Health-related physical fitness for children with cerebral palsy

Integrating Heart Rate Monitoring Into a Camp for Children With Neuromotor Disorders: A Case Series

PURPOSE

This case series investigated the implementation fidelity, feasibility, and effectiveness of integrating continuous heart rate monitoring with visual feedback into an established, intensive physical therapy camp for children with neuromotor disorders.

SUMMARY OF KEY POINTS

The provision of continuous visual feedback through color-coded, individually calculated heart rate zones was a feasible and effective intervention, encouraging pediatric gait camp participants to exercise at intensities that produced aerobic and functional gains. The use of technology facilitated participation with peers, an outcome equally as important as their endurance and functional improvements.

CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE

Pediatric physical therapists play a crucial role in enhancing the well-being and physical fitness of children with disabilities. Encouraging regular exercise in a social environment fosters enjoyable, inclusive experiences while promoting overall health. It is important for clinicians in various pediatric rehabilitation settings to establish programs that offer such opportunities for children with neuromotor disorders.

Intervenções de esportes modificados para crianças e adolescentes com deficiência: Uma revisão de escopo

Resumo gráfico: Intervenções de esportes modificados para crianças e adolescentes com deficiência: Uma revisão de escopo.

Effect of Cardiovascular Endurance Training on the Exercise Capacity and Endurance in Children With Cerebral Palsy

BACKGROUND

Cerebral palsy (CP) is non-progressive brain damage that occurs before, during, or shortly after birth. CP is associated with poor physical fitness, which is linked to health problems and the development of secondary illnesses like obesity, cardiovascular disease, and diabetes. Compared to healthy peers without CP, children with CP have considerably lower VO2 peaks, which reduces their performance and aerobic capacity.

OBJECTIVE

This study aimed to evaluate changes in exercise capacity and endurance among children with CP, as well as fatigue levels among their parents and caregivers, after participation in cardiovascular endurance training.

METHODOLOGY

This study included 16 children aged 7-12 years with CP (Gross Motor Function Classification System levels I, II, or III). Participants completed a 12-week cardiovascular endurance program consisting of 60-minute sessions three times weekly designed to achieve 64-95% of their heart rate maximum,based on the American College of Sports Medicine guidelines. Pre- and post-intervention measurements were recorded for the following: distance covered in a six-minute walk, maximal oxygen consumption (VO2 max) level, Early Activity Scale for Endurance rating, and Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Fatigue Scale score and PROMIS Parent Proxy Scale and Fatigue Scale scores.  Result: Upon completing the cardiovascular endurance training, the distance covered during a six-minute walk improved by 20.95 points, resting heart rate by 5.19 points, VO2 max by 0.06 points, Early Activity Scale for Endurance by 4.06 points, PROMIS Pediatric Fatigue Scale by 7.29 points, PROMIS Parent Proxy Scale by 6.81 points, and PROMIS Fatigue Scale by 5.07 points. The maximum heart rate also showed a slight improvement of 0.33 points (p<0.01).

CONCLUSION

A structured exercise protocol aimed at improving cardiovascular endurance can benefit children with CP by improving their exercise capacity and endurance, which in turn can help decrease fatigue levels among their parents and caregivers.

Modified sports interventions for children and adolescents with disabilities: A scoping review

AIM

To establish the scope of the literature on modified sports interventions for children and adolescents with disabilities.

METHOD

For this scoping review, articles were screened and the characteristics of studies were extracted. The modified sports interventions were described in terms of their structure, using the items of the Template for Intervention Description and Replication. Components of intervention treatment were described by using the language of the Rehabilitation Treatment Specification System. Results were analysed and validated by a group of professionals, using the Public and Patient Involvement strategy.

RESULTS

Twelve studies were eligible for inclusion, investigating interventions for children with autism spectrum disorder, cerebral palsy, and other conditions. Most studies presented a moderate level of evidence. Active ingredients were repeated sports-related motor training and introduction to the sport through a 'learning by action' mechanism. The intervention target was gross motor skills performance, and intervention aims (indirect outcomes) were physical activity participation and different body functions.

INTERPRETATION

The inclusion of stakeholders in this review helped to validate our findings about the characteristics and structure of modified sports interventions, to identify research gaps, and to provide a step process for clinical implementation. Future investigations are warranted of the effectiveness of modified sports investigations with better quality studies, including participation outcomes and studies with non-ambulant children.

Effects of the EXECP Intervention on Motor Function, Muscle Strength, and Joint Flexibility in Individuals with Cerebral Palsy

PURPOSE

Numerous exercise interventions to enhance motor function in cerebral palsy (CP) have been proposed, with varying degrees of effectiveness. Because motor function requires a combination of muscle strength, joint flexibility, and motor coordination, we designed a supervised multicomponent exercise intervention (EXErcise for Cerebral Palsy, or EXECP) for individuals with CP. Our aim was to evaluate the effects of the EXECP intervention and its retention after it ceased.

METHODS

The EXECP intervention combined strength training for the lower limbs and trunk muscles, passive stretching for the lower limb muscles, and inclined treadmill gait training. Eighteen participants with CP (mean age, 14 yr; 13 were male) were tested twice before the 3-month intervention and twice after the intervention, each test separated by 3 months. Seventeen typically developing age- and sex-matched controls were tested twice. Motor function was assessed with the 6-min walking test (6MWT) and the gross motor function measure dimensions D and E. Passive joint flexibility was measured with goniometry. Isometric and concentric muscle strength were assessed at the knee, ankle, and trunk joints.

RESULTS

The EXECP intervention successfully increased 6MWT ( P < 0.001), gross motor function measure ( P = 0.004), and muscle strength for knee and trunk muscles ( P < 0.05), although no changes were observed for ankle joint muscles. Hip and knee joint flexibility also increased ( P < 0.05). After the retention period, all tested variables except the 6MWT and knee joint flexibility regressed and were not different from the pretests.

