Measurement of habitual physical activity performance in adolescents with cerebral palsy: a systematic review

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.

Association between upper limb clinical tests and accelerometry metrics for arm use in daily life in children with unilateral cerebral palsy

PURPOSE

To evaluate the association between upper-limb (UL) clinical tests and UL accelerometry-derived metrics in children with unilateral Cerebral Palsy (CP).

METHODS

In this cross-sectional study, twenty children with unilateral CP and Manual Ability Classification System level I-III were included. Outcomes of the Assisting Hand Assessment, Box and Block-Test and accelerometry metrics were collected in the clinical setting and in daily life. UL asymmetry index (i.e., the ratio between the well-functioning UL and the affected UL use) was evaluated in different physical activity levels and relative use of UL was evaluated during daily living. Spearman's correlation was used to determine the association between UL clinical tests and accelerometry metrics in a clinical setting and in daily life.

RESULTS

The strongest negative association was between the Assisting Hand Assessment units and accelerometry metrics during the sedentary time in daily life (rs = -0.64). The asymmetries between ULs were highest during the child's sedentary time (asymmetry index: 45.15) compared to when the child was in light (asymmetry index: 23.97) or higher intensity physical activity (asymmetry index: 13.39). The children used both ULs simultaneously for 44% of the time during daily life.

CONCLUSION

Accelerometry metrics may provide additional objective information to clinical tests by quantifying the amount of UL movements and the amount of asymmetry between the upper limbs in daily life.

Emerging methods for measuring physical activity using accelerometry in children and adolescents with neuromotor disorders: a narrative review

BACKGROUND

Children and adolescents with neuromotor disorders need regular physical activity to maintain optimal health and functional independence throughout their development. To this end, reliable measures of physical activity are integral to both assessing habitual physical activity and testing the efficacy of the many interventions designed to increase physical activity in these children. Wearable accelerometers have been used for children with neuromotor disorders for decades; however, studies most often use disorder-specific cut points to categorize physical activity intensity, which lack generalizability to a free-living environment. No reviews of accelerometer data processing methods have discussed the novel use of machine learning techniques for monitoring physical activity in children with neuromotor disorders.

METHODS

In this narrative review, we discuss traditional measures of physical activity (including questionnaires and objective accelerometry measures), the limitations of standard analysis for accelerometry in this unique population, and the potential benefits of applying machine learning approaches. We also provide recommendations for using machine learning approaches to monitor physical activity.

CONCLUSIONS

While wearable accelerometers provided a much-needed method to quantify physical activity, standard cut point analyses have limitations in children with neuromotor disorders. Machine learning models are a more robust method of analyzing accelerometer data in pediatric neuromotor disorders and using these methods over disorder-specific cut points is likely to improve accuracy of classifying both type and intensity of physical activity. Notably, there remains a critical need for further development of classifiers for children with more severe motor impairments, preschool aged children, and children in hospital settings.

The Decline of Physical Activity with Age in School-Aged Children with Cerebral Palsy: A Single-Center Cross-Sectional Observational Study

Maintaining physical activity is important for children with cerebral palsy (CP). This study examined whether age predicted habitual physical activity (HPA) or cardiorespiratory fitness (CRF) in school-aged children with CP and clarified the relationship between HPA and CRF. We utilized cross-sectional data from 39 children with CP (18 girls and 21 boys; mean age 7.44 years; mean body weight 24.76 kg; mean body mass index 15.97 kg/m²; hemiplegic or diplegic CP). The participants wore an accelerometer (ActiGraph) for five days to measure HPA, physical activity energy expenditure (kcal/kg/d), sedentary physical activity (%SPA), light physical activity, moderate-to-vigorous physical activity (%MVPA), and activity counts (counts/min). Participants underwent cardiopulmonary exercise tests on a treadmill using a modified Naughton protocol. Linear regression and correlation analyses were performed. p-value (two-tailed) < 0.05 was considered statistically significant. Age was positively associated with SPA. MVPA negatively correlated with resting heart rate (HR), and activity counts were negatively correlated with resting HR. In conclusion, our study found strong evidence of a negative association between HPA and age in school-aged children with CP. It highlights the importance of creating and improving recreational opportunities that promote physical activity in all children with CP, regardless of whether they are considered therapeutic.

Acceptability of wearable inertial sensors, completeness of data, and day-to-day variability of everyday life motor activities in children and adolescents with neuromotor impairments

Monitoring the patients' motor activities in a real-world setting would provide essential information on their functioning in daily life. In this study, we used wearable inertial sensors to monitor motor activities of children and adolescents with congenital and acquired brain injuries. We derived a set of clinically meaningful performance measures and addressed the following research questions: Is the target population willing to wear the sensors in their habitual environment? Which factors lead to missing data, and can we avoid them? How many measurement days are needed to obtain reliable estimates of the children's and adolescents' motor performance? The study participants wore our sensor system for seven consecutive days during waking hours. First, we derived the daily hand use of all participants, the duration of different body positions and the wheeling activity of individuals using a manual wheelchair, and walking-related measures in individuals being able to walk. Then, we analyzed the reasons for missing data and determined the reliability of the performance measures mentioned above. The large majority (41 of 43 participants) was willing to wear the sensor system for a week. However, forgetting to reattach the sensors after charging them overnight and taking them off during bathing and swimming was the main contributor to missing data. Consequently, improved battery life and waterproofness of the sensor technology are essential requirements for measurements in daily life. Besides, 5 of 11 performance measures showed significant differences between weekdays and weekend days. The reliability, measured with the intraclass correlation coefficient, ranged between 0.82 and 0.98. Seven measurement days were enough to obtain significantly higher reliability scores than the desired level of 0.8 for all but two performance measures. In children and adolescents with neuromotor impairments, we recommend monitoring everyday life motor activities on seven consecutive days. The target population accepted this measurement protocol, it covers school days and weekend days, and the number of measurement days is sufficient to obtain reliable estimates of motor performance.

