations between physical activity, health-related quality of life and happiness in young people with cerebral palsy.

METHOD

A total of 70 young people with cerebral palsy (45 males, 25 females; mean age 13 years 11 months, SD 2 years 0 month) took part in a cross-sectional, descriptive postal survey assessing physical activity (Physical Activity Questionnaire for Adolescents), functional ability (Gross Motor Function Classification System), quality of life (Pediatric Quality of Life Inventory 4.0) and happiness (single Likert-scale item). Relationships between physical activity, quality of life and happiness were examined using backward stepwise linear regression.

RESULTS

Physical activity significantly predicted physical quality of life (R(2 )= 0.64, β = 6.12, p = 0.02), social quality of life (R(2 )= 0.28, β = 9.27, p < 0.01) and happiness (R(2 )= 0.08, β = 0.9, p = 0.04). Physical activity was not associated with emotional or school quality of life.

CONCLUSIONS

This study found a positive association between physical activity, social and physical quality of life, and happiness in young people with cerebral palsy. Findings underscore the potential benefits of physical activity for the wellbeing of young people with cerebral palsy, in addition to its well-recognised physical and health benefits.

IMPLICATIONS FOR REHABILITATION

Physical activity is a key predictor of quality of life and happiness in young people with cerebral palsy. Physical activity is widely recognised as having physical health benefits for young people with cerebral palsy; however, this study also highlights that it may have important benefits for wellbeing, quality of life and happiness. This emphasises the need for clinical services and intervention studies aimed specifically at increasing physical activity amongst children and adolescents with cerebral palsy.

Cardiorespiratory endurance in children with and without cerebral palsy as measured by an ergometer: a case series study

[Purpose] This preliminary study aimed to determine the cardiorespiratory endurance of children with cerebral palsy (CP) using a case series study in order to provide the reference data required for interventions appropriate for South Korean CP sufferers, since aerobic ability evaluation and interventions for children with CP are not well recognized in South Korea. [Subjects and Methods] Four children and adolescents with CP GMFCS (Gross Motor Function Classification System) level I and II and two normally developing children (ND) (age: 7–15 years) were studied. Cycle ergometer testing was performed to determine their VO₂ peak and RER peak concentrations as well as VE peak and 6MWT distance. [Results] The VO₂ peak was lower in subject E (CP) at 44.5 than in subject B (ND), and it was lower in subject A (ND) at 22.9 than in subject C (CP). The 6MWT distance was longer in subjects A and B (ND) than in age-matched CP subjects. [Conclusion] This case report demonstrates that the cardiorespiratory parameters values of CP children were similar to those reported previously. Further research is required to evaluate the normative values of CP and the optimal cardiorespiratory parameters.

Obesity in children with developmental and/or physical disabilities

Children with developmental or physical disabilities, many of whom face serious health-related conditions, also are affected by the current obesity crisis. Although evidence indicates that children with disabilities have a higher prevalence of obesity than do children without disabilities, little is known of the actual magnitude of the problem in this population. To address this concern, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) held a conference on obesity in children with intellectual, developmental, or physical disabilities, bringing together scientists and practitioners in the fields of obesity and disability to foster collaboration, identify barriers to healthy weight status in populations with disabilities, propose avenues to solutions through research and practice, and develop a research agenda to address the problem. This article describes current knowledge about prevalence of obesity in this population, discusses factors influencing obesity risk, and summarizes recommendations for research presented at the conference.

The effect of treadmill exercise on gait efficiency during overground walking in adults with cerebral palsy

Objective

To investigate the effect of treadmill walking exercise as a treatment method to improve gait efficiency in adults with cerebral palsy (CP) and to determine gait efficiency during overground walking after the treadmill walking exercise.

Methods

Fourteen adults with CP were recruited in the experimental group of treadmill walking exercise. A control group of 7 adults with CP who attended conventional physical therapy were also recruited. The treadmill walking exercise protocol consisted of 3-5 training sessions per week for 1-2 months (total 20 sessions). Gait distance, velocity, VO₂, VCO₂, O₂ rate (mL/kg·min), and O₂ cost (mL/kg·m) were assessed at the beginning and at the end of the treadmill walking exercise. The parameters were measured by KB1-C oximeter.

Results

After the treadmill walking exercise, gait distance during overground walking up to 6 minutes significantly increased from 151.29±91.79 to 193.93±79.01 m, and gait velocity increased from 28.09±14.29 to 33.49±12.69 m/min (p<0.05). Energy efficiency evaluated by O₂ cost during overground walking significantly improved from 0.56±0.36 to 0.41±0.18 mL/kg·m (p<0.05), whereas O₂ rate did not improve significantly after the treadmill walking exercise. On the other hand, gait velocity and O₂ cost during overground walking were not significantly changed in the control group.

Conclusion

Treadmill walking exercise improved the gait efficiency by decreased energy expenditure during overground walking in adults with CP. Therefore, treadmill walking exercise can be an important method for gait training in adults with CP who have higher energy expenditure.

Factors associated with physical activity in children and adolescents with a physical disability: a systematic review

AIM

The aim of this review was to summarize the important factors associated with participation in physical activity in children and adolescents with physical disabilities.