CONCLUSIONS

The improvements in strength, flexibility, and possibly motor coordination brought by the EXECP intervention were transferred to significant functional gains. The regression toward baseline after the intervention highlights that training must be a lifelong decision for individuals with CP.

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.

Association of liver function with health-related physical fitness: a cross-sectional study

BACKGROUND

In this study, by analyzing the correlation between various components of health-related physical fitness (HPF) and liver function indicators, the indicators of physical fitness that were highly correlated with liver function and could be monitored at home were screened to prevent more serious liver disease in the future, and to provide experimental basis for prescribing personalized exercise.

METHODS

A total of 330 faculties (female = 198) of a university were recruited. The indicators of HPF and liver function were measured. Spearman correlation analysis, multivariate linear regression, and cross-lagged panel model was used to data statistics.

RESULTS

In males, body fat (BF) was positively correlated with alanine aminotransferase (ALT); vital capacity and the vital capacity index were positively correlated with albumin; and vertical jump was positively correlated with globulin and negatively correlated with the albumin-globulin ratio (P < 0.05). However, there was no significant correlation among all indicators controlled confounding factors. In females, BF was negatively correlated with direct bilirubin; VO2max was positively correlated with indirect bilirubin; and vertical jump was positively correlated with the albumin-globulin ratio and significantly negatively correlated with globulin (P < 0.05). Controlled confounding factors, body fat percentage was positively correlated with globulin (β = 0.174) and negatively correlated with direct bilirubin (β = -0.431), and VO2max was positively correlated with indirect bilirubin (β = 0.238, P < 0.05). Cross-lagged panel analysis showed that BF percentage can negatively predict direct bilirubin levels with great significance (β = -0.055, P < 0.05).

CONCLUSIONS

HPF may play a crucial role in liver function screening, particularly for female faculty members. For males, BF, vertical jump, vital capacity and vital capacity index could be associated with liver function but are susceptible to complex factors such as age, smoking, diabetes, and hypertension. In females, BF percentage is an important predictor of abnormal liver function in addition to VO2max and vertical jump, which are not affected by complex factors.

Evaluation of daily and social participation of children with Cerebral Palsy across different age groups with a focus on the 'F'-words: Function, family, fitness, fun, friends and future

BACKGROUND

The impact of disability differs across cultures. This study aimed to determine the predictors of participation in children with cerebral palsy (CP) in Turkey, based on the six F-words.

METHODS

Cross-sectional study exploring participation profiles of 450 children with CP, aged between 2 and 18 years. Pediatric Evaluation of Disability Inventory (PEDI) evaluated functional skills, and Assessment of Life Habits (LIFE-H) version 3.0 assessed daily and social participation. Hierarchical linear regression models were done to determine the predictors of participation in daily activities (PDA) and social roles (PSR) in three age groups (2-4, 5-13 and 14-18 years) based on the 6 F-words (mobility of PEDI for 'fitness'; four classification systems and self-care of PEDI for 'functioning'; social functions of PEDI for 'friends'; demographic information by parents for 'family'; the recreation of LIFE-H for 'fun'; and different stages of development for 'future').

RESULTS

The most important predictors for total PDA by age group were: self-care (p = 0.012) of PEDI in 2-4 y; self-care (p = 0.001) and mobility (p = 0.005) of PEDI in 5-13 y; GMFCS (p = 0.006) and mobility (p = 0.002) of PEDI in 14-18 y. Significant predictors for PSR differed by age group: self-care (p = 0.001) of PEDI in 2-4 y; self-care (p = 0.023) and mobility (p = 0.006) of PEDI in 5-13 y; and GMFCS (p = 0.004) and MACS (p = 0.003) in 14-18 y.

CONCLUSIONS

Six F-words of function and fitness focussed on self-care in younger children with an increasing emphasis on mobility and ability levels according to age. Therefore, rehabilitation for different aspects of the functional levels is needed to improve participation in life across the six F-words framework; plus take into consideration context, age-differences, family's expectations, life requirements, environmental needs, and cultural differences.

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.

Exercise intensity of active video gaming in cerebral palsy: hip- versus wrist-worn accelerometer data

OBJECTIVE

The aim of this study was to compare exercise intensity of active video games (AVGs) between hip- and wrist-worn accelerometer data in cerebral palsy (CP).

METHODS

Twenty children and adolescents (9.35 ± 3.71 years) with CP performed two exercise sessions, completing a standardized series of AVGs. Exercise intensity was collected, while one accelerometer was fitted to wrist and hip in separate, counterbalanced sessions.

RESULTS

Accelerometer counts per minute and cut-points determined were significantly different between the wrist- and hip-worn outputs (p < .001). Metabolic equivalents (METs) of performing AVGs exceeded the three METs moderate intensity threshold in wrist-worn (3.12 ± 0.86) accelerometer and hip-worn data tend to underestimate intensity (1.16 ± 0.08).

CONCLUSIONS

Previous studies showed METs required to perform AVGs were related to moderate intensity (3-6 METs) in CP with mild deficits. Wrist-worn accelerometer, exceeding 3 METs, seem to have higher accuracy in measuring exercise intensity of AVGs than hip-worn.

Effectiveness of Modified Sports for Children and Adolescents With Cerebral Palsy: A Pragmatic Study Protocol

PURPOSE

Sports Stars is a modified sports intervention that aims to prepare individuals with cerebral palsy for the transition from usual physical therapy care to community sports participation. This is a pragmatic randomized controlled trial protocol of a Brazilian applicability of this intervention.