Sensor-based outcomes to monitor everyday life motor activities of children and adolescents with neuromotor impairments: A survey with health professionals

In combination with appropriate data processing algorithms, wearable inertial sensors enable the measurement of motor activities in children's and adolescents' habitual environments after rehabilitation. However, existing algorithms were predominantly designed for adult patients, and their outcomes might not be relevant for a pediatric population. In this study, we identified the needs of pediatric rehabilitation to create the basis for developing new algorithms that derive clinically relevant outcomes for children and adolescents with neuromotor impairments. We conducted an international survey with health professionals of pediatric neurorehabilitation centers, provided them a list of 34 outcome measures currently used in the literature, and asked them to rate the clinical relevance of these measures for a pediatric population. The survey was completed by 62 therapists, 16 doctors, and 9 nurses of 16 different pediatric neurorehabilitation centers from Switzerland, Germany, and Austria. They had an average work experience of 13 ± 10 years. The most relevant outcome measures were the duration of lying, sitting, and standing positions; the amount of active self-propulsion during wheeling periods; the hand use laterality; and the duration, distance, and speed of walking periods. The health profession, work experience, and workplace had a minimal impact on the priorities of health professionals. Eventually, we complemented the survey findings with the family priorities of a previous study to provide developers with the clinically most relevant outcomes to monitor everyday life motor activities of children and adolescents with neuromotor impairments.

Feasibility of audio-motor training with the multisensory device ABBI: Implementation in a child with hemiplegia and hemianopia

Spatial representation is crucial when it comes to everyday interaction with the environment. Different factors influence spatial perception, such as body movements and vision. Accordingly, training strategies that exploit the plasticity of the human brain should be adopted early. In the current study we developed and tested a new training protocol based on the reinforcement of audio-motor associations. It supports spatial development in one hemiplegic child with an important visual field defect (hemianopia) in the same side of the hemiplegic limb. We focused on investigating whether a better representation of the space using the sound can also improve the involvement of the hemiplegic upper limb in daily life activity. The experimental training consists of intensive but entertaining rehabilitation for two weeks, during which a child performed ad-hoc developed audio-motor-spatial exercises with the Audio Bracelet for Blind Interaction (ABBI) for 2 h/day. We administered a battery of tests before and after the training that indicated that the child significantly improved in both the spatial aspects and the involvement of the hemiplegic limb in bimanual tasks. During the assessment, ActiGraph GT3X+ was used to measure asymmetry in the use of the two upper limbs with a standardized clinical tool, the Assisting Hand Assessment (AHA), pre and post-training. Additionally, the study measured and recorded spontaneous daily life activity for at least 2 h/day. These results confirm that one can enhance perceptual development in motor and visual disorders using naturally associated auditory feedback to body movements.

Physical Activity Energy Expenditure Predicts Quality of Life in Ambulatory School-Age Children with Cerebral Palsy

Background: Participation in physical activities is positively associated with better quality of life in children with cerebral palsy (CP). The objective of this study was to elucidate the relationship between the intensity of habitual physical activity (HPA) measured with an accelerometer and health-related quality of life (HRQOL) in school-age children with CP. Method: A secondary analysis of the cross-sectional data of 46 ambulatory children with CP was conducted. The participants wore an accelerometer for seven days to measure HPA: activity counts (counts/min) and physical activity energy expenditure (PAEE, kcal/kg/day), as well as %moderate-to-vigorous intensity physical activity (%MVPA), %light intensity physical activity (%LPA), and %sedentary physical activity (%SPA) were measured. Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and Child Health Questionnaire Parent Form 50 Questions (CHQ-PF50) were used to measure HRQOL. A Pearson analysis and a hierarchical regression analysis were performed. Results: PAEE significantly predicted the results of the PedsQL(child) physical domain (β = 0.579, p = 0.030), PedsQL(child) emotional domain (β = 0.570, p = 0.037), PedsQL(child) social domain (β = 0.527, p = 0.043), and PedsQL(child) total (β = 0.626, p = 0.017). However, other HPA parameters could not predict any other HRQOL. Conclusions: PAEE could be used as a biomarker in studies on HRQOL and HPA in ambulatory school-age children with CP.

A home-based telehealth Movement-to-Music program can increase physical activity participation among adolescents with cerebral palsy: pilot randomized controlled trial (Preprint)

Background

Adolescents with cerebral palsy (CP) who have mobility limitations have almost no access to inexpensive and enjoyable home-based programs that can be disseminated on a large scale to help them independently manage their health through participation in leisure-time physical activity (LTPA).

Objective

The primary aim of this study was to determine the preliminary efficacy of the early adoption phase of an adult Movement-to-Music (M2M) program with behavioral telecoaching for increasing LTPA and activity participation compared with a waitlist control group in adolescents with CP. The secondary aim was to explore the effects of the program on perceived levels of pain and fatigue. The tertiary aim was to qualitatively evaluate the factors that influenced adherence and develop a theory that would inform the development of a more targeted M2M telehealth program for this group.

Methods

This randomized controlled trial piloted a 4-week M2M program with weekly behavioral telecoaching among 58 adolescents with CP who walked or used wheelchairs. The participants were randomized into one of 2 groups: M2M or control, which maintained their daily activities. M2M included videos that participants were asked to complete 3 times each week at home (asynchronous training). Adherence to video minutes was objectively measured using cloud-based analytics. Changes in activity and LTPA participation were measured before and after the intervention using the Children’s Assessment of Participation and Enjoyment total domain scores and active physical recreation domain scores, respectively. Perceived pain and fatigue were measured using the National Institutes of Health Neuro-QoL short forms. The changes in scores were compared between the groups using analysis of covariance. A grounded theory approach was used to analyze one-on-one interviews, coaching notes, and feedback surveys.

Results

A total of 58 people were enrolled, of which 49 (84%) completed the primary outcome follow-up assessment. The mean adherence to the prescribed exercise video minutes across all 4 weeks was 68%, starting from 90% in week 1 and gradually declining to 43% in week 4. Mean adherence to coaching calls was 91%. Analysis of covariance revealed a statistically significant difference between the pre- to postchange scores for Children’s Assessment of Participation and Enjoyment Active Physical Recreation–Intensity domain scores in favor of the intervention group (F_1,47=8.76; P=.005; effect size=0.17, also known as volume of LTPA). The qualitative findings highlighted 5 critical factors that influenced participants’ adherence to the program: caregiver support, video elements, suitable exercises, music, and behavioral coaching.

Conclusions

This project determined that adolescents with CP responded well to an M2M telehealth program that could enhance their LTPA levels. This paper describes a theory in which adherence to a telehealth LTPA program can be optimized through functional and age-specific modifications for adolescents with CP.

