Sedentary Behavior in Children With Cerebral Palsy Between 1.5 and 12 Years: A Longitudinal Study

Physical activity and sedentary behavior among ambulatory children with cerebral palsy using accelerometer: a cross-sectional study

Background and objective

Physical activity (PA) is paramount for childhood development and growth. However, children diagnosed with Cerebral Palsy (CP) were often considered sedentary, and their physical inactivity was associated with adverse health conditions and complications. Therefore, this study aimed to objectively describe and compare the PA levels and SB levels of children with and without CP of the same age group. It also studied the factors correlating with PA, SB, and step count per day in children with CP.

Subjects and methods

A cross-sectional study using a wrist-worn accelerometer was conducted. PA and SB were measured over seven consecutive days.

Results

Eighty-five children aged 6-12 years, consisting of 41 children with CP and 44 TD children, participated in this study with a mean age of 9.18 ± 1.95 and 8.45 ± 1.78 years, respectively. According to the gross functional measures, 53.6% of children with CP were classified as first classification. A significant amount of time was spent in SB and Light PA (LPA) by children with CP compared to TD children, and no significant differences were observed in moderate PA (MPA) or step count. Gender mainly affected MPA as girls spent more time in MPA than boys. The age, height, and weight of children with CP correlate significantly with SB. As children's age, height, and weight increase, SB increases. Additionally, children with higher weights have lower step counts per day.

Conclusion

This study showed that children with CP spend more time in LPA and SB than typically developed children. Therefore, concerted efforts are needed to encourage physical activity and reduce the sedentary lifestyle, to take into account the gender and anthropometric measures of children to enhance the quality of life among children with CP, and to consider gender and anthropometric measures of the children.

Subjective measurement of physical activity and sedentary behaviour in children and adolescents with cerebral palsy: a scoping review

PURPOSE

Physical activity is essential for maintaining overall health. Cost-effective and easily administered outcome instruments are valuable for clinical practice and large-scale population studies. The scoping review aimed to identify and map subjective instruments developed or validated to measure habitual physical activity and/or sedentary behaviour in children and adolescents with cerebral palsy aged 0-18 years across all levels of the GMFCS-E&R.

MATERIALS AND METHODS

This scoping review was conducted in accordance with the JBI methodology for scoping reviews and searched the databases PubMed, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, JBI Database of Systematic Reviews and Implementation Reports, Embase and Pedro to identify articles.

RESULTS

From 288 full-text references, 13 studies met the inclusion criteria. Nine instruments measured habitual physical activity and/or sedentary behaviour in children and adolescents with cerebral palsy aged 18 months to 18 years. Six subjective instruments were tested for ambulatory children, while three instruments were tested in children and adolescents at GMFCS-E&R level I-V.

CONCLUSION AND IMPLICATIONS

Reporting of the psychometric properties were found on reliability in three instruments, while data on validity were reported in all instruments. Further studies assessing the psychometric properties of subjective instruments in the target population are needed.

More than just having fun! Understanding the experience of involvement in physical activity of adolescents living with cerebral palsy

Purpose: To explore the experiences of involvement of adolescents living with cerebral palsy, and their parents, while participating in physical activity. Understanding involvement in physical activity may be used to guide future participation.Methods: Eight adolescents (mean age 13 years 11 months, SD 1 year 6 months) with cerebral palsy participated in a New Zealand-based high-level mobility programme (HLMP) focused on running skills, twice per week for 12 weeks. The adolescents and 12 parents were interviewed before, after the 12 weeks and 9-months following the HLMP. Guided by interpretative description, 38 interviews were coded, analysed, and interpreted.Results: Four themes were: "Turning up is not enough" ("There's no point being there if you're not involved"); "In it all the way", "Changes on a dime", and "What works for me." Perceptions of involvement varied between adolescents and parents. Being "very involved" related to high levels of focus, concentration, effort; but not always enjoyment.Conclusions: Focusing on enjoyment as the key experience of involvement understates the complexity and dynamic nature of involvement. "Being involved" is not always easy and may not mean the absence of discomfort or effort. Optimising the individuals' involvement continuum during physical activity may be essential to promote lifelong participation.IMPLICATIONS FOR REHABILITATIONAdolescents living with cerebral palsy and their parents have differing perspective of involvement and utilise different strategies to encourage being and staying active.Teaching adolescents living with cerebral palsy about their involvement continuum and optimal level of involvement for each activity, context and environment could promote sustained participation.To ensure adolescents are "being involved" in physical activity, opportunities for engagement, motivation and persistence are important; enjoyment is a possible, but not essential attribute of involvement.Encouraging involvement in physical activity can be a source of family conflict from a young age therefore clinicians have a role as an essential supporter, motivator and educator.