METHOD

This study will compare the effectiveness of Sports Stars Brazil with standard care. Seventy-six children who walk and adolescents with cerebral palsy will be randomly assigned into an intervention or control group. The intervention group will receive 8 weekly group sessions. Each session will include 1 hour of sports-focused gross motor activity training and teamwork development, centered on popular Brazilian sports. Participation, levels of physical activity and, physical literacy domains will be measured at baseline, postintervention, and at 12-weeks of follow-up.

DISCUSSION

The investigation of Sports Stars Brazil will provide high-quality evidence regarding the effectiveness of modified sports intervention to support participation in sports in this population.

Parent and Adolescent Perspectives on the Impact of COVID on the Care of Seriously Ill Children

CONTEXT

Few studies have explored the impact of the Coronavirus Pandemic (COVID-19) on the care of seriously ill children which may be especially affected due to the child's vulnerability, complexity of care, and high reliance on hospital-based care.

OBJECTIVE

To explore parental and adolescent perspectives on the impact of COVID-19 on care of seriously children.

METHODS

We recruited a convenience sample of families of seriously ill children between September and December 2020. The study involved a semi-structured interview through Zoom followed by an online sociodemographic survey. Interviews were transcribed and coded using the constant comparison method. The sample intended to represent diversity in child age and diagnoses, and family sociodemographic characteristics.

RESULTS

Sixty-four families were approached; 29 enrolled (response rate 45%), including 30 parents and three AYAs. Most parents and AYAs identified as white (62%). Some families reported new financial hardships, with 17.2% having difficulty paying bills after March 2020 compared to 6.9% before. Emerging themes from interviews included additional roles parents managed due to cancelled services or shifting to telehealth, increased isolation, high emotional distress due increased in-home demands, uncertainty, and visitor restrictions in medical facilities, and benefits and challenges to telehealth. One positive outcome was the use of a hybrid care model whereby families choose telehealth appointments and in-person services, when necessary.

CONCLUSION

Families caring for seriously ill children during COVID-19 face increased challenges. Health systems should consider long-term telehealth/in-person hybrid care models that have potential to improve access to and satisfaction with care.

Effect of muscle strength training in children and adolescents with spastic cerebral palsy: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis investigates the effects of strength training program in children and adolescents with cerebral palsy to improve function, activity, and participation.

DATA SOURCES

Five electronic databases (MEDLINE-Pubmed, Cochrane Library, PEDro, CINAHL, and SPORTDiscus) were systematically searched for full-text articles published from inception to 30 June 2021.

REVIEW METHODS

Randomized controlled trials were included, who compared: (i) child population with spastic cerebral palsy population between 0 and 22 years; (ii) studies in which a muscle strength training program was performed and included dosing information; (iii) studies comparing strength training with other physical therapy technique(s) or untreated control group. Studies with similar outcomes were pooled by calculating standardized mean differences. Risk of bias was assessed with Cochrane Collaboration's tool for assessing the risk of bias and PROSPERO's registration number ID: CRD42020193535.

RESULTS

Twenty-seven studies, comprising 847 participants with spastic cerebral palsy. The meta-analyses demonstrated significant standardized mean differences in favor of strength training program compared to other physical therapy technique(s) or untreated control group(s) for muscle strength at the knee flexors, at the knee extensor, at the plantarflexors, maximum resistance, balance, gait speed, GMFM (global, D and E dimension) and spasticity.

CONCLUSION

A strength training program has positive functional and activity effects on muscle strength, balance, gait speed, or gross motor function without increasing spasticity for children and adolescents with cerebral palsy in Gross Motor Function Classification System levels I, II, and III when adequate dosage and specific principles are utilized.

Do physical activity interventions influence subsequent attendance and involvement in physical activities for children with cerebral palsy: a systematic review

PURPOSE

To investigate if children with cerebral palsy have sustained attendance and involvement in physical activities after completing physical activity interventions.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Seven databases were searched for the period 2001-2020 with hand-searching of pertinent reference lists. Criteria for study inclusion were participants aged 0-18 years and ≥50% with cerebral palsy; follow-up ≥1 month beyond completion of the physical activity intervention; and measurement of attendance and/or involvement in any physical activity post-intervention. Study selection, data extraction, and risk of bias assessments (Physiotherapy Evidence Database (PEDro) or tool for non-randomised studies) were completed independently by paired reviewers. Results were compiled by narrative synthesis.

RESULTS

Thirteen studies were included (11 randomised controlled trials (RCTs), two non-randomised case series; intervention sample sizes: 6-34). All study participants had cerebral palsy and were aged 4-16.7 years. PEDro scores for the RCTs ranged from 5 to 10; 10 did not blind one or more therapist, participant, or assessor. Two case series showed high risk of bias. Twelve studies reported on attendance, with positive changes in three studies. At 4-14 weeks post-intervention, two studies demonstrated positive changes were maintained. Four studies included involvement outcomes; one reporting positive changes in physical activity involvement four weeks after intervention completion.

CONCLUSIONS

Physical activity attendance may be influenced by physical activity interventions in the short term, but more robust research designs are required to investigate whether gains can be sustained. Activity involvement, which may influence ongoing participation, is under-researched.Implications for RehabilitationPositive changes in attendance and involvement following physical activity interventions appear short term at best.Physical activity interventions should have longer follow-up periods to determine the effect on sustained physical activity participation.Careful selection and reporting of attendance and involvement outcome measures is required.The optimal physical activity intervention to increase attendance or involvement in physical activities remains uncertain.