Trial Registration

ClinicalTrials.gov NCT04264390; https://clinicaltrials.gov/ct2/show/NCT04264390

The impact of COVID-19 on the lifestyles of adolescents with cerebral palsy in the Southeast United States

Background

The impact of COVID-19 on adolescents with cerebral palsy (CP) and their families is underinvestigated, particularly in the Southeastern United States.

Objective/Hypothesis

The objective of this study was to examine the impact of COVID-19 on lifestyle activities, general and mental health, and basic needs among a cohort of adolescents with CP in the Southeast U.S. The second purpose was to identify key factors that impacted their lifestyles.

Methods

This was a cross-sectional survey of adolescents with CP (aged 10–19 years) who completed a child-modified version of the Coronavirus Disability Survey. Health and behavior items were associated with the perceived lifestyle impact of COVID-19.

Results

A total of 101 respondents completed the survey (mean age: 14 ± 2 years). Respondents reported minimal to no change in general health since the COVID-19 outbreak. Basic needs were met for most families. Nearly all participants (94.1%) reported a mental health concern that resulted from COVID-19: 32.7% felt down or depressed; 47.5% felt little pleasure in doing things; and 64.4% felt isolated. Moreover, 74.3% reported decreased socialization, 51.5% reported reduced exercise participation, and 43.6% reported difficulties in obtaining medical care. Most participants (90.1%) were negatively affected by COVID-19, and key associated factors were reduced interactions with friends and family (p = 0.001), exercise participation (p = 0.016), interest in doing things (p = 0.005), worsened depression (p = 0.015), increased isolation from others (p = 0.02) and at home (p = 0.006), technological communication (p = 0.00), and virus exposure (p = 0.008).

Conclusions

Study findings highlight problem areas that warrant urgent intervention among adolescents with CP located within the Southeast U.S.

Measurement of physical activity in children and adolescents with cerebral palsy: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify and map subjective instruments that have been developed for children and adolescents with cerebral palsy from birth to 18 years to measure physical activity and sedentary behavior.

INTRODUCTION

Children and adolescents with cerebral palsy often do not meet the recommended levels of physical activity, even though regular physical activity is an important determinant of good health. Considering the importance of physical activity, there is a need for systematic collection of data on daily activity and sedentary behavior of children and adolescents with cerebral palsy. Subjective instruments with clinical utility for use in quality registers are needed to evaluate interventions and investigate the relationship between activity and health outcomes.

INCLUSION CRITERIA

This review will consider studies that include children and adolescents from birth to 18 years with cerebral palsy across levels I to V of the Gross Motor Function Classification System. Specifically, this scoping review will report on subjective instruments used to measure physical activity and sedentary behavior and that distinguish between physical activity performance and physical activity capability.

METHODS

This scoping review will be conducted in accordance with the JBI methodology for scoping reviews and will search the following databases: MEDLINE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, Embase, and PEDro, as well as specific journals relating to physical activity assessment.

Exercise load and physical activity intensity in relation to dystonia and choreoathetosis during powered wheelchair mobility in children and youth with dyskinetic cerebral palsy

PURPOSE

To explore the relation between exercise load, physical activity intensity, and movement disorders during powered wheelchair (PW) mobility in people with severe dyskinetic cerebral palsy (DCP).

METHODS

Ten participants with DCP, 6-21 years old, users of a head/foot steering system were included. Dystonia and choreoathetosis were assessed using the Dyskinesia Impairment Mobility Scale (DIMS), heart rate (HR) was used to assess the exercise load of the tasks on the participants, and the accelerometry-based activity index (AI) to measure the physical activity intensity and energy expenditure during mobility task performance.

RESULTS

Neck- and distal arm dystonia showed significant correlations with HR (0.64 < r_s < 0.77; 0.009 < p < 0.048), whereas neck- and proximal arm choreoathetosis with AI (0.64 < r_s < 0.76, 0.011 < p < 0.044). Total-body AI was strongly correlated to the AI of the arms (0.66 < r_s < 0.90,  < 0.001 < p < 0.038), but not to the AI of the head.

CONCLUSIONS

During PW mobility tasks, dystonia is associated to exercise load and choreoathetosis to physical activity intensity and energy expenditure. Findings highlight the difficulties in measuring exercise load and activity intensity in PW users with DCP due to the involuntary hypertonic and/or hyperkinetic hallmark of the movement disorders. Nevertheless, a relaxed surrounding with minimal distractions during PW training may increase learning efficiency. Future studies with a bigger sample size are highly recommended to fully establish the relationship between the variables and to allow generalizability of results.Implications for rehabilitationDystonia is positively related to heart rate during powered mobility, which may be explained by the hypertonic hallmark of dystonia causing an increase in exercise load.Choreoathetosis is positively related to the physical activity index during powered mobility where the hyperkinetic hallmark of choreoathetosis may lead to an increase in physical activity intensity and energy expenditure.Arm overflow movements are the component which contribute the most to total-body activity index, thus, minimizing these movements may lower the overall energy expenditure during powered mobility.Mobility training in a relaxed surrounding with minimal distractions and minimized arm overflow movements may lead to a less-demanding powered wheelchair mobility experience and increased learning efficiency.

An Online Physical Activity Intervention for Youth With Physical Disabilities: A Pilot Study

Background: Physical activity (PA) interventions are limited in number and reach for youth with physical disabilities (YPD) who experience systemic barriers that may preclude their in-person participation. Further, a lack of theory in the development and evaluation of PA interventions impedes our understanding and replication of active components of behavior change. These limitations pose challenges in the effective promotion of PA in YPD. Theory-based and more inclusive methods of PA intervention delivery must be explored in our efforts to promote PA and overall health in YPD.

Methods: A pilot study was conducted to evaluate the feasibility and outcomes of an online, 4-week social cognitive theory-based PA intervention for YPD. Intervention feasibility (implementation fidelity, intervention compliance, and intervention acceptability) was evaluated through manual documentation, weekly feedback questionnaires, and open-ended feedback at 1-month post-intervention. Targeted social cognitive (outcome expectations, self-efficacy [task, self-regulatory, barrier] and self-regulation) and PA behavior outcomes were self-reported at baseline and 1-week and 1-month post-intervention.