METHOD

A systematic mixed-studies review was conducted using the databases Academic Search Elite, CINAHL, The Cochrane Library, EMBASE, PEDro, PsycINFO, PubMed, and SPORTDiscus, searching for studies conducted from January 2000 to May 2013. The studies were identified by two independent researchers following predetermined inclusion and exclusion criteria. The methodological quality was determined using the McMaster University critical review forms for qualitative or quantitative research and was numerically rated according to the criteria developed by Imms.

RESULTS

The initial electronic search yielded 10 161 articles, of which six were qualitative and 12 were quantitative studies. These studies showed that a diverse range of positive and negative factors were associated with participation in physical activity, such as self-efficacy, physical fitness, increasing age, and the availability of equipment and local facilities.

INTERPRETATION

Future intervention studies could use these results, within the context of an individual child and his or her environment, as the basis for increasing physical activity levels, starting in early childhood and continuing throughout adolescence and into adulthood. An increased awareness of and focus on providing appropriate equipment and adapted sports in the child's own environment by policy makers might increase physical activity levels.

Habitual physical activity of independently ambulant children and adolescents with cerebral palsy: are they doing enough?

BACKGROUND

Despite the health benefits of regular physical activity, children with cerebral palsy (CP) are thought to participate in reduced levels of physical activity.

OBJECTIVE

The study objective was to assess physical activity and determine the proportion adhering to the recommended 60 minutes of moderate-to-vigorous physical activity (MVPA) daily in independently ambulant children and adolescents with unilateral CP.

DESIGN

This was a cross-sectional study.

METHOD

Children (N=102; 52 boys, 50 girls; mean age=11 years 3 months, SD=2 years 4 months) with spastic hemiplegia classified at Gross Motor Function Classification System (GMFCS) levels I (n=44) and II (n=58) recorded physical activity over 4 days using an accelerometer. Activity counts were converted to daily and hourly time spent inactive and in light physical activity or MVPA using uniaxial cutpoints (inactive: ≤100 vertical counts·min(-1), light: 101 to 2,295 vertical counts·min(-1), MVPA: ≥2,296 vertical counts·min(-1)) and recorded step counts. Differences between groups were examined using t tests.

RESULTS

Of a potential 396 days, 341 days (86%) were recorded. The average wear time was 11:44 (SD=1:56) hours. On a typical day, participants recorded 438 (SD=234) counts·min(-1), took 7,541 (SD=3,894) steps, spent 8:36 (SD=1:09) hours inactive, spent 2:38 (SD=0:51) hours in light activity, and spent 0:44 (SD=0:26) hours in MVPA. Only 25% of participants met the recommended level of MVPA on at least one day. Physical activity was highest in boys (versus girls), in children (versus adolescents), and on weekdays (versus weekends).

LIMITATIONS

Participants were limited to children with unilateral spasticity who were classified at GMFCS levels I and II.

CONCLUSIONS

The majority of independently ambulant children with unilateral CP did not perform sufficient physical activity to meet public health recommendations.

The scope of pediatric physical therapy practice in health promotion and fitness for youth with disabilities

PURPOSE

The purpose of this report is to discuss the scope of pediatric physical therapy practice in health promotion and fitness for youth with disabilities.

SUMMARY OF KEY POINTS

Evidence is provided that supports integration of health promotion and fitness strategies in physical therapy clinical management. Physical therapists' roles in community-based adapted sports and fitness interventions and reimbursement considerations are discussed.

CONCLUSIONS

Physical therapists are in a unique position to provide expertise in the design and implementation of health promotion and fitness programs for youth with disabilities. These programs are important to promote active, healthy lifestyles and reduce comorbidities associated with sedentary behaviors and unhealthy weight, which are often seen in youth with disabilities.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Pediatric physical therapists should incorporate health promotion and fitness strategies into practice.

Focus on fatigue amongst young adults with spastic cerebral palsy

Background

This study aimed to assess fatigue amongst young adults with spastic cerebral palsy (CP), to determine subgroups at risk for fatigue and to explore the relationship between fatigue and cardiopulmonary fitness and daily physical activity level.

Participants

Young adults with spastic CP, Gross Motor Function Classification System (GMFCS) levels I to III, aged 16 to 24 years.

Methods

Fatigue (Fatigue Severity Scale) and self-reported daily physical activity (Physical Activity Scale for Individuals with Physical Disabilities) were assessed for 56 participants using questionnaires. Daily physical activity was objectively measured using accelerometry (Vitamove system) over 72 hours. Progressive maximal aerobic cycling was used to measure cardiopulmonary fitness.

Results

The mean Fatigue Severity Scale (FSS) score was 3.7 (SD 1.4). Forty percent of participants were fatigued, including 12.5% who were severely fatigued. Participants with bilateral CP (FSS = 4.2 (SD 1.4)) were more fatigued compared to those with unilateral CP (FSS = 3.1 (SD 1.3)) (p < 0.01). Levels of cardiopulmonary fitness (2.4 L/min (SD 0.8)) and daily physical activity (8.5% (SD 3.0)) were not significantly related to fatigue (respectively p = 0.10 and p = 0.55), although for cardiopulmonary fitness a trend was found.

Conclusions

Fatigue is already present at a relatively young age amongst adults with CP, and CP subtype is a determinant of fatigue. We did not find significant evidence for a cross-sectional relation of fatigue with cardiopulmonary fitness or daily physical activity.

Trial registration

Nederland’s trial register: NTR1785.