Overground Robot-Assisted Gait Training for Pediatric Cerebral Palsy

The untethered exoskeletal robot provides patients with the freest and realistic walking experience by assisting them based on their intended movement. However, few previous studies have reported the effect of robot-assisted gait training (RAGT) using wearable exoskeleton in children with cerebral palsy (CP). This pilot study evaluated the effect of overground RAGT using an untethered torque-assisted exoskeletal wearable robot for children with CP. Three children with bilateral spastic CP were recruited. The robot generates assistive torques according to gait phases automatically detected by force sensors: flexion torque during the swing phase and extension torque during the stance phase at hip and knee joints. The overground RAGT was conducted for 17~20 sessions (60 min per session) in each child. The evaluation was performed without wearing a robot before and after the training to measure (1) the motor functions using the gross motor function measure and the pediatric balance scale and (2) the gait performance using instrumented gait analysis, the 6-min walk test, and oxygen consumption measurement. All three participants showed improvement in gross motor function measure after training. Spatiotemporal parameters of gait analysis improved in participant P1 (9-year-old girl, GMFCS II) and participant P2 (13-year-old boy, GMFCS III). In addition, they walked faster and farther with lower oxygen consumption during the 6-min walk test after the training. Although participant P3 (16-year-old girl, GMFCS IV) needed the continuous help of a therapist for stepping at baseline, she was able to walk with the platform walker independently after the training. Overground RAGT using a torque-assisted exoskeletal wearable robot seems to be promising for improving gross motor function, walking speed, gait endurance, and gait efficiency in children with CP. In addition, it was safe and feasible even for children with severe motor impairment (GMFCS IV).

Exercise intervention protocol in children and young adults with cerebral palsy: the effects of strength, flexibility and gait training on physical performance, neuromuscular mechanisms and cardiometabolic risk factors (EXECP)

Background

Individuals with cerebral palsy (CP) have problems in everyday tasks such as walking and climbing stairs due to a combination of neuromuscular impairments such as spasticity, muscle weakness, reduced joint flexibility and poor coordination. Development of evidence-based interventions are in pivotal role in the development of better targeted rehabilitation of CP, and thus in maintaining their motor function and wellbeing. Our aim is to investigate the efficacy of an individually tailored, multifaceted exercise intervention (EXECP) in children and young adults with CP. EXECP is composed of strength, flexibility and gait training. Furthermore, this study aims to verify the short-term retention of the adaptations three months after the end of the EXECP intervention.

Methods

Twenty-four children and young adults with spastic CP will be recruited to participate in a 9-month research project with a 3-month training intervention, consisting of two to three 90-min sessions per week. In each session, strength training for the lower limbs and trunk muscles, flexibility training for the lower limbs and inclined treadmill gait training will be performed. We will evaluate muscle strength, joint flexibility, neuromuscular and cardiometabolic parameters. A nonconcurrent multiple baseline design with two pre-tests and two post-tests all interspaced by three months is used. In addition to the CP participants, 24 typically developing age and sex-matched participants will perform the two pre-tests (i.e. no intervention) to provide normative data.

Discussion

This study has a comprehensive approach examining longitudinal effects of wide variety of variables ranging from physical activity and gross motor function to sensorimotor functions of the brain and neuromuscular and cardiometabolic parameters, providing novel information about the adaptation mechanisms in cerebral palsy. To the best of our knowledge, this is the first intervention study providing supervised combined strength, flexibility and gait training for young individuals with CP.

Trial registration number

ISRCTN69044459, prospectively registered (21/04/2017).

Cerebral Palsy: Sport and Exercise Considerations

ABSTRACT

Cerebral palsy (CP) is a group of debilitating motor disorders that carries a wide array of clinical presentations ranging from isolated physical or cognitive impairment to global loss of function. Despite the prevalence of CP, recommendations and benefits of physical activity/exercise have historically not been clearly defined. The research on the subject has several limitations, including small sample size, power, standardized measures/outcomes, and poor classification regarding severity of the disease. Nonetheless, the general consensus and new research shows that individuals with CP who participate in sports and exercise regimens, even at reduced frequency and intensity, exhibit improvements in health care benefits, including cardiorespiratory endurance, gross motor function, gait stability, and reduction in pain. These regimens can be prescribed safely and individualized by health care providers to improve morbidity and mortality in patients suffering from CP.

Effect of Long-Term Repeated Interval Rehabilitation on the Gross Motor Function Measure in Children with Cerebral Palsy

BACKGROUND

The efficacy of interventions for cerebral palsy (CP) has been frequently investigated with inconclusive results and motor function measured by the Gross Motor Function Measure (GMFM-66) is common.

OBJECTIVE

In this observational analysis, we quantify the GMFM-66 change scores of the second and third year of a multimodal rehabilitation program (interval rehabilitation including home-based, vibration-assisted training) in children with CP.

METHODS

The study was a retrospective analysis of children with CP (2-13 years) participating for a second (n = 262) and third year (n = 86) in the rehabilitation program with GMFM-66 scores at start (M0), after 4 months (M4) of intensive training, and after 8 months of follow-up (M12). A method was previously developed to differentiate between possible treatment effects and expected development under standard of care for GMFM-66 scores using Cohen's d effect size (ES; size of difference).

RESULTS

After the treatment phase of 4 months (M4) in the second year, 125 of 262 children were responder (ES ≥ 0.2) and 137 children nonresponder (ES < 0.2); mean ES for nonresponder was -0.212 (trivial) and for responder 0.836 (large). After M4 in the third year, 43 children of 86 were responder (ES = 0.881 [large]) and 43 nonresponder (ES = -0.124 [trivial]).

DISCUSSION AND CONCLUSION

Repeated rehabilitation shows a large additional treatment effect to standard of care in 50% of children which is likely due to the intervention, because in the follow-up period (standard of care), no additional treatment effect was observed and the children followed their expected development.