Results: Sixteen YPD (M_age = 17.4 ± 2.7 years, 69% female) completed the study. Intervention feasibility was supported by high implementation fidelity (100%), high intervention compliance (>90%), and positive ratings on indicators of acceptability for all weeks of the intervention (weekly feedback questionnaire means ranging from 5.74 to 6.19 out of 7). Through open-ended feedback, participants indicated the intervention was easy to use and understand, favorably shifted their self-awareness and personal meaning of PA, and provided value and potential for future use pertaining to the learned self-regulation skills and strategies. Participants also provided formatting and content recommendations for intervention improvement. Repeated measures ANOVAs showed significant and large effect sizes for changes in participants' task (p = 0.01, n²p = 0.28) and barrier (p = 0.02, n²p = 0.24) self-efficacy, goal-setting and planning and scheduling behaviors (ps < 0.001, n²ps = 0.42), and self-reported PA behavior (p = 0.02, n²p = 0.26).

Conclusions: An online PA intervention for YPD is feasible and may offer potential benefit through the enhancement of self-efficacy, self-regulation, and PA behavior. Continued research is necessary to understand the efficacy and longer-term outcomes of online, theory-based interventions for YPD as a PA promotion strategy.

Physical Activity Measurement in Children Who Use Mobility Assistive Devices: Accelerometry and Global Positioning System

PURPOSE

To explore the usefulness of combining accelerometry, global positioning systems, and geographic information systems, to describe the time spent in different locations and physical activity (PA) duration/count levels by location for 4 children with cerebral palsy (CP) who use assistive devices (AD).

METHODS

A descriptive multiple-case study.

RESULTS

Combining the 3 instruments was useful in describing and differentiating duration by location, and amount and location of PA across differing functional levels and AD. For example, the child classified with a Gross Motor Function Classification System (GMFCS) level II exhibited large amounts of PA in community settings. In contrast, the child classified with a GMFCS level V had small amounts of PA and spent most measured time at home.

CONCLUSIONS

Combined accelerometry, global positioning system, and geographic information system have potential to capture time spent and amount/intensity of PA relative to locations within daily environments for children with CP who use AD.

Machine Learning to Quantify Physical Activity in Children with Cerebral Palsy: Comparison of Group, Group-Personalized, and Fully-Personalized Activity Classification Models

Pattern recognition methodologies, such as those utilizing machine learning (ML) approaches, have the potential to improve the accuracy and versatility of accelerometer-based assessments of physical activity (PA). Children with cerebral palsy (CP) exhibit significant heterogeneity in relation to impairment and activity limitations; however, studies conducted to date have implemented “one-size fits all” group (G) models. Group-personalized (GP) models specific to the Gross Motor Function Classification (GMFCS) level and fully-personalized (FP) models trained on individual data may provide more accurate assessments of PA; however, these approaches have not been investigated in children with CP. In this study, 38 children classified at GMFCS I to III completed laboratory trials and a simulated free-living protocol while wearing an ActiGraph GT3X+ on the wrist, hip, and ankle. Activities were classified as sedentary, standing utilitarian movements, or walking. In the cross-validation, FP random forest classifiers (99.0–99.3%) exhibited a significantly higher accuracy than G (80.9–94.7%) and GP classifiers (78.7–94.1%), with the largest differential observed in children at GMFCS III. When evaluated under free-living conditions, all model types exhibited significant declines in accuracy, with FP models outperforming G and GP models in GMFCS levels I and II, but not III. Future studies should evaluate the comparative accuracy of personalized models trained on free-living accelerometer data.

Effects of a training programme of functional electrical stimulation (FES) powered cycling, recreational cycling and goal-directed exercise training on children with cerebral palsy: a randomised controlled trial protocol

INTRODUCTION

Children with cerebral palsy (CP) experience declines in gross motor ability as they transition from childhood to adolescence, which can result in the loss of ability to perform sit-to-stand transfers, ambulate or participate in leisure activities such as cycling. Functional electrical stimulation (FES) cycling is a novel technology that may provide opportunities for children with CP to strengthen their lower limbs, improve functional independence and increase physical activity participation. The proposed randomised controlled trial will test the efficacy of a training package of FES cycling, adapted cycling and goal-directed functional training to usual care in children with CP who are susceptible to functional declines.

METHODS AND ANALYSIS

Forty children with CP (20 per group), aged 6-8 years and classified as Gross Motor Function Classification System (GMFCS) levels II-IV will be recruited across South East Queensland. Participants will be randomised to either an immediate intervention group, who will undertake 8 weeks of training, or a waitlist control group. The training group will attend two 1 hour sessions per week with a physiotherapist, consisting of FES cycling and goal-directed, functional exercises and a 1 hour home exercise programme per week, consisting of recreational cycling. Primary outcomes will be the gross motor function measure and Canadian occupational performance measure, and secondary outcomes will include the five times sit-to-stand test, habitual physical activity (accelerometry), power output during cycling and Participation and Environment Measure-Children and Youth. Outcomes will be assessed at baseline, postintervention (8 weeks) and 8 weeks following the intervention (retention).

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Griffith University (2018/037) and the Children's Health Queensland Hospital and Health Service (CHQHHS) Human Research Ethics Committee (HREC/17/QRCH/88). Site-specific approval was obtained from CHQHHS research governance (SSA/17/QRCH/145). Results from this trial will be disseminated via publication in relevant peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000644369p.

Novel approaches to measuring community integration in adults with cerebral palsy

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

Actigraph assessment for measuring upper limb activity in unilateral cerebral palsy

BACKGROUND

Detecting differences in upper limb use in children with unilateral cerebral palsy (UCP) is challenging and highly dependent on examiner experience. The recent introduction of technologies in the clinical environment, and in particular the use of wearable sensors, can provide quantitative measurement to overcome this issue. This study aims to evaluate ActiGraph GT3X+ as a tool for measuring asymmetry in the use of the two upper limbs (ULs) during the assessment with a standardized clinical tool, the Assisting Hand Assessment (AHA) in UCP patients aged 3-25 years compared to age-matched typically developing (TD) subjects.