Effects of a 12 week community-based high-level mobility programme on sustained participation in physical activity by adolescents with cerebral palsy: a single subject research design study

PURPOSE

To assess if a high-level mobility programme (HLMP) can promote sustained participation in physical activity by adolescents with cerebral palsy.

METHODS

Eight adolescents with cerebral palsy, Gross Motor Function Classification System levels I-II, 11-16 years, participated in 24 community-based group HLMP sessions across 12 weeks. Participants set attendance, involvement, and physical performance goals, completed activity diaries over 58 weeks and undertook physical capacity tests. Measures of activity frequency and diversity (attendance) and involvement level were collected weekly across baseline (4-6 weeks), intervention (12 weeks), and nine months follow-up (including Covid lockdown).

RESULTS

Median attendance was 23 of 24 HLMP sessions. Attendance goal/s attainment was highest during COVID lockdown. Involvement goals were consistently attained throughout all phases. Physical performance goal/s attainment was highest during intervention phase but reduced during nine months follow-up. Frequency of participation in physical activities varied greatly across study phases (range 0-33 episodes/week) with stable variety of activities and generally high 'involvement.' During the intervention, seven participants improved physical capacity and six maintained, or increased, the gains six months later.

CONCLUSION

Most participants improved physical capacity post-intervention but only some had sustained attendance and involvement in physical activity, highlighting the complexity of physical activity participation.

Facilitators and barriers to participation in physical activities in children and adolescents living with cerebral palsy: a scoping review

PURPOSE

This scoping review aimed to synthetize personal and environmental facilitators and barriers to participation in physical activities among youths living with cerebral palsy.

METHODS

A systematic literature search was performed in five databases: CINAHL, EMBASE, MEDLINE, PsycINFO, Cochrane, WEB OF SCIENCE. The studies were selected by two independent researchers based on inclusion and exclusion criteria. A semi-quantitative evaluation assessed the consistency of results for a given variable. Variables displaying consistent associations were classified based on the Physical Activity for people with Disability Model.

RESULTS

The electronic search yielded 10 795 articles, of which 57 were included. The main barriers to physical activity identified were motor impairments (30 studies), older age (15 studies), pain (6 studies), attendance in regular school (6 studies), and communication problems (4 studies). Barriers such as upper limb impairment and visual deficit were less frequently studied, while cognitive attributes, adapted physical environments and positive attitude, and family support were identified as facilitators.

CONCLUSION

Personal and environmental factors influencing physical activities behaviors among youths living with cerebral palsy are multiple and complex since they interact with each other. Rehabilitation interventions need to adopt a person-based approach to address barriers and reinforce facilitators.IMPLICATIONS FOR REHABILITATION:Physical activity participation among youths with cerebral palsy is a multidimensional phenomenon, dependent on different personal and environmental factors.Gross motor impairments, communication problems, and pain were the most common personal factors limiting physical activity participation.Environmental factors consistently associated with physical activity participation were school settings, physical environment such as transportation, and social and family support and attitude.Rehabilitation interventions to promote an active lifestyle should consider not only personal factors but their interaction with the child's environment.