Gross motor function is an important predictor of daily physical activity in young people with bilateral spastic cerebral palsy

AIM

The aim of the study was to describe daily physical activity levels of adolescents and young adults with bilateral spastic cerebral palsy (CP) and to identify factors that help predict these levels.

METHOD

Daily physical activity was measured using an accelerometer-based activity monitor in 45 young people with bilateral spastic CP (23 males, 22 females; mean age 18y 6mo [SD 2y 5mo] range 16y 1mo-20y 11mo); classified as Gross Motor Function Classification System (GMFCS) level II or III and with contractures of <20° at hip and knee. Predictor variables included demographic characteristics (age, sex, weight) and physical characteristics (gross motor function, lower limb muscle strength, 6min walk distance). Data were analyzed using the information-theoretic approach, using the Akaike information criterion (AIC) and linear regression.

RESULTS

Daily activity levels were low compared with published norms. Gross Motor Function Measure Dimension-E (GMFM-E; walking, running, and jumping) was the only common predictor variable in models that best predicted energy expenditure, number of steps, and time spent sitting/lying. GMFM Dimension-D (standing) and bilateral reverse leg press strength contributed to the models that predicted daily physical activity.

INTERPRETATION

Adolescents and young adults with bilateral spastic CP and mild to moderate walking disabilities have low levels of daily activity. The GMFM-E was an important predictor of daily physical activity.

Validity of an activity monitor in young people with cerebral palsy gross motor function classification system level I

The activPAL™ activity monitor has potential for use in youth with Cerebral Palsy (CP) as it has demonstrated acceptable validity for the assessment of sedentary and physical activity in other populations. This study determined the validity of the activPAL™ activity monitor for the measurement of sitting, standing, walking time, transitions and step count for both legs in young people with hemiplegic and asymmetric diplegic CP. Seventeen participants with CP Gross Motor Function Classification System level I completed two video recorded test protocols that involved wearing an activPAL™ activity monitor on alternate legs. Agreement between observed video recorded data and activPAL™ activity monitor data was assessed using the Bland and Altman (BA) method and intraclass correlation coefficients (ICC 3,1). There was perfect agreement for transitions and high agreement for sitting (BA mean differences (MD): -1.8 and -1.8 s; ICCs: 0.49 and 0.95) standing (MD: 0.8 and 0.1 s; ICCs: 0.59 and 0.98) walking (MD: 1 and 1.1 s; ICCs: 0.99 and 0.94) timings and low agreement for step count (MD: 4.1 and 2.8 steps; ICCs: 0.96 and 0.95) for both legs. This study found clinically acceptable agreement with direct observation for all activPAL™ activity monitor functions, except for step count measurement with respect to the range of measurement values obtained for both legs in this study population.

Validation of the activPAL activity monitor in children with hemiplegic gait patterns resultant from cerebral palsy

BACKGROUND

Current investigation of treatment outcomes by clinicians is currently hampered by a lack of clinically viable tools. The use of activity monitors specifically validated for a population could help resolve this situation.

OBJECTIVES

The purpose of the study was to validate an activity monitor for monitoring children with cerebral palsy. The study was designed to validate the duration of time spent sitting, standing and walking and the number of steps taken when being measured by the activPAL activity monitor.

STUDY DESIGN

A validation study was undertaken.

METHODS

Observations of participants were carried out while completing a specifically designed activity course using video footage, which were then compared to the output from the activity monitor.

RESULTS

The activity monitor was found to be valid for the time spent standing and walking, the number of steps taken and the number of transitions.

CONCLUSIONS

The results demonstrated that the monitor may prove useful to clinicians as a measurement outcome device for children with hemiplegic gait patterns resultant from cerebral palsy. However, the sensitivity of the device is variable, and further investigations are necessary to confirm it would also be able to detect minor changes after interventions.

CLINICAL RELEVANCE

The monitor may provide clinicians with a simplistic tool that is easily utilised, to enable audit exercises of current and future treatments.

Habitual physical activity and cardiometabolic risk factors in adults with cerebral palsy

Adults with cerebral palsy (CP) are known to participate in reduced levels of total physical activity. There is no information available however, regarding levels of moderate-to-vigorous physical activity (MVPA) in this population. Reduced participation in MVPA is associated with several cardiometabolic risk factors. The purpose of this study was firstly to compare levels of sedentary, light, MVPA and total activity in adults with CP to adults without CP. Secondly, the objective was to investigate the association between physical activity components, sedentary behavior and cardiometabolic risk factors in adults with CP. Adults with CP (n=41) age 18-62 yr (mean ± SD=36.5 ± 12.5 yr), classified in Gross Motor Function Classification System level I (n=13), II (n=18) and III (n=10) participated in this study. Physical activity was measured by accelerometry in adults with CP and in age- and sex-matched adults without CP over 7 days. Anthropometric indicators of obesity, blood pressure and several biomarkers of cardiometabolic disease were also measured in adults with CP. Adults with CP spent less time in light, moderate, vigorous and total activity, and more time in sedentary activity than adults without CP (p<0.01 for all). Moderate physical activity was associated with waist-height ratio when adjusted for age and sex (β=-0.314, p<0.05). When further adjustment was made for total activity, moderate activity was associated with waist-height ratio (β=-0.538, p<0.05), waist circumference (β=-0.518, p<0.05), systolic blood pressure (β=-0.592, p<0.05) and diastolic blood pressure (β=-0.636, p<0.05). Sedentary activity was not associated with any risk factor. The findings provide evidence that relatively young adults with CP participate in reduced levels of MVPA and spend increased time in sedentary behavior, potentially increasing their risk of developing cardiometabolic disease.