METHODS

Fifty children with UCP and 50 TD subjects were assessed with AHA while wearing ActiGraphs GT3X+ on both wrists. The mean activity of each hand (dominant and non-dominant, MADH and MANDH, respectively) and the asymmetry index (AI) were calculated. Two linear mixed model analyses were carried out to evaluate how dependent actigraphic variables (i.e. MANDH and AI) varied by group (TD vs UCP) and among levels of manual ability based on Manual Ability Classification System (MACS). In both models age, sex, side of hemiplegia, presence/absence of mirror movements were specified as random effects.

RESULTS

The MANDH was significantly lower in UCP compared to TD, while the AI was significantly higher in UCP compared to TD. Moreover, in UCP group there were significant differences related to MACS levels, both for MANDH and AI. None of the random variables (i.e. age, sex, side, presence/absence of mirror movements) showed significant interaction with MANDH and AI.

CONCLUSIONS

These results confirm that actigraphy could provide, in a standardized setting, a quantitative description of differences between upper limbs activity.

TRIAL REGISTRATION

ClincalTrials.gov, NCT03054441 . Registered 15 February 2017.

Effects of task-specific movement patterns during resistance exercise on the respiratory functions and thickness of abdominal muscles of children with cerebral palsy: randomized placebo-controlled double-blinded clinical trial

[Purpose] This study was conducted to examine the effects of task-specific movement patterns during resistance exercise program, which are applied to children with cerebral palsy, on respiratory functions and thickness of abdominal muscles. [Participants and Methods] This study was conducted with randomized double-blinded controlled research was pursued since it is a clinical trial with minors with disabilities as the participants. Seventeen children with cerebral palsy were randomly allocated to both experimental group and placebo group by means of simple randomized sampling. The experimental group wore weighted vest to which loaded-resistance was applied by means of sand bag while the placebo group wore weighted vest without loaded-resistance. Task-specific movement patterns during resistance exercise were performed for 40 minutes 2 times a week over a period of 12 weeks for the participants in both groups. Differences in respiratory functions and thickness of abdominal muscles measured prior to and after 12 weeks of the experiment were compared. [Results] All the measurement values for the respiratory functions and abdominal muscle thickness displayed statistically significant changes between those prior to and after the exercise in both of the experimental group and the placebo group. There were statistically significant differences in the changes prior to and following the exercise between the two groups. [Conclusion] Therefore, task-specific movement patterns in anatomical plane, diagonal patterns and combined forms during resistance exercise program on for children with cerebral palsy can be considered as an efficient intervention method in improving respiratory capacity.

PREDICT-CP: study protocol of implementation of comprehensive surveillance to predict outcomes for school-aged children with cerebral palsy

OBJECTIVES

Cerebral palsy (CP) remains the world's most common childhood physical disability with total annual costs of care and lost well-being of $A3.87b. The PREDICT-CP (NHMRC 1077257 Partnership Project: Comprehensive surveillance to PREDICT outcomes for school age children with CP) study will investigate the influence of brain structure, body composition, dietary intake, oropharyngeal function, habitual physical activity, musculoskeletal development (hip status, bone health) and muscle performance on motor attainment, cognition, executive function, communication, participation, quality of life and related health resource use costs. The PREDICT-CP cohort provides further follow-up at 8-12 years of two overlapping preschool-age cohorts examined from 1.5 to 5 years (NHMRC 465128 motor and brain development; NHMRC 569605 growth, nutrition and physical activity).

METHODS AND ANALYSES

This population-based cohort study undertakes state-wide surveillance of 245 children with CP born in Queensland (birth years 2006-2009). Children will be classified for Gross Motor Function Classification System; Manual Ability Classification System, Communication Function Classification System and Eating and Drinking Ability Classification System. Outcomes include gross motor function, musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function, communication difficulties, oropharyngeal dysphagia, dietary intake and body composition, participation, parent-reported and child-reported quality of life and medical and allied health resource use. These detailed phenotypical data will be compared with brain macrostructure and microstructure using 3 Tesla MRI (3T MRI). Relationships between brain lesion severity and outcomes will be analysed using multilevel mixed-effects models.

ETHICS AND DISSEMINATION

The PREDICT-CP protocol is a prospectively registered and ethically accepted study protocol. The study combines data at 1.5-5 then 8-12 years of direct clinical assessment to enable prediction of outcomes and healthcare needs essential for tailoring interventions (eg, rehabilitation, orthopaedic surgery and nutritional supplements) and the projected healthcare utilisation.

TRIAL REGISTRATION NUMBER

ACTRN: 12616001488493.

Decision Trees for Detection of Activity Intensity in Youth with Cerebral Palsy

PURPOSE

To develop and test decision tree (DT) models to classify physical activity (PA) intensity from accelerometer output and Gross Motor Function Classification System (GMFCS) classification level in ambulatory youth with cerebral palsy (CP) and compare the classification accuracy of the new DT models to that achieved by previously published cut points for youth with CP.

METHODS

Youth with CP (GMFCS levels I-III) (N = 51) completed seven activity trials with increasing PA intensity while wearing a portable metabolic system and ActiGraph GT3X accelerometers. DT models were used to identify vertical axis (VA) and vector magnitude (VM) count thresholds corresponding to sedentary (SED) (<1.5 METs), light-intensity PA (LPA) (≥1.5 and <3 METs) and moderate-to-vigorous PA (MVPA) (≥3 METs). Models were trained and cross-validated using the "rpart" and "caret" packages within R.

RESULTS

For the VA (VA_DT) and VM DT (VM_DT), a single threshold differentiated LPA from SED, whereas the threshold for differentiating MVPA from LPA decreased as the level of impairment increased. The average cross-validation accuracies for the VC_DT were 81.1%, 76.7%, and 82.9% for GMFCS levels I, II, and III. The corresponding cross-validation accuracies for the VM_DT were 80.5%, 75.6%, and 84.2%. Within each GMFCS level, the DT models achieved better PA intensity recognition than previously published cut points. The accuracy differential was greatest among GMFCS level III participants, in whom the previously published cut points misclassified 40% of the MVPA activity trials.

CONCLUSIONS

The GMFCS-specific cut points provide more accurate assessments of MVPA levels in youth with CP across the full spectrum of ambulatory ability.