Accurate Monitoring of 24-h Real-World Movement Behavior in People with Cerebral Palsy Is Possible Using Multiple Wearable Sensors and Deep Learning

Monitoring and quantifying movement behavior is crucial for improving the health of individuals with cerebral palsy (CP). We have modeled and trained an image-based Convolutional Neural Network (CNN) to recognize specific movement classifiers relevant to individuals with CP. This study evaluates CNN's performance and determines the feasibility of 24-h recordings. Seven sensors provided accelerometer and gyroscope data from 14 typically developed adults during videotaped physical activity. The performance of the CNN was assessed against test data and human video annotation. For feasibility testing, one typically developed adult and one adult with CP wore sensors for 24 h. The CNN demonstrated exceptional performance against test data, with a mean accuracy of 99.7%. Its general true positives (TP) and true negatives (TN) were 1.00. Against human annotators, performance was high, with mean accuracy at 83.4%, TP 0.84, and TN 0.83. Twenty-four-hour recordings were successful without data loss or adverse events. Participants wore sensors for the full wear time, and the data output were credible. We conclude that monitoring real-world movement behavior in individuals with CP is possible with multiple wearable sensors and CNN. This is of great value for identifying functional decline and informing new interventions, leading to improved outcomes.

The Journey to Sustainable Participation in Physical Activity for Adolescents Living with Cerebral Palsy

PURPOSE

To understand adolescents' and their parents' perspectives on 'being active', this study explored the experience of participation in physical activity (PA), the role of long-term participation in PA, and the importance of remaining active for life.

METHODS

Eight ambulant adolescents with CP (aged 11-16 years, seven male) participated in a high-level mobility programme twice per week for 12 weeks. Guided using interpretive description, adolescents and 12 of their parents were interviewed before, after and nine months following the programme. Thirty-eight interviews were coded, analysed, and interpreted, informed by audit information, reflective journaling, and team discussions.

RESULTS

Adolescents and their parents highly value being active now and into adulthood. Sustainable participation in PA requires adolescents and families to navigate complex environments (interpersonal, organisational, community, and policy). Core themes were: 'Just Doing it', 'Getting the Mix Right' (right people, right place, right time), 'Balancing the Continua' and 'Navigating the Systems'. The continua involved balancing intra-personal attributes: 'I will try anything' through to 'I will do it if I want to' and 'It's OK to be different' through to 'It sucks being disabled'.

CONCLUSIONS

The journey to sustainable participation was complex and dynamic. Experiences of successful journeys are needed to help adolescents with CP "stay on track" to sustainable participation.

Asymmetry in sensory-motor function between the lower limbs in children with hemiplegic cerebral palsy: An observational study

The objective of this study was to examine the difference in sensory-motor impairments (i.e., balance, contracture, coordination, strength, spasticity, and sensation) between legs in children with hemiplegic cerebral palsy. An observational study measured both lower limbs of children with hemiplegic cerebral palsy over one session. Six sensory-motor impairments (balance, coordination, strength, spasticity, contracture, and proprioception) were measured. The between-leg differences were analyzed using the paired t-tests and presented as the mean differences (95% confidence interval (CI)). Twenty-four participants aged 10.3 years (standard deviation: 1.3) participated. The affected leg was less than the less-affected leg in terms of the strength of dorsiflexors (mean difference (MD) -2.8 Nm, 95% CI -4.2 to -1.4), plantarflexors (MD -2.6 Nm, 95% CI -4.1 to -1.0), knee extensors (MD -5.3 Nm, 95% CI -10.2 to -0.5) as well as range of ankle dorsiflexion (MD -8 deg, 95% CI -13 to -3), and balance (median difference -11.1, 95% CI -11.6 to -10.6). There was a trend toward a difference in terms of the strength of hip abductors (MD -2.6 Nm, 95% CI -5.3 to 0.1) and coordination (MD -0.20 taps/s, 95% CI -0.42 to 0.01). The legs were similar in terms of the strength of hip extensors (MD 0.3 Nm, 95% CI -4.7 to 5.3), proprioception (MD 1 deg, 95% CI 0 to 2), and spasticity (median difference 0, 95% CI 0 to 0). Examination of the difference in sensory-motor impairments between legs in children with hemiplegic cerebral palsy has given us some insights into the deficits in both legs. Not only was balance, strength, and coordination decreased compared with the less-affected leg but also the less-affected leg was markedly decreased compared with typically developing children. Therefore, an intervention aimed at increasing muscle strength and coordination in both legs might have a positive effect, particularly on more challenging physical activities. This may, in turn, lead to successful participation in mainstream sport and recreation.