Objectively measured sedentary time in youth with cerebral palsy compared with age-, sex-, and season-matched youth who are developing typically: an explorative study

BACKGROUND

Children with cerebral palsy (CP) demonstrate reduced physical activity levels compared with children with typical development. Sedentary behavior, including the duration and frequency of sedentary bouts, has not yet been objectively examined in this population but may have clinical implications for the development of secondary health complications.

OBJECTIVE

The aim of this study was to identify time spent sedentary and frequency of breaks interrupting sedentary time in youth with CP compared with youth without CP. It was hypothesized that individuals with CP would spend more hours sedentary than their peers and take fewer breaks to interrupt sedentary time.

DESIGN

This was a cross-sectional, prospective study.

METHODS

A convenience sample of 17 ambulatory children with CP (15 boys and 2 girls) (mean age=13.0 years, SD=2.2) and 17 age-, sex-, and season-matched youth who were developing typically (TD group) (mean age=12.9 years, SD=2.5) wore an accelerometer over a 7-day period. Sedentary time (in minutes) and number of breaks from sedentary time, corrected for monitoring and sedentary time, respectively, were examined. Differences between groups were determined with an independent-samples t test.

RESULTS

Children with CP engaged in significantly more sedentary time (X̅=47.5 min/h, SD=4.9) compared with the TD group (X̅=43.6 min/h, SD=4.2), with significantly fewer breaks from sedentary time (CP group: X̅=179, SD=70; TD group: X̅=232 breaks/h sedentary, SD=61).

LIMITATIONS

The sample included only ambulatory youth with CP, classified as Gross Motor Function Classification System levels I to III.

CONCLUSIONS

Sedentary time was higher in the CP group and was characterized by less frequent breaks compared with the TD group. Future research should examine the extent to which sedentary time is associated with cardiovascular and metabolic risk in youth with CP.

Reduced moderate-to-vigorous physical activity and increased sedentary behavior are associated with elevated blood pressure values in children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) participate in reduced levels of physical activity and spend increased time in sedentary behavior. The effect of reduced activity and increased sedentary behavior on their cardiometabolic health has not been investigated.

OBJECTIVES

The purposes of this study were: (1) to investigate the prevalence of overweight/obesity and elevated blood pressure (BP) among a cohort of ambulatory children with CP and (2) to investigate the associations among physical activity, sedentary behavior, overweight/obesity, and BP in children with CP.

STUDY DESIGN

This was a cross-sectional study of 90 ambulatory children, aged 6 to 17 years, with CP.

METHODS

Body mass index (BMI), waist circumference, waist-height ratio, and BP were measured on 1 occasion. Habitual physical activity was measured by accelerometry over 7 days.

RESULTS

The prevalence of overweight/obesity in the cohort was 18.9%. Twenty-two percent of the children had BP values within the hypertensive or prehypertensive range. Systolic BP was positively associated with waist circumference (β=.324, P<.05) and BMI (β=.249, P<.05). Elevated BP values were associated with reduced time in moderate-to-vigorous activity, vigorous activity, and total activity, as well as increased time in sedentary behavior. The strongest association was observed between elevated BP and vigorous activity alone (odds ratio=0.61, 95% confidence interval=0.37-0.99, P<.05).

LIMITATIONS

A convenience sample was recruited for this study, and it is possible that this limitation resulted in selection bias.

CONCLUSIONS

Despite the relatively low prevalence of overweight/obesity, a relatively high proportion of children with CP had elevated BP values. Reducing sedentary behavior and increasing habitual physical activity, particularly vigorous activity, should be primary aims of rehabilitation in order to reduce cardiometabolic disease risk in this population.

Role of virtual reality for cerebral palsy management

Virtual reality is the use of interactive simulations to present users with opportunities to perform in virtual environments that appear, sound, and less frequently, feel similar to real-world objects and events. Interactive computer play refers to the use of a game where a child interacts and plays with virtual objects in a computer-generated environment. Because of their distinctive attributes that provide ecologically realistic and motivating opportunities for active learning, these technologies have been used in pediatric rehabilitation over the past 15 years. The ability of virtual reality to create opportunities for active repetitive motor/sensory practice adds to their potential for neuroplasticity and learning in individuals with neurologic disorders. The objectives of this article is to provide an overview of how virtual reality and gaming are used clinically, to present the results of several example studies that demonstrate their use in research, and to briefly remark on future developments.

Health-related physical fitness for children with cerebral palsy

Low levels of physical activity are a global health concern for all children. Children with cerebral palsy have even lower physical activity levels than their typically developing peers. Low levels of physical activity, and thus an increased risk for related chronic diseases, are associated with deficits in health-related physical fitness. Recent research has provided therapists with the resources to effectively perform physical fitness testing and physical activity training in clinical settings with children who have cerebral palsy, although most testing and training data to date pertains to those who walk. Nevertheless, on the basis of the present evidence, all children with cerebral palsy should engage, to the extent they are able, in aerobic, anaerobic, and muscle-strengthening activities. Future research is required to determine the best ways to evaluate health-related physical fitness in nonambulatory children with cerebral palsy and foster long-term changes in physical activity behavior in all children with this condition.