Domains of Daily Physical Activity in Children with Mitochondrial Disease: A 3D Accelerometry Approach

Feasible, sensitive and clinically relevant outcome measures are of extreme importance when designing clinical trials. For paediatric mitochondrial disease, no robust end point has been described to date. The aim of this study was to select the domains of daily physical activity, which can be measured by 3D accelerometry, that could serve as sensitive end points in future clinical trials in children with mitochondrial disorders.In this exploratory observational study, 17 patients with mitochondrial disease and 16 age- and sex-matched controls wore 3D accelerometers at the upper leg, upper arm, lower arm and chest during one weekend. Using the raw data obtained by the accelerometers, we calculated the following outcome measures: (1) average amount of counts per hour the sensors were worn; (2) the maximal intensity; (3) the largest area under the curve during 30 min and (4) categorized activities lying, standing or being dynamically active. Measuring physical activity during the whole weekend was practically feasible in all participants. We found good face validity by visually correlating the validation videos and activity diaries to the accelerometer data-graphs. Patients with mitochondrial disorders had significantly lower peak intensity and were resting more, compared to their age- and sex-matched peers.Finally, we suggest domains of physical activity that could be included when measuring daily physical activity in children with mitochondrial disorders, preferably using more user-friendly devices. These include peak activity parameters for the arms (all patients) and legs (ambulatory patients). We recommend using or developing devices that measure these domains of physical activity in future clinical studies.

Measuring Habitual Physical Activity in Neuromuscular Disorders: A Systematic Review

BACKGROUND

Free-living or habitual physical activity (HPA) refers to someone's performance in his or her free-living environment. Neuromuscular disorders (NMD) manifest through HPA, and the observation of HPA can be used to identify clinical risks and to quantify outcomes in research. This review summarizes and analyses previous studies reporting the assessment of HPA in NMD, and may serve as the basis for evidence-based decision-making when considering assessing HPA in this population.

METHODS

A systematic review was performed to identify all studies related to HPA in NMD, followed by a critical appraisal of the assessment methodology and a final review of the identified HPA tools.

RESULTS

A total of 22 studies were selected, reporting on eight different direct tools (or activity monitors) and ten structured patient-reported outcomes. Overall, HPA patterns in NMD differ from healthy control populations. There was a noticeable lack of validation studies for these tools and outcome measures in NMD. Very little information regarding feasibility and barriers for the application of these tools in this population have been published.

CONCLUSIONS

The variety and heterogeneity of tools and methods in the published literature makes the comparison across different studies difficult, and methodological guidelines are warranted. We propose a checklist of considerations for the assessment and reporting of HPA in NMD.

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.

The effects of progressive resistance training on daily physical activity in young people with cerebral palsy: a randomised controlled trial

PURPOSE

To examine if individualised resistance training increases the daily physical activity of adolescents and young adults with bilateral spastic cerebral palsy (CP).

METHOD

Young people with bilateral spastic CP were randomly assigned to intervention or to usual care. The intervention group completed an individualised lower limb progressive resistance training programme twice a week for 12 weeks in community gymnasiums. The primary outcome was daily physical activity (number of steps, and time sitting and lying). Secondary outcomes included muscle strength measured with a one-repetition maximum (1RM) leg press and reverse leg press. Outcomes were measured at baseline, 12 weeks and 24 weeks.

RESULTS

From the 36 participants with complete data at 12 weeks, there were no between-group differences for any measure of daily physical activity. There was a likely increase in leg press strength in favour of the intervention group (mean difference 11.8 kg; 95% CI -1.4 to 25.0). No significant adverse events occurred during training.

CONCLUSIONS

A short-term resistance training programme that may increase leg muscle strength was not effective in increasing daily physical activity. Other strategies are needed to address the low-daily physical activity levels of young people with bilateral spastic CP.

IMPLICATIONS FOR REHABILITATION

Progressive resistance training may increase muscle strength but does not lead to increases in daily physical activity of young people with bilateral spastic cerebral palsy (CP) and mild to moderate walking disabilities. Other strategies apart from or in addition to resistance training are needed to address the low daily physical activity levels of young people with bilateral spastic CP and mild to moderate walking disabilities.

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.

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.

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.

A systematic review of activities of daily living measures for children and adolescents with cerebral palsy

AIM

This study aimed to systematically review the psychometric properties and clinical utility of measures of activities of daily living (ADL) for children with cerebral palsy (CP) aged 5 to 18 years.

METHOD

Five electronic databases were searched to identify available ADL measures with published psychometric data for school-aged children with CP. Measures were included if at least 60% of the items addressed ADL in the full assessment or in an independent domain. A modified CanChild Outcome Rating Form was used to report the validity, reliability, responsiveness, and clinical utility of the measures.

RESULTS

Twenty-six measures were identified and eight met inclusion criteria. The Pediatric Evaluation of Disability Inventory (PEDI) had the strongest psychometric properties but was limited by its age range. The Assessment of Motor and Process Skills (AMPS) was the most comprehensive evaluation of underlying motor and cognitive abilities yet further psychometric testing is required for children with CP.

INTERPRETATION

The PEDI should be used to measure ADL capability in elementary school aged children. The AMPS is the best measure to evaluate ADL performance or capacity and is suitable for all ages. Future research should examine the reliability of the AMPS to determine its stability in children and adolescents with CP.

Interventions for promoting physical activity in people with cystic fibrosis

BACKGROUND

In individuals with cystic fibrosis there are no established targets for participation in physical activity, nor have any ideal strategies to promote participation in physical activity been identified

OBJECTIVES

To evaluate the effect of treatment to increase participation in physical activity in people with cystic fibrosis.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register using the terms 'physiotherapy and exercise'.Date of the most recent search: 05 December 2013.Additionally, we conducted searches of the electronic databases MEDLINE, CINAHL (Ebscohost), PsycINFO (OvidSP) and the Physiotherapy Evidence Database (PEDro). We also searched for potentially relevant, completed but unpublished studies, on several clinical trials registers.Date of the most recent searches: 10 September 2012.

SELECTION CRITERIA

All randomised and quasi-randomised controlled studies which investigated strategies designed to promote increased participation in daily physical activity for individuals with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, assessed the risk of bias and extracted data. Any disagreements were resolved by discussion and consensus, or in arbitration with a third author.