Emerging health challenges for children with physical disabilities and their parents during the COVID-19 pandemic: The ECHO French survey

BACKGROUND

The daily lives of children with physical disabilities and their families have been significantly affected by the COVID-19 pandemic. The children face health risks, especially mental, behavioral, social and physical risks.

OBJECTIVE

This study aimed to identify potential healthcare issues relating to the wellbeing of disabled children, continuity of rehabilitation and medical care, and parental concerns during the COVID-19 lockdown.

METHODS

The Enfant Confinement Handicap besOins (ECHO [child lockdown disability needs]) national survey was developed by a multidisciplinary group and disseminated in France from April 6, 2020 via email and social networks. This online survey was addressed to the parents of children with physical disabilities aged 0 to 18 years. It explored the experiences of children and their families during the lockdown. Information regarding children's wellbeing, rehabilitation and family organization was collected. The first 1000 eligible surveys were analyzed.

RESULTS

The children (mean [SD] age 9.5 [4.8] years) mostly had cerebral palsy (42%) or neuromuscular diseases (11%). The lockdown had negative effects on morale (44% of children), behaviour (55% of children) and social interactions (55% no contact with other children). Overall, 44% of children stopped physical activities; 76% were educated at home; 22% maintained medical follow-up, and 48% and 27% continued physiotherapy and occupational therapy respectively. For more than 60% of children, parents performed the therapy. The main parental concern was rehabilitation (72%) and their main difficulty was the mental load (50%); parents complained of lack of help and support (60%).

CONCLUSIONS

This study highlighted substantial effects on the health of children with physical disabilities and loss of opportunity, with a massive interruption of medical follow-up and rehabilitation, during the lockdown. Regular assessment of the health benefit/risk is essential to support families and ensure continuity of care during a pandemic.

Fatigue in Children and Young Adults With Physical Disabilities: Relation With Energy Demands of Walking and Physical Fitness

PURPOSE

To examine whether general fatigue and fatigue during or after walking are related to energy demands during walking and physical fitness in children and young adults with physical disabilities.

METHODS

Sixty-eight individuals with physical disabilities participated. General fatigue (Checklist Individual Strength [CIS8R] questionnaire), walking-induced fatigue (OMNI [OMNIwalk] scale after walking for 6 min), gross and net energy costs (ECs) of walking, physical strain of walking, and aerobic and anaerobic fitness were measured.

RESULTS

Regression analyses showed no relations with the CIS8R. For all participants, a higher net EC was weakly related to an increased OMNIwalk. For teenagers only, low anaerobic fitness and high physical strain of walking values were moderately related to high OMNIwalk scores.

CONCLUSION

Low anaerobic fitness and high physical strain values partly explain fatigue after walking in teenagers with cerebral palsy, but not in younger children. General fatigue was not explained by low fitness levels or high energy demands of walking.

Pilot Evaluation of a School-Based Programme Focused on Activity, Fitness, and Function among Children with Cerebral Palsy at GMFCS Level IV: Single-Subject Research Design

Purpose: Children with cerebral palsy (CP) who function at Gross Motor Function Classification System (GMFCS) Level IV have difficulty achieving sufficient levels of physical activity to promote fitness. The purpose of this pilot evaluation was to investigate the practicability and impact of a school-based supported physical activity programme, using adaptive bicycles, on cardiorespiratory fitness and gross motor function among children with CP at GMFCS Level IV. Method: We used a single-subject, A-B-A-B research design replicated across three participants aged 8-14 years with CP at GMFCS Level IV who attended three different schools. Cardiorespiratory fitness was assessed weekly during all study phases using the energy expenditure index (EEI). Gross motor function was assessed using the Gross Motor Function Measure-66 (GMFM-66) and goal attainment scaling (GAS). During the intervention phases, an adaptive bicycle-riding programme was carried out daily at school for up to 30 minutes. Results: One participant demonstrated significant improvement on the EEI. All participants demonstrated improvement in gross motor function as determined by the GMFM-66 and GAS. Insights were garnered pertaining to the design for large-scale future studies. Conclusions: This pilot evaluation supports further investigation of school-based adaptive bicycle-riding programmes for children who have CP at GMFCS Level IV.

Heart Rate Variability in Children and Adolescents with Cerebral Palsy-A Systematic Literature Review

Cardiac autonomic dysfunction has been reported in patients with cerebral palsy (CP). The aim of this study was to assess the existing literature on heart rate variability (HRV) in pediatric patients with CP and a special attention was paid to the compliance of the studies with the current HRV assessment and interpretation guidelines. A systematic review was performed in PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases searched for English language publications from 1996 to 2019 using Medical Subject Headings (MeSH) terms “heart rate variability” and “cerebral palsy” in conjunction with additional inclusion criteria: studies limited to humans in the age range of 0–18 years and empirical investigations. Out of 47 studies, 12 were included in the review. Pediatric patients with CP presented a significantly higher resting heart rate and reduced HRV, different autonomic responses to movement stimuli compared to children with normal development, but also reduced HRV parameters in the children dependent on adult assistance for mobility compared to those generally independent. None of the included studies contained the necessary details concerning RR intervals acquisition and HRV measurements as recommended by the guidelines. Authors of HRV studies should follow the methodological guidelines and recommendations on HRV measurement, because such an approach may allow a direct comparison of their results.

Effectiveness of treadmill training on gait function in children with cerebral palsy: meta-analysis

The purpose of this review was to analysis the effects of treadmill training on gait function in children with cerebral palsy. Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science were searched. Investigating the effects of treadmill training on gait endurance, gait speed, limb support time, cadence, and step length in children with cerebral palsy. Similar outcomes were pooled by calculating the standardized mean difference. Of the eight studies, 179 participants were included. The average PEDro score was 6.25/10. The results of the sensitivity test for bias evaluation using the duval and tweedie's trim and fill method showed low publication bias. The test regarding the effect of treadmill training on overall gait function yielded a moderate effect size of 0.53, which was a statistically significant effect as its confidence interval did not include. The overall effect size of gait endurance was 0.85. The overall effect size of gait speed and limb support time were 0.52 and 0.73. The overall effect size of cadence and step length were 0.14 and 0.21, indicating a nonsignificant improvement. These findings suggested that treadmill training on cerebral palsy was effective for gait endurance, gait speed and limb support time than cadence and step length.