Well-being, health and fitness of children who use wheelchairs: feasibility study protocol to develop child-centred 'keep-fit' exercise interventions

AIM

To undertake the pre-clinical and modelling phases of the Medical Research Council complex intervention framework to underpin development of child-centred 'keep-fit', exercise and physical activity interventions for children and young people who use wheelchairs.

BACKGROUND

Children who use wheelchairs face many barriers to participation in physical activity, which compromises fitness, obesity, well-being and health. 'Keep-fit' programmes that are child-centred and engaging are urgently required to enhance participation of disabled children and their families as part of a healthy lifestyle. Nurses will likely be important in promoting and monitoring 'keep-fit' intervention(s) when implemented in the community.

DESIGN

Mixed-method (including economic analysis) feasibility study to capture child and family preferences and keep-fit needs and to determine outcome measures for a 'keep-fit' intervention.

METHODS

The study comprises three stages. Stage 1 includes a mixed-method systematic review of effectiveness, cost effectiveness and key stakeholder views and experiences of keep-fit interventions, followed by qualitative interviews with children, young people and their parents to explore preferences and motivations for physical activity. Stage 2 will identify standardized outcome measures and test their application with children who use wheelchairs to obtain baseline fitness data. Options for an exercise-based keep-fit intervention will then be designed based on Stage 1 and 2 findings. In stage 3, we will present intervention options for feedback and further refinement to children and parents/carers in focus groups. (Project funded October 2012).

DISCUSSION

At completion, this study will lead to the design of the intervention and a protocol to test its efficacy.

Duration and patterns of habitual physical activity in adolescents and young adults with cerebral palsy

AIM

Adolescents and young adults with cerebral palsy (CP) show reduced motor function and gait efficiency, and lower levels of habitual physical activity (HPA), than adolescents with typical development and children with CP. This study examined activity duration and patterns in this population in the Middle East through long-term monitoring of a large sample using accelerometers.

METHOD

Adolescents and young adults with bilateral CP at Gross Motor Function Classification System (GMFCS) levels II, III, and IV, were monitored in their habitual environment for four consecutive days with ActivPAL3 monitors. Time spent in sedentary, standing, and walking activities, and frequency of walking steps and transitions, were analysed for each GMFCS level.

RESULTS

Measurements were made on 222 participants (132 males, 90 females; mean age 16 y 9 mo SD 2y, range 13 y 4 mo-22 y). The Mann-Whitney U test demonstrated significant differences (p<0.05) between GMFCS levels, showing reduced walking and standing activity and increased sedentary duration at higher GMFCS levels (p<0.001), except for increased standing time between GMFCS levels II and III (p=0.07). Participants in educational facilities exhibited less sedentary behaviour than those who were homebound (p<0.05).

INTERPRETATION

These descriptions of duration and frequency of active and sedentary behaviours may serve as a basis for recommendations to minimize inactivity in this population. Adolescents and young adults with CP in the Middle East demonstrate similar patterns of HPA to their peers in other regions.

Systematic review of the relationship between habitual physical activity and motor capacity in children with cerebral palsy

Habitual physical activity (HPA) has many benefits for general health. Motor capacity in children with cerebral palsy (CP) can impact on their HPA. This study aimed to systematically review the available literature on the relationship between HPA and motor capacity in children with CP aged 3-12 years for all gross motor functional abilities (GMFCS I-V) compared to typically developing children. Five electronic databases (Pubmed, Cochrane, Embase, Cinahl and Web of Science from 1989 to November, 2013) were searched using keywords "children with cerebral palsy", "physical activity", "motor capacity" and "motor function" including their synonyms and MesH terms. Studies were included if they (i) were conducted in children with CP aged between 3 and 12 years, (ii) assessed HPA or time spent sedentary, (iii) assessed motor capacity in order to evaluate the relationship between HPA and motor capacity. All articles retrieved were reviewed by two independent reviewers and discussed until they reached consensus. Study quality of reporting was evaluated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Search results identified 864 articles but after review of the title and abstract only 21 articles warranted closer consideration. Ten articles met the strict inclusion criteria as nine articles did not assess HPA and two were conference abstracts. Study quality assessment (STROBE) found nine articles were good quality (≥ 60%) and one was poor quality (55.9%). Participants were mean age 8.4 (SD=2.1) years (range 2-17 years) and included children at all GMFCS levels (3 studies), while seven studies only recruited GMFCS level I-III. HPA measurements were either subjective (Activity Scale for Kids, Dutch Questionnaire of Participation in physical activity and assessment of participation in physical education at school and regular physical activity in leisure time) or objective (StepWatch(®) and ActiGraph(®)7164). Nine studies found that motor capacity was directly associated with HPA, HPA in children with CP with high functional level (GMFCS I) was higher than those with lower functional levels (GMFCS III-V); while one study reported no relationship between HPA and GMFCS level (HPA was measured by questionnaire, a potential limitation). Further studies are required to further elucidate HPA levels (active, sedentary behavior) according to objective motor capacity measures, age and gender to inform healthy lifestyle behavior (active/sedentary) in children with CP.