The 'heROIC' trial: Does the use of a robotic rehabilitation trainer change quality of life, range of movement and function in children with cerebral palsy?

BACKGROUND

Children with severe cerebral palsy (CP) (GMFCS IV/V) can find it difficult to access equipment that allows them to exercise effectively, potentially impacting their quality of life. Physiotherapists working within special schools are well placed to facilitate increased physical activity as part of the school day. This study explored whether the Innowalk Pro, a robotic rehabilitation trainer, could influence quality of life (measured by the CPCHILD questionnaire), in children with CP, alongside, joint range of movement, spasticity and functional goals of the lower limbs, measured by goniometry, modified Tardieu scale and goal attainment scoring, GAS, respectively.

METHODS

A prospective single-arm, pre-post trial was undertaken. The Innowalk Pro was used four times a week for 30 min alongside usual physiotherapy care in a school setting over a 6-week period. Outcomes were evaluated immediately pre/post intervention and at 6 weeks and 3 months post intervention. Analysis also explored differences between primary and secondary age participants.

RESULTS

Twenty-seven participants aged 5-18 years with a diagnosis of CP GMFCS IV/V (10 female, 17 male, mean age 12 years) were included from a convenience sample in a special school. Quality of life improved in 36% of participants, the majority of these being secondary aged. Knee extension reduced significantly 3 months post intervention. There were no meaningful changes in spasticity. GAS goals improved in 88% of participants after using the Innowalk Pro. GAS goals tended to decline after a break from using the equipment, with 21% declining by two or more units at 3 months post intervention.

CONCLUSION

A 6-week course of the Innowalk Pro can improve quality of life and functional goals for children with CP aged 5-18 years. After a break of 6-12 weeks, functional goals tend to return to baseline. Further research is needed to explore different prescriptions of the Innowalk Pro, to see if increasing the time used/increasing the frequency or number of weeks it is used for can provide longer lasting benefits.

Desenvolvimento de crianças, adolescentes e jovens adultos com Paralisia Cerebral de acordo com a CIF? Uma revisão do escopo

Estudos sobre o desenvolvimento de indivíduos com PC ajudam terapeutas e pais a planejarem abordagens de tratamento e prognóstico futuro. Os principais desfechos investigados em indivíduos com PC foram atividade e estruturas e funções corporais. Pouco tem sido explorado em desfechos de participação e de fatores contextuais ao longo do tempo.

Development of children, adolescents, and young adults with cerebral palsy according to the ICF: A scoping review

AIM

To identify and provide a descriptive overview of the development of children, adolescents, and young adults with cerebral palsy (CP) in longitudinal studies; and map areas of focus according to the components of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF).

METHOD

Longitudinal studies of the development of children, adolescents, and/or young adults with CP were included in this scoping review. A search for eligible studies was conducted in the databases MEDLINE, PubMed, LILACS, EMBASE, Cochrane, CINAHL, and Scopus, and was restricted to the years 2002 to 2022. All outcome measures of the studies were classified into ICF components.

RESULTS

In the 56 studies included, there were 19 438 participants, involving mainly children, followed by adolescents, and lastly young adults. All components of the ICF were investigated and many studies reported outcomes in more than one component. Activity was the most investigated (67.9%; n = 38 studies), followed by body functions and structures (42.9%; n = 24 studies). Participation (14.2%; n = 8 studies) and environmental factors (3.6%; n = 2 studies) were the least studied. None of the studies investigated personal factors as an outcome.