Physical activity in non-ambulatory toddlers with cerebral palsy

BACKGROUND

Children with cerebral palsy are less likely to be physically active than their peers, however there is limited evidence regarding self-initiated physical activity in toddlers who are not able, or who may never be able, to walk.

AIMS

The aim of this study was to measure self-initiated physical activity and its relationship to gross motor function and participation in non-ambulatory toddlers with cerebral palsy.

METHODS AND PROCEDURES

Participants were between the ages of 1-3 years. Physical activity during independent floor-play at home was recorded using a wearable tri-axial accelerometer worn on the child's thigh. The Gross Motor Function Measure-66 and the Child Engagement in Daily Life, a parent-reported questionnaire of participation, were administered.

OUTCOMES AND RESULTS

Data were analyzed from the twenty participants who recorded at least 90 min of floor-play (mean: 229 min), resulting in 4598 total floor-play minutes. The relationship between physical activity and gross motor function was not statistically significant (r = 0.20; p = 0.39), nor were the relationships between physical activity and participation (r = 0.05-0.09; p = 0.71-0.84).

CONCLUSIONS AND IMPLICATIONS

The results suggest physical activity during floor-play is not related to gross motor function or participation in non-ambulatory toddlers with cerebral palsy. Clinicians and researchers should independently measure physical activity, gross motor function, and participation.

Effect of assisted walking-movement in patients with genetic and acquired neuromuscular disorders with the motorised Innowalk device: an international case study meta-analysis

People with physical disabilities (PD) suffer from consequences due to lack of physical activity and consequently, are at increased risk of chronic diseases. We aimed to evaluate the ability of a motorised assistive device for dynamic standing with weight-bearing in addition to standard state-of-the-art therapy to improve clinical outcome in a meta-analysis of available studies. A total of 11 studies were identified from different European countries analysing the effect of the dynamic device Innowalk. Raw data of nine studies were pooled including a total of 31 patients observed between 2009 and 2017. Standardised questionnaires and physical outcomes were examined in this exploratory meta-analysis. We recorded patients' characteristics, duration, intensity, and location of usage as well as general clinical outcomes and improvement of passive range of motion (PROM). The analysed population consisted in 90% cases of patients younger than 18 years of age. Patients were severely disabled individuals (aged 8 (6-10) years; 58% male; 67% non-ambulatory, 86% cerebral palsy). A total of 94% used the Innowalk in a home-based or day-care setting. For nearly all individuals (94%), improvements were recorded for: walking or weight-bearing transfer (n = 13), control/strength of the trunk or head (n = 6), joint mobility (n = 14), sleep (n = 4 out of 6/67%), or muscle strength (n = 17), vital functions (n = 16), bowel function (n = 10), attention/orientation (n = 2). PROM of the hip (flexion, abduction, and adduction) significantly (p < 0.001 for multiple comparisons) increased after 1 month (p < 0.05 flexion, adduction) and further after 5 months (p < 0.05 each) in contrast (p < 0.05 each) to a control group with state-of-the-art therapy. Similarly, PROM showed a trend towards improvement in dorsal extension of the ankle (p = 0.07). In summary, this is the first report of a novel device with additional benefit to standard therapy for severe PD. These intriguing results warrant the planned prospective randomised controlled trial to prove the concept and mechanism of action of this device.

Usefulness of Cerebral Palsy Curves in Mexican Patients: A Cross-Sectional Study

Cerebral palsy describes a group of movement and posture disorders that cause activity limitation, and are attributable to nonprogressive disorders that occur in the fetal or infant brain. The growth of these children should not be compared with those of the healthy population. We studied 452 children, 186 female and 266 male. We compared the results in 2 growth charts, Centers for Disease Control and Prevention (CDC) and cerebral palsy, and the results were statistically significant ( P = .00001). With the CDC charts, 40.71% of the patients were below the 5th percentile and only 5.5% of them when we used the charts for cerebral palsy patients. The Mexican cerebral palsy patients were similar to US cerebral palsy patients when we compared height ( P = .4075) and body mass index (BMI) ( P = .4075). Only the weight was found to be different ( P = .00001). All the correlation indexes were negative: Eating and Drinking Ability Classification System (EDACS)-BMI (rho = -0.4798) ( P = .00001), Communication Function Classification System (CFCS)-BMI (rho = -0.4353) ( P = .00001), and Gross Motor Function Classification System (GMFCS)-BMI (rho = -0.3584) ( P = .00001). The growth charts of the healthy pediatric population tend to overestimate the underweight. We propose to use cerebral palsy charts as a reference in our patients. It is possible to determine a functional profile (communication, gross motor function and safety, and feed efficiency) for the cerebral palsy population based on their BMI.

Children and Teens in Charge of their Health (CATCH): A protocol for a feasibility randomised controlled trial of solution-focused coaching to foster healthy lifestyles in childhood disability

INTRODUCTION

Children with physical disabilities are rarely included in interventions to promote healthy lifestyles, despite being at higher risk for suboptimal dietary and physical activity behaviours. The Children and Teens in Charge of their Health study explores the feasibility and acceptability of conducting a randomised controlled trial (RCT) of a strengths-based, solution-focused coaching intervention for improving and sustaining physical activity and healthy dietary habits in children and young people with physical disabilities.