Upper limb training using Wii Sports Resort™ for children with hemiplegic cerebral palsy: a randomized, single-blind trial

Objective:

To investigate whether Wii Sports Resort™ training is effective and if any benefits are maintained.

Design:

Randomized, single-blind trial.

Participants:

Sixty-two hemiplegic children with cerebral palsy (6–13 years).

Intervention:

Experimental group undertook six weeks of home-based Wii Sports Resort™ training plus usual therapy, while the control group received usual therapy.

Main measures:

Outcomes were coordination, strength, hand function, and carers’ perception of hand function, measured at baseline, six, and 12 weeks by a blinded assessor.

Results:

There was a trend of mean difference (MD) for the experimental group to have more grip strength by six (MD 4.0 N, 95% confidence interval (CI) −0.8 to 8.8, p = 0.10) and 12 (MD 4.1 N, 95% CI −2.1 to 10.3, p = 0.19) weeks, and to have a higher quantity of hand function according to carers’ perception by six (MD 4.5 N, 95% CI −0.7 to 9.7, p = 0.09) and strengthened by 12 (MD 6.4, 95% CI 0.6 to 12.3, p = 0.03) weeks than the control group. There was no difference between groups in coordination and hand function by six or 12 weeks.

Conclusion:

Wii™ training did not improve coordination, strength, or hand function. Beyond the intervention, carers perceived that the children used their hands more.

'Keep fit' exercise interventions to improve health, fitness and well-being of children and young people who use wheelchairs: mixed-method systematic review protocol

AIM

This mixed-method systematic review aims to establish the current evidence base for 'keep fit', exercise or physical activity interventions for children and young people who use wheelchairs.

BACKGROUND

Nurses have a vital health promotion, motivational and monitoring role in optimizing the health and well-being of disabled children. Children with mobility impairments are prone to have low participation levels in physical activity, which reduces fitness and well-being. Effective physical activity interventions that are fun and engaging for children are required to promote habitual participation as part of a healthy lifestyle. Previous intervention programmes have been trialled, but little is known about the most effective types of exercise to improve the fitness of young wheelchair users.

DESIGN

Mixed-method design using Cochrane systematic processes. Evidence regarding physiological and psychological effectiveness, health economics, user perspectives and service evaluations will be included and analysed under distinct streams.

METHODS

The project was funded from October 2012. Multiple databases will be searched using search strings combining relevant medical subheadings and intervention-specific terms. Articles will also be identified from ancestral references and by approaching authors to identify unpublished work. Only studies or reports evaluating the effectiveness, participation experiences or cost of a physical activity programme will be included. Separate analyses will be performed for each data stream, including a meta-analysis if sufficient homogeneity exists and thematic analyses. Findings across streams will be synthesized in an overarching narrative summary.

DISCUSSION

Evidence from the first systematic review of this type will inform development of effective child-centred physical activity interventions and their evaluation.

European study of frequency of participation of adolescents with and without cerebral palsy

Children with cerebral palsy participate less in everyday activities than children in the general populations. During adolescence, rapid physical and psychological changes occur which may be more difficult for adolescents with impairments. Within the European SPARCLE project we measured frequency of participation of adolescents with cerebral palsy by administering the Questionnaire of Young People's Participation to 667 adolescents with cerebral palsy or their parents from nine European regions and to 4666 adolescents from the corresponding general populations. Domains and single items were analysed using respectively linear and logistic regression. Adolescents with cerebral palsy spent less time with friends and had less autonomy in their daily life than adolescents in the general populations. Adolescents with cerebral palsy participated much less in sport but played electronic games at least as often as adolescents in the general populations. Severity of motor and intellectual impairment had a significant impact on frequency of participation, the more severely impaired being more disadvantaged. Adolescents with an only slight impairment participated in some domains as often as adolescents in the general populations. Regional variation existed. For example adolescents with cerebral palsy in central Italy were most disadvantaged according to decisional autonomy, while adolescents with cerebral palsy in east Denmark and northern England played sports as often as their general populations. Participation is an important health outcome. Personal and environmental predictors of participation of adolescents with cerebral palsy need to be identified in order to design interventions directed to such predictors; and in order to inform the content of services.

A pedometer based physical activity self-management program for children and adolescents with physical disability - design and methods of the StepUp study

Background

Physical activity affords a wide range of physiological and psychological benefits for children and adolescents, yet many children with physical disabilities are insufficiently active to achieve these benefits. The StepUp program is a newly developed 6-week pedometer-based self-management program for children and adolescents with physical disability. Participants use a pedometer to undertake a 6-week physical activity challenge, with personalised daily step count goals set in consultation with a physiotherapist. The study aims to evaluate the effectiveness of the StepUp program, using a randomised control trial design.

Methods/design

A target sample of 70 young people with physical disabilities (aged 8–17 years, ambulant with or without aid, residing in Adelaide) will be recruited. Participants will be randomly allocated to either intervention or control following completion of baseline assessments. Assessments are repeated at 8 weeks (immediately post intervention) and 20 weeks (12 weeks post intervention). The primary outcome is objective physical activity determined from 7 day accelerometry, and the secondary outcomes are exercise intention, physical self-worth, quality of life and fatigue. Analyses will be undertaken on an intention-to-treat basis using random effects mixed modelling.