INTERPRETATION

This scoping review provides an overview of studies on the development of children, adolescents, and young adults with CP, using the ICF framework, identifying current areas of focus and gaps in the research. Future studies should target participation, contextual factors, and the transition into adulthood.

Study protocol for Running for health (Run4Health CP): a multicentre, assessor-blinded randomised controlled trial of 12 weeks of two times weekly Frame Running training versus usual care to improve cardiovascular health risk factors in children and youth with cerebral palsy

INTRODUCTION

Children and youth with moderate-severe (Gross Motor Function Classification System (GMFCS) levels II-V) cerebral palsy (CP) participate less frequently in physical activities compared with peers without CP and have elevated risk of cardiorespiratory morbidity and mortality in adulthood. Frame Running (RaceRunning) is a new athletics discipline that is an accessible option for physical activity participation for people with moderate-severe CP. There is no high-quality evidence for the effect of Frame Running on cardiovascular disease in children and young people with CP. The primary aim of this study is to conduct a randomised controlled trial of the effect of 12 weeks of Frame Running training on risk factors for cardiovascular disease.

METHODS AND NALYSIS

Sixty-two children and youth with CP (age 8-20 years) in GMFCS levels II-V will be recruited across four sites and randomised to receive either 12 weeks of Frame Running training two times weekly for 60 min, or usual care. Outcomes will be measured at baseline, immediately postintervention (primary endpoint) and 12 weeks later for retention of training effects. The primary outcome is cardiorespiratory fitness as measured by distance covered on Six Minute RaceRunner Test with 1 min heart rate recovery. Other outcomes include blood pressure, objectively measured physical activity, body mass index, waist circumference, percentage body fat, gross motor function capacity, community participation, feasibility, tolerability and safety. Adverse events will be monitored, and participants and their caregivers will be interviewed to discern their experiences of participation in Frame Running.

ETHICS AND DISSEMINATION

The Children's Health Queensland Hospital and Health Service and the University of Queensland Human Research Ethics Committees have approved this study. Results will be disseminated in peer-reviewed journals and scientific conferences; through professional and athletic organisations; and to people with CP and their families.

TRIAL REGISTRATION NUMBER

ACTRN12621000317897; Australian New Zealand Clinical Trials Registry number.

Operationalization, measurement, and health indicators of sedentary behavior in individuals with cerebral palsy: a scoping review

PURPOSE

To explore the operationalization and measurement of sedentary behavior (SB) in individuals with cerebral palsy (CP).

MATERIALS AND METHODS

We searched five databases from 2011 to 2020 for primary studies of experimental, qualitative, longitudinal, or observational designs measuring SB or postures typically characterized as sedentary (sitting, reclining, lying).

RESULTS

We screened 1112 citations and selected 47 studies. SB was operationalized through muscle activation, energy expenditure or oxygen consumption in typically sedentary postures (n = 9), and through thresholds and postures used by accelerometers, activity monitors, and a questionnaire to measure time spent in SB (n = 25). Seven out of the eight studies that measured energy expenditure found ≤1.5 metabolic equivalents of task (METs) for sitting and lying. While different accelerometer thresholds were used to measure SB, the behavior (SB) was consistently operationalized as sitting and lying. Little consistency existed in the subpopulation, instruments and cut-points for studies on validity or reliability of tools for measuring SB (n = 19).

CONCLUSIONS

Sitting and lying are considered sedentary postures, which is defined as ≤1.5 METs in individuals with CP. There is variability in the tools used to measure SB in individuals with CP. Therefore, consensus on the definition and reporting of SB is needed.Implications for rehabilitationAlthough sedentary behavior (SB) is increased in individuals with cerebral palsy (CP) compared to the typically developing population, there is no standard definition for SB for these individuals; this makes it difficult to synthesize data across studies.Sitting and lying are ≤1.5 METs in individuals with CP, suggesting we only need to measure posture to show change in SB.The commonly used accelerometer cut-point in the typically developing population of ≤100 counts per minute generally has excellent reliability across multiple devices in ambulatory children with CP.