METHODS AND ANALYSIS

Thirty children aged 10-18 years with a diagnosis of spina bifida or cerebral palsy who are able to set healthy lifestyle goals will be recruited from two children's rehabilitation hospitals in Ontario, Canada. Participants will be enrolled in the study for twelve months. All participants will receive standard care and printed information about healthy lifestyles. Of the 30 participants, 15 will be randomised to receive a coaching intervention for the first 6 months. Health indicators and psychosocial outcomes will be assessed by blinded assessors four times: at the start of the trial, immediately postintervention (6 months after randomisation), and at 3 and 6 months postintervention (9 and 12 months after randomisation, respectively). Predefined success criteria will be used to assess the feasibility of trial processes such as recruitment, attrition, stratification and intervention fidelity. Acceptability and perceived impact of the intervention will be explored qualitatively.

ETHICS AND DISSEMINATION

The study has been approved by Holland Bloorview Kids Rehabilitation Hospital's Research Ethics Board (Ref: 17-752). A knowledge translation planning template will be used to ensure our findings have maximum reach.

TRIAL REGISTRATION NUMBER

NCT03523806.

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

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

Walking and Fitness Improvements in a Child With Diplegic Cerebral Palsy Following Motor-Assisted Elliptical Intervention

PURPOSE

To quantify effects of motor-assisted elliptical (Intelligently Controlled Assistive Rehabilitation Elliptical [ICARE]) training on walking and fitness of a child with cerebral palsy (CP).

KEY POINTS

A 12-year-old boy with walking limitations due to spastic diplegic CP (Gross Motor Function Classification System II) participated in 24 sessions of primarily moderate- to vigorous-intensity ICARE exercise. Fitness improvements were evidenced clinically across sessions by the child's capacity to train for longer periods, at faster speeds, and while overriding motor's assistance. Postintervention, the child walked faster with greater stability and endurance and more rapidly completed the modified Time Up and Go test.

CONCLUSION

The child's fitness and gait improved following engagement in a moderate- to vigorous-intensity gait-like exercise intervention.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Integration of moderate- to vigorous-intensity motor-assisted elliptical training can promote simultaneous gains in fitness and function for children with CP.

The paediatric version of Wisconsin gait scale, adaptation for children with hemiplegic cerebral palsy: a prospective observational study

Background

In clinical practice there is a need for a specific scale enabling detailed and multifactorial assessment of gait in children with spastic hemiplegic cerebral palsy. The practical value of the present study is linked with the attempts to find a new, affordable, easy-to-use tool for gait assessment in children with spastic hemiplegic cerebral palsy. The objective of the study is to evaluate the Wisconsin Gait Scale (WGS) in terms of its inter- and intra-rater reliability in observational assessment of walking in children with hemiplegic cerebral palsy.

Methods

The study was conducted in a group of 34 patients with hemiplegic cerebral palsy. At the first stage, the original version of the ordinal WGS was used. The WGS, consisting of four subscales, evaluates fourteen gait parameters which can be observed during consecutive gait phases. At the second stage, a modification was introduced in the kinematics description of the knee and weight shift, in relation to the original scale. The same video recordings were rescored using the new, paediatric version of the WGS. Three independent examiners performed the assessment twice. Inter and intra-observer reliability of the modified WGS were determined.

Results

The findings show very high inter- and intra-observer reliability of the modified WGS. This was reflected by a lack of systematically oriented differences between the repeated measurements, very high value of Spearman’s rank correlation coefficient 0.9 ≤ |R| < 1, very high value of ICC > 0.9, and low value of CV < 2.5% for the specific physical therapists.

Conclusions

The new, ordinal, paediatric version of WGS, proposed by the authors, seems to be useful as an additional tool that can be used in qualitative observational gait assessment of children with spastic hemiplegic cerebral palsy. Practical dimension of the study lies in the fact that it proposes a simple, easy-to-use tool for a global gait assessment in children with spastic hemiplegic cerebral palsy. However, further research is needed to validate the modified WGS by comparing it to other observational scales and objective 3-dimensional spatiotemporal and kinematic gait parameters.

Trial registration

anzctr.org.au, ID: ACTRN12617000436370. Registered 24 March 2017.

Active exercise interventions improve gross motor function of ambulant/semi-ambulant children with cerebral palsy: a systematic review

PURPOSE

Evaluate effectiveness of active exercise interventions for improving gross motor activity/participation of school-aged, ambulant/semi-ambulant children with cerebral palsy (CP).

METHOD

A systematic review was conducted following PRISMA guidelines. Five databases were searched for papers including school-aged children with CP, participating in active, exercise interventions with gross motor outcomes measured at the Activity/Participation level. Interventions with previous systematic reviews were excluded (e.g. hippotherapy). Evidence Level and conduct were examined by two raters.

RESULTS

Seven interventions (34 studies) met criteria. All studies reported on gross motor function, however, a limited number investigated participation outcomes. Strong positive evidence was available for Gross Motor Activity Training (n= 6, Evidence Level II-IV), and Gross Motor Activity Training with progressive resistance exercise plus additional physiotherapy (n = 3, all Evidence Level II). Moderate positive evidence exists for Gross Motor Activity Training plus additional physiotherapy (n = 2, all Evidence Level II) and Physical Fitness Training (n = 4, Evidence Level II-V). Weak positive evidence was available for Modified Sport (n = 3, Evidence Level IV-V) and Non-Immersive Virtual Reality (n = 12, Evidence Level II-V). There was strong evidence against Gross Motor Activity Training plus progressive resistance exercise without additional physiotherapy (n = 4, all Evidence Level II).