Discussion

This study will provide information about the potential of a low-touch and low-cost physical activity intervention for children and adolescents with cerebral palsy.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000023752.

Health-enhancing physical activity in children with cerebral palsy: more of the same is not enough

Physical activity is important for young people's health. The emphasis over the last 2 decades has been on moderate to vigorous exercise when designing activity and exercise programs for children and adolescents with cerebral palsy (CP). Emerging evidence suggests that sedentary behavior is distinctly different from a lack of moderate to vigorous physical activity and has independent and different physiological mechanisms. The concept of concurrently increasing moderate to vigorous physical activity and replacing sedentary behavior with light physical activity may be beneficial for children and adolescents with CP. This article is a summary of the evidence for what works and what does not work for improving the physical activity of children and adolescents with CP. It also discusses what is known about sedentary behavior of children and adolescents with CP and what research directions are needed to build foundational knowledge in this area with this population.

Development of social functioning and communication in school-aged (5-9 years) children with cerebral palsy

The aim of this study was to examine determinants of the course and level of social functioning and communication in school-aged children with cerebral palsy (CP) over a 2-year period. A clinic-based sample of 5 and 7 years old children with CP (n=108; 72 males; mean age 6 y 3 mo, SD 12 mo; Gross Motor Function Classification System (GFMCS) level I-V) was followed longitudinally in three yearly assessments. Social functioning and communication were measured with the Vineland Adaptive Behavior Scales (VABS). Data were analyzed with generalized estimated equations. The results showed that social function followed a course of progressive restrictions over time in non-ambulatory children with CP aged 5-9 compared to children who could walk with or without walking aids. Overall lower levels of social functioning were found in children with GMFCS V, epilepsy, speech problems, lower intellectual capacity and older age at baseline. For communication more restrictions over time were found in children with lower intellectual capacity. Children with GMFCS V, speech problems and older age at baseline had overall greater restrictions in communication. It was concluded that motor functioning and intellectual ability can be used to identify children at risk for progressive restrictions in social functioning and communication. For children with CP and social and communicative restrictions, multidisciplinary assessment and treatment may be indicated to counteract an unfavorable development.

Walking activity patterns in youth with cerebral palsy and youth developing typically

PURPOSE

To describe daily walking stride rate patterns of young children with cerebral palsy (CP) as compared to a typically developing youth (TDY) cohort relative to age and functional level.

METHOD

A cross-sectional comparison cohort study compared 209 youth with CP with 368 TDY aged 2-13 years. Youth with CP had Gross Motor Function Classification System (GMFCS) levels I-III with 60% bilateral involvement and 79% spastic. Five days of StepWatch data were averaged and classified into low, moderate and high stride rates. Group differences were examined by t-test and analysis of variance.

RESULTS

Children with CP walk significantly less each day than TDY (F = 245, p ≤ 0.001) and differ by GMFCS (F = 1.51, p < 0.001). TDY walk a similar number of strides in low and moderate stride rates each day while youth with CP do not. TDY attained high stride rates (>60 strides/min) for 8 min/d with levels I-III at 4.0, 3.2 and 0.53 min/d, respectively.

CONCLUSIONS

The relative relationship of walking intensity levels within total daily stride activity differs for youth with CP as compared to TDY. The influence of functional walking ability on walking stride activity levels and intensity does not appear to differ significantly across age groups.

IMPLICATIONS FOR REHABILITATION

Limitation in the ability to attain moderate stride-rate intensity, regardless of total number of strides taken each day for ambulatory youth with CP, is a potential area of focus for intervention. Understanding of stride activity levels and intensity in youth with CP may be employed to focus rehabilitation strategies to enhance habitual walking activity. Community-based stride rate data has potential as an effectiveness outcome for rehabilitation strategies focused on walking (i.e. orthopedic surgery, orthoses and injections therapies).

Do children participate in the activities they prefer? A comparison of children and youth with and without physical disabilities

Objective:

To assess the discrepancy between the leisure activities children prefer and the leisure activities they actually participate in, for children with and without a physical disability, and to explore how in both groups this is related to age and gender.

Design:

Cross-sectional comparison.

Subjects:

Children with and without physical disabilities that were recruited from schools for special education and regular schools in the Netherlands.

Main measures:

The Children’s Assessment of Participation and Enjoyment (CAPE) and the Preferences for Activities of Children (PAC). A discrepancy score was calculated representing high preference but no participation in the activity in the past four months.

Results:

A total of 141 children (6–18 years) with a physical disability (mean age 12.5, 43% girls, 57% boys) and 156 children without physical disabilities (mean age 11.5, 55% girls,45% boys) were included in the study. There was no significant difference in discrepancy scores between children with and without physical disabilities (informal activities 9.8 ± 5.0 vs. 9.8 ± 4.6, formal activities 6.4 ± 3.4 vs. 6.6 ± 2.8). Discrepancy between preference and performance varied by age and gender for children without disabilities but not for children with disabilities.

Conclusions:

Both groups are equally able to participate in the activities they prefer. Age and gender had a significant effect on the discrepancy scores for children and adolescents without physical disabilities but not for children with physical disabilities.

The reliability and validity of a research-grade pedometer for children and adolescents with cerebral palsy

AIM

The aim of this study was to determine the reliability, validity, and optimal placement of pedometers in children with cerebral palsy (CP) who ambulate without aids.