MAIN RESULTS

Four studies (199 participants) met the inclusion criteria and were predominantly conducted in children with cystic fibrosis. Only one study had a combined cohort of adult and paediatric participants. The description of study methods was inadequate to assess the risk of bias, particularly with regard to blinding of assessors and selective reporting. One study was conducted in an inpatient setting with follow up in the outpatient setting; while the remaining three studies were conducted in individuals with stable respiratory disease in the outpatient setting. All included studies used exercise training to promote participation in physical activity, with the duration of the intervention period ranging from 18 days to three years. No improvement in physical activity participation was reported with any intervention period less than or equal to six months. Improvements in physical activity participation were only seen where follow up occurred beyond 12 months. There was no significant impact on quality of life from any of the intervention strategies.

AUTHORS' CONCLUSIONS

Although participation in physical activity is generally regarded as beneficial for people with cystic fibrosis, there is a lack of evidence regarding strategies to promote the uptake and the continued participation in physical activity for this population. This review provides very limited evidence that activity counselling and exercise advice, undertaken over at least six months, to engage in a home exercise programme may result in improved physical activity participation in people with cystic fibrosis. Further research is needed to determine the effect of strategies such as health coaching or telemedicine applications, in promoting the uptake and adherence to regular participation in physical activity. In addition, establishing the ideal duration of any interventions that promote physical activity, including exercise training programmes, will be important in addressing issues relating to participation in physical activity for people with cystic fibrosis.

What proportion of people with hip and knee osteoarthritis meet physical activity guidelines? A systematic review and meta-analysis

OBJECTIVE

To determine the proportion of people with hip and knee osteoarthritis that meet physical activity guidelines recommended for adults and older adults.

METHOD

Systematic review with meta-analysis of studies measuring physical activity of participants with hip and knee osteoarthritis using an activity monitor. Physical activity levels were calculated using the mean average [95% confidence interval (CI)] weighted according to sample size. Meta-analyses determined the proportion of people meeting physical activity guidelines and recommendations of (1) ≥150 min per week of moderate to vigorous physical activity (MVPA) in bouts of ≥10 min; (2) ≥150 min per week of MVPA in absence of bouts; (3) ≥10,000 steps per day and ≥7000 steps per day. The Grades of Research, Assessment, Development and Evaluation (GRADE) approach was used to determine the quality of the evidence.

RESULTS

For knee osteoarthritis, 21 studies involving 3266 participants averaged 50 min per week (95% CI = 46, 55) of MVPA when measured in bouts of ≥10 min, 131 min per week (95% CI = 125, 137) of MVPA, and 7753 daily steps (95% CI = 7582, 7924). Proportion meta-analyses provided high quality evidence that 13% (95% CI = 7, 20) completed ≥150 min per week of MVPA in bouts of ≥10 min, low quality evidence that 41% (95% CI = 23, 61) completed ≥150 min per week of MVPA in absence of bouts, moderate quality evidence that 19% (95% CI = 8, 33) completed ≥10,000 steps per day, and low quality evidence that 48% (95% CI = 31, 65) completed ≥7000 steps per day. For hip osteoarthritis, 11 studies involving 325 participants averaged 160 min per week (95% CI = 114, 216) of MVPA when measured in bouts of ≥10 min, 189 min per week (95% CI = 166, 212) of MVPA, and 8174 daily steps (95% CI = 7670, 8678). Proportion meta-analyses provided low quality evidence that 58% (95% CI = 18, 92) completed ≥150 min per week of MVPA in absence of bouts, low quality evidence that 30% (95% CI = 13, 50) completed ≥10,000 steps per day, and low quality evidence that 60% (95% CI = 47, 73) completed ≥7000 steps per day.

CONCLUSION

A small to moderate proportion of people with knee and hip osteoarthritis met physical activity guidelines and recommended daily steps. Future research should establish the effects of increasing physical activity in this population to meet the current physical activity guidelines.

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.

To total amount of activity….. and beyond: perspectives on measuring physical behavior

The aim of this paper is to describe and discuss some perspectives on definitions, constructs, and outcome parameters of physical behavior. The paper focuses on the following constructs: Physical activity and active lifestyle vs. sedentary behavior and sedentary lifestyle; Amount of physical activity vs. amount of walking; Detailed body posture and movement data vs. overall physical activity data; Behavioral context of activities; Quantity vs. quality; Physical behavior vs. physiological response. Subsequently, the following outcome parameters provided by data reduction procedures are discussed: Distribution of length of bouts; Variability in bout length; Time window; Intensity and intensity threshold. The overview indicates that physical behavior is a multi-dimensional construct, and it stresses the importance and relevance of constructs and parameters other than total amount of physical activity. It is concluded that the challenge for the future will be to determine which parameters are most relevant, valid and responsive. This is a matter for physical behavior researchers to consider, that is critical to multi-disciplinary collaboration.

Functional progressive resistance training improves muscle strength but not walking ability in children with cerebral palsy

QUESTION

Does functional progressive resistance exercise (PRE) improve walking ability and participation in school-aged children with cerebral palsy (CP)?

DESIGN

Randomised, controlled trial with concealed allocation and blinded outcome assessment.

SETTING

Three special schools for children with physical disability in the Netherlands.

PARTICIPANTS

Ambulatory children (Gross Motor Function Classification System 1-3) with spastic unilateral or bilateral cerebral palsy aged 6-13 years. Botulinum toxin injections in the previous three months or orthopaedic surgery in the previous six months were exclusion criteria. Randomisation of 51 participants allocated 26 to the functional PRE group and 25 to a usual care group.

INTERVENTIONS

The intervention group participated in a 12-week functional PRE program, three times a week for 60 minutes in groups of 4 or 5. The program comprised four exercises: one using a leg press machine and three functional exercises (sit-to-stand, lateral step-up, half knee-rise) using body weight and a weighted vest to provide resistance. Participants completed 3 sets of 8 repetitions for each exercise. Intensity was increased progressively based on repeated estimation of 8 RM (repetition maximum). The control group received conventional physiotherapy 1-3 sessions a week.

OUTCOME MEASURES

The primary outcomes were walking ability (timed 10m walk, 1-minute fast walk test, timed stair test) and participation (intensity scores of 17 items of Children's Assessment of Participation and Enjoyment questionnaire recalculated on a 0-100 scale) measured at baseline, after 6 and 12 weeks training, and 6 weeks after the intervention. Secondary outcome measures were anaerobic muscle power, muscle strength, spasticity and range of movement (ROM).