INTERPRETATION

Active, performance-focused exercise with variable practice opportunities improves gross motor function in ambulant/semi-ambulant children with CP. Implications for rehabilitation Active exercise interventions improve gross motor function of ambulant/semi-ambulant children with cerebral palsy. Gross Motor Activity Training is the most common and effective intervention. Practice variability is essential to improve gross motor function. Participation was rarely measured and requires further research, particularly in interventions that embed real-world participation opportunities like Modified Sport.

Body mass index and fitness in high-functioning children and adolescents with cerebral palsy: What happened over a decade?

BACKGROUND

In recent decades, improving fitness has become an important goal in rehabilitation medicine in children and adolescents with cerebral palsy (CP).

AIMS

To compare body mass index (BMI), performance-related fitness, and cardiorespiratory fitness of children with CP measured in 2014 with a comparable sample from 2004.

METHODS AND PROCEDURES

In total, 25 high-functioning children with CP (i.e., GMFCS I-II) measured in 2004 (13 boys; mean age 13.2 (2.6) years) were matched to 25 children measured in 2014. Outcomes included body mass and BMI, muscle power sprint test (MPST), 10×5m sprint test, and a shuttle run test (SRT). Data of 15 participants from 2004 (10 boys; mean age 12.6 (2.5) years) were matched and analysed for VO₂peak.

OUTCOMES AND RESULTS

Body mass and BMI were higher (both: p<0.05) in the 2014 cohort compared to the 2004 cohort. Further, performance-related fitness was better for the 2014 cohort on the MPST (p=0.004), the 10×5m sprint test (p=0.001), and the SRT (p<0.001). However, there were no differences for VO₂peak.

CONCLUSIONS AND IMPLICATIONS

In high-funcitoning children with CP, there are positive ecological time trends in performance-related fitness, but not in VO₂peak between 2004 and 2014. The substantial higher body mass and BMI is alarming and requires further investigation.

Patterns of sedentary time and ambulatory physical activity in a Danish population of girls and women with Rett syndrome

BACKGROUND

Rett syndrome (RTT) is a rare neurodevelopmental disorder leading to multiple disabilities and high dependency on caregivers. This study aimed to: (1) describe the patterns of sedentary time and daily steps and (2) identify the association of individual and environmental characteristics with sedentary time.

METHODS

All Danish females with RTT older than 5 years of age and with a MECP2 mutation were invited to participate. The activPAL and StepWatch Activity Monitor (SAM) were worn by participants for at least four days. Sedentary time and step counts were plotted by time to examine daily activity patterns. Associations between sedentary time and individual and environmental covariates were assessed with linear regression models.

RESULTS

The median (interquartile range) age of participants was 22.0 (14.3-36.5) years. On average 83.3% (standard deviation 13.9%) of waking hours were spent in sedentary behaviours (n = 48) and the median (interquartile range) daily step count was 5128 (2829-7704) (n = 28). Females older than 33.5 years, and those unable to walk independently were more sedentary.

CONCLUSIONS

This study demonstrated high levels of sedentary time and low daily step counts in a Danish population of females with RTT. Advancing age and lower walking skills were associated with higher levels of sedentary time. Implications for Rehabilitation Sedentary lifestyles in individuals with disabilities have a negative impact on health and quality of life. High levels of sedentary time and low daily step counts were demonstrated in a Danish population of females with Rett syndrome. Advancing age and inability to walk independently were strongly associated with higher levels of sedentary time in females with Rett syndrome. Understanding patterns of sedentary behaviour and physical activity can aid health care professionals in developing health-promoting physical activity interventions.

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

BACKGROUND AND PURPOSE

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

SUMMARY OF KEY POINTS

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

RECOMMENDATIONS FOR CLINICAL PRACTICE

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

A randomized controlled trial of web-based training to increase activity in children with cerebral palsy

AIM

To determine the efficacy of web-based training on activity capacity and performance in children with unilateral cerebral palsy (CP).

METHOD

In a matched-pairs randomized waitlist controlled trial, independently ambulant children and adolescents with unilateral CP were allocated to receive 30 minutes of training (intervention) 6 days per week, or usual care (waitlist control) for 20 weeks. Activity capacity was assessed using maximal repetitions of functional strength tasks and 6-minute walk test (6MWT); performance using 4-day ActiGraph GT3X+ accelerometer records at baseline and 20 weeks. Data were analysed by intention to treat comparing between groups using hierarchical linear modelling.

RESULTS

Participants were n=101, 52 males, mean age 11 years 3 months (SD 2y 4mo). Intervention participants completed a mean 32.4 hours (SD 17.2) of training, associated with significant improvements in functional strength (mean difference 19.3 repetitions; 95% confidence interval [CI] 10.8-27.7; p<0.001) and 6MWT distance (mean difference 38.9m; 95% CI 12.3-51.9; p<0.001) compared with the control group at 20 weeks, although not activity performance (p>0.05).

INTERPRETATION

Training was effective at increasing functional strength and walking endurance in independently ambulant children with unilateral CP. This did not translate into improvements in activity performance.

Hand-Held Dynamometry Isometric Torque Reference Values for Children and Adolescents

PURPOSE

To establish hand-held dynamometry (HHD) maximal isometric muscle torque (MIT) reference values for children and adolescents who are developing typically.

METHODS

The MIT of 10 upper and lower limb muscle groups was assessed in 351 Caucasian youth (4 years 2 months to 17 years) using a standardized HHD protocol, previously shown to be feasible, valid, and reliable.

RESULTS

The mean MIT and 95% confidence interval of the mean for all muscle groups, for each of the 14 age groups (1 year age span for each group), and for each sex, were reported in both absolute (Nm) and normalized (Nm/kg) values.

CONCLUSION

These HHD reference values may be helpful in the identification of muscle strength impairments in several pediatric populations, especially when bilateral impairments are present.