METHOD

Seventeen participants aged 7 to 17 years with CP (eight males, nine females; mean age 12y 4mo; SD 3y 2mo), who could ambulate without aids, wore four New Lifestyles pedometers (NL-1000) on an elasticized waist belt. Fourteen participants had hemiplegia, two diplegia, and one triplegia; all were classified in Gross Motor Function Classification System (GMFCS) level I (n=8) or II (n=9). Participants completed 3-minute walking and running trials around an indoor course and were videotaped to verify the actual number of steps taken during each trial. Inter-pedometer reliability was determined by comparing pedometer readings using intraclass correlation coefficients (ICCs). Validity was determined by comparing pedometer step counts with video step counts using ICC, t-tests, and Bland-Altman plots. Optimal pedometer placement was determined using Wilcoxon signed-rank tests to compare the percentage error for pedometers positioned on the dominant and non-dominant hips.

RESULTS

Excellent reliability (ICC 0.88-0.99) and validity (ICC 0.78-0.95) were demonstrated with no significant difference between the video step counts and pedometer step counts. There was no significant difference between the step counts recorded by pedometers on the dominant and non-dominant hips.

INTERPRETATION

This study showed that NL-1000 pedometers have a high degree of reliability and validity in ambulant children with CP in controlled conditions.

A systematic review of the clinimetric properties of measures of habitual physical activity in primary school aged children with cerebral palsy

Regular participation in physical activity is an important determinant of health for children and adolescents with cerebral palsy (CP). However, there is little consensus on the most valid or reliable method to measure physical activity in this population. This study aimed to systematically review the psychometric properties of habitual physical activity (HPA) measures in primary school-aged children with CP. Databases were systematically searched for measures assessing physical activity over more than one day and had evidence of validity, reliability and/or clinical utility in children aged 6-12 years with CP. Ten measures met inclusion criteria and their quality was assessed in twelve studies. Quality of the included studies was appraised using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist. Measures were moderately to strongly correlated to criterion measures, with study quality rated as Fair (+) to Poor (0). Only four measures had evidence of reliability. Accelerometers provide a valid measure of HPA with good clinical utility; however they do not have documented reliability in this population. No one measure appears ideal to record HPA in primary school-age children with CP and further research is necessary to determine the psychometric properties of HPA measurement instruments in this population.

The Questionnaire of Young People's Participation (QYPP): a new measure of participation frequency for disabled young people

INTRODUCTION

The concept of participation was introduced by the World Health Organisation in the International Classification of Functioning, Disability and Health, 2001. Instruments to measure participation have been developed for children and adults, but none specifically for adolescents. Adolescence is a life stage with distinct patterns of participation, and previous research has shown that young people with disabilities have poorer participation than the general population. The aim of this study was to develop a measure of participation frequency, covering all major domains, for young people with cerebral palsy (CP). CP was chosen as an exemplar because it is a significant cause of disability in young people, with affected individuals experiencing a range of different impairments of varying severity.

METHODS

A pool of 88 items was developed using the published literature, existing measures and qualitative data from young people. The item pool was revised following expert review by 17 experts. Cognitive interviews on the items were carried out with 12 young people and 12 carers; field-testing was then undertaken with 107 young people with CP aged 13-21 years, and 540 young people from the general population to enable item reduction and to examine reliability and construct validity.

RESULTS

The content review resulted in a 92-item draft questionnaire, content validity index of 93%. Cognitive interviews led to further wording changes. Following field-testing, the questionnaire was shortened to 45 items. Known-groups validity was demonstrated by correlation with impairment severity. Test-retest reliability was satisfactory for all domains. Internal consistency varied between domains.

CONCLUSION

This is the first instrument developed specifically to measure frequency of participation across multiple domains for young people with disability. Use of the questionnaire in research and clinical work will enable its properties to be better understood and its generalizability to wider groups to be clearer.

Reliability and validity of the Trunk Impairment Scale in children and adolescents with cerebral palsy

Standardized clinical tools are useful for treatment planning and evaluation, however clinical tools to assess quality in trunk movements in children with cerebral palsy (CP) are sparse. We have recently reported good intra- and inter-observer reliability of the Trunk Impairment Scale (TIS) in 5-12 year old children with CP. The aim of this study was to assess reliability in adolescents (13-19 years old), and to assess the construct validity in children and adolescents in the whole age spectrum from 5 to 19 years. Video recordings of 17 children with CP with Gross Motor Function Classification (GMFCS) level I-IV were analyzed by three observers on two occasions. For construct validity the TIS was compared with Gross Motor Function Measure (GMFM), in 37 children with GMFCS levels I-IV. Intraclass correlation coefficients varied between 0.82 and 0.98, and 86% of the kappa values varied between 0.61 and 1.00, suggesting high inter- and intra-observer reliability. The smallest detectable difference (SDD) of the TIS (scale range 0-23) varied between 2.55 and 3.82 for intra- and 4.07-8.23 for inter-observer observations. The high inter-observer SDD was partly due to consistently lower TIS scores by one observer. The correlation between the TIS total score and the dimension scores of the GMFM was high (Spearman's rho: 0.80-0.87), while decreasing GMFCS levels were associated with increasing total TIS score; both findings indicating good construct validity of the TIS. This study suggests that the TIS is a reliable and valid measure of trunk control for both children and adolescents with cerebral palsy.