RESULTS

49 participants completed the study. At the end of the intervention period, there was no difference between the groups for comfortable (-0.04, 95% CI -0.18 to 0.1m/s) or fast walking speed (0.04, 95% CI -0.04 to 0.12m/s), timed stair test (0.8, 95% CI -2.6 to 4.3s) or participation (-1, 95% CI -11 to 9). Muscle strength improved significantly more in the intervention group than the control group immediately after the intervention by 1.3N/kg (95% CI 0.6 to 2.5) for total isometric muscle strength and by 14% BW (95% CI 2 to 26) for 6 RM leg press. Knee flexion range had decreased in the intervention group by 15° (95% CI -29 to -1) compared to the control group 6 weeks after training stopped. The groups did not significantly differ on anaerobic muscle power, spasticity or other ROM outcomes.

CONCLUSION

A 12-week functional PRE program improved muscle strength, but did not improve functional walking activity in school-aged ambulatory children with CP.

Reliably measuring ambulatory activity levels of children and adolescents with cerebral palsy

OBJECTIVE

To identify sources of variance in step counts and to examine the minimum number of days required to obtain a stable measure of habitual ambulatory activity in the cerebral palsy (CP) population.

DESIGN

Cross-sectional.

SETTING

Free-living environments.

PARTICIPANTS

Children and adolescents with CP (N=209; mean age ± SD, 8y, 4mo ± 3y, 4mo; n=118 boys; Gross Motor Function Classification System [GMFCS] levels I-III) were recruited through 3 regional pediatric specialty care hospitals.

INTERVENTIONS

Daily walking activity was measured with a 2-dimensional accelerometer over 7 consecutive days. An individual information-centered approach was applied to days with <100 steps, and participants with ≥3 days of missing values were excluded from the study. Participants were categorized into 6 groups according to age and functional level. Generalizability theory was used to analyze the data.

MAIN OUTCOME MEASURES

Mean step counts, relative magnitude of variance components in total step activity, and generalizability coefficients (G coefficients) of various combinations of days of the week.

RESULTS

Variance in step counts attributable to participants ranged from 33.6% to 65.4%. For youth ages 2 to 5 years, a minimum of 8, 6, and 2 days were required to reach acceptable G coefficient (reliability) of ≥.80 for GMFCS levels I, II, and III, respectively. For those ages 6 to 14 years, a minimum of 6, 5, and 4 days were required to reach stable measures of step activity for GMFCS levels I, II, and III, respectively.

CONCLUSIONS

The findings of the study suggest that an activity-monitoring period should be determined based on the GMFCS levels to reliably measure ambulatory activity levels in youth with CP.

A systematic review of the clinimetric properties of habitual physical activity measures in young children with a motor disability

Aim. To identify and systematically review the clinimetric properties of habitual physical activity (HPA) measures in young children with a motor disability. Method. Five databases were searched for measures of HPA including: children aged <6.0 years with a neuromuscular disorder, physical activity defined as "bodily movement produced by skeletal muscles causing caloric expenditure", reported HPA as duration, frequency, intensity, mode or energy expenditure, and evaluated clinimetric properties. The quality of papers was assessed using the COSMIN-checklist. A targeted search of identified measures found additional studies of typically developing young children (TDC). Results. Seven papers assessing four activity monitors met inclusion criteria. Four studies were of good methodological quality. The Minimod had good ability to measure continuous walking but the demonstrated poor ability to measure steps during free-living activities. The Intelligent Device for Energy Expenditure and Activity and Ambulatory Monitoring Pod showed poor ability to measure activity during both continuous walking and free-living activities. The StepWatch showed good ability to measure steps during continuous walking in TDC. Interpretation. Studies assessing the clinimetric properties of measures of HPA in this population are urgently needed to allow assessment of the relationship between HPA and health outcomes in this group.

Accelerometry: a feasible method to quantify physical activity in ambulatory and nonambulatory adolescents with cerebral palsy

Objective. To determine the feasibility of physical activity monitoring in adolescents with cerebral palsy (CP). Methods. A convenience sample of ambulatory and non-ambulatory adolescents (N = 23; 17 males, 6 females; mean age 13.5 y, SD 2.6 y; Gross Motor Function Classification System (GMFCS) distribution: n = 9 Level I, n = 5 Level II, n = 5 Level III, n = 4 Level IV) was recruited. Physical activity (PA) was objectively assessed using the ActiGraph GT1M activity monitor. Discomfort or adverse effects of wearing the accelerometers were recorded by participants. Levels of physical activity were determined as total PA, light PA (LPA), moderate PA (MPA), moderate-to-vigorous (MVPA), and vigorous PA (VPA) using cut-points recently validated for CP. Results. Most participants showed little reluctance. Mean daily MVPA for all participants was 30.7 minutes (SD 30.3), which corresponded to 2.7 (SD 2.4) minutes of MVPA per hour or 4.5% (SD 3.9) of the total monitoring time. Total PA and MVPA were greatest in ambulatory youth (GMFCS levels I and II) compared with youth who use a walking aid or wheelchair (GMFCS levels III and IV) (P < 0.05). Conclusion(s). The results support the use of the accelerometer as a feasible and useful measure of activity in ambulatory and nonambulatory adolescents with CP.

Factors influencing physical activity in children and youth with special health care needs: a pilot study

Background. Evidence suggests that children and youth with special health care needs (CYSHCN) have decreased physical activity compared to peers. This study describes weight status and physical activity in CYSHCN and identifies factors associated with physical activity and community resources to promote physical activity. Methods. Parents (n = 21) and CYSHCN (n = 23) were recruited from a pediatric clinic. The most prevalent diagnoses were autism (n = 7, 30%) and cerebral palsy (n = 3, 13%). Interviews were conducted with parents for information on physical activity and community resources. Children's height and weight were measured to calculate body mass index (BMI). Results. The majority of CYSHCN (n = 13, 59%) were obese. CYSHCN did not meet recommended levels of 60 minutes of daily physical activity and engaged in more screen time than recommended. More children with cognitive/behavioral/emotional diagnoses were obese compared to children with physical/medical diagnoses. A majority of parents (n = 16, 73%) indicated their CYSHCN need more supervision to participate in physical activity in community programs. Conclusion. The majority of CYSHCN in this study were obese and sedentary. Resources to promote physical activity are needed for this population.