Sedentary and Active Time in Toddlers with and without Cerebral Palsy

Exploring Factors Associated With Accelerometer Validity Among Ethnically Diverse Toddlers

PURPOSE

Studying physical activity in toddlers using accelerometers is challenging due to noncompliance with wear time (WT) and activity log (AL) instructions. The aims of this study are to examine relationships between WT and AL completion and (1) demographic and socioeconomic variables, (2) parenting style, and (3) whether sedentary time differs by AL completion.

METHODS

Secondary analysis was performed using baseline data from a community wellness program randomized controlled trial for parents with toddlers (12-35 mo). Parents had toddlers wear ActiGraph wGT3x accelerometers and completed ALs. Valid days included ≥600-minute WT. Analysis of variance and chi-square analyses were used.

RESULTS

The sample (n = 50) comprised racial and ethnically diverse toddlers (mean age = 27 mo, 58% male) and parents (mean age = 31.7 y, 84% female). Twenty-eight families (56%) returned valid accelerometer data with ALs. Participants in relationships were more likely to complete ALs (P < .05). Toddler sedentary time did not differ between those with ALs and those without.

CONCLUSIONS

We found varied compliance with WT instructions and AL completion. Returned AL quality was poor, presenting challenges in correctly characterizing low-activity counts to improve internal validity of WT and physical activity measures. Support from marital partners may be important for adherence to study protocols.

A pilot randomised controlled trial of ride-on cars and postural combinations of standing and sitting for mobility and social function in toddlers with motor delays

PURPOSE

Locomotor experiences in upright postures are essential for developing toddlers' mobility and social functions. This pilot randomised controlled trial aimed to examine the effectiveness of using a modified ride-on car (ROC) with postural combinations of standing and sitting on mobility and social function in toddlers with motor delays.

MATERIALS AND METHODS

Nineteen participants aged 1-3 years with mild, moderate or severe motor delays were randomly assigned to four ROC groups. The ROC groups had different combinations of standing and sitting, namely standing for 70 min (ROC-Stand70, five participants), standing for 45 min (ROC-Stand45, four participants), standing for 25 min (ROC-Stand25, five participants) and sitting for 70 min (ROC-Sit70, five participants). All participants participated in 2-h sessions twice a week for 12 weeks. The Pediatric Evaluation of Disability Inventory, Goal Attainment Scaling and Bayley-III tests were administered before and after the intervention, and after 12 weeks of follow-up. A mixed-model analysis of variance was used to compare inter- and intra-group differences. This trial was registered at ClinicalTrials.gov (NCT03707405).

RESULTS

All groups showed significantly improved mobility, social function and goal achievement at the post-test (p < .001). However, no significant changes were observed in Bayley scores.

CONCLUSIONS

Combining physical and social environmental modifications with active exploration is crucial for early power mobility training in toddlers with motor delays. To enhance the robustness and generalisability of our findings, future studies should include larger sample sizes, consider variations in motor delays, and measure energy expenditure during the intervention.Implications for rehabilitationProviding active exploratory experience using ride-on cars (ROCs) with various postural combinations can improve a child's mobility.The ROC training with various postural combinations can improve social function, and the degree of improvement may depend on the severity of motor delays.Setting goals with caregivers and incorporating their roles in the training process can empower them to interact with children more frequently and actively.

andomised to early neuroprotection and neurorehabilitation: protocol for a follow-up study of participants from four randomised clinical trials

INTRODUCTION

School readiness includes cognitive, socio-emotional, language and physical growth and development domains which share strong associations with life-course opportunities. Children with cerebral palsy (CP) are at increased risk of poor school readiness compared with their typically developing peers. Recently, earlier diagnosis of CP has allowed interventions to commence sooner, harnessing neuroplasticity. First, we hypothesise that early referral to intervention for children at-risk of CP will lead to improved school readiness at 4-6 years relative to placebo or care as usual. Second, we hypothesise that receipt of early diagnosis and early intervention will lead to cost-savings in the form of reduced healthcare utilisation.

METHODS AND ANALYSIS

Infants identified as at-risk of CP ≤6 months corrected age (n=425) recruited to four randomised trials of neuroprotectants (n=1), early neurorehabilitation (n=2) or early parenting support (n=1) will be re-recruited to one overarching follow-up study at age 4-6 years 3 months. A comprehensive battery of standardised assessments and questionnaires will be administered to assess all domains of school readiness and associated risk factors. Participants will be compared with a historical control group of children (n=245) who were diagnosed with CP in their second year of life. Mixed-effects regression models will be used to compare school readiness outcomes between those referred for early intervention versus placebo/care-as-usual. We will also compare health-resource use associated with early diagnosis and intervention versus later diagnosis and intervention.

ETHICS AND DISSEMINATION

The Children's Health Queensland Hospital and Health Service, The University of Queensland, University of Sydney, Monash University and Curtin University Human Research Ethics Committees have approved this study. Informed consent will be sought from the parent or legal guardian of every child invited to participate. Results will be disseminated in peer-reviewed journals, scientific conferences and professional organisations, and to people with lived experience of CP and their families.

TRIAL REGISTRATION NUMBER

ACTRN12621001253897.

Validity and reliability of the turkish version of the early activity scale for endurance in preschool children with cerebral palsy

This study presented the Turkish translation of the Early Activity Scale for Endurance (T-EASE) which was developed to evaluate the endurance for physical activity of preschool children with Cerebral Palsy (CP), and its validity and reliability. Fifty-five children with CP aged between 2 and 5 years were included in the study. The Gross Motor Function Classification Scale (GMFCS) and Pediatric Outcomes Data Collection Instrument (PODCI) were used to determine motor function levels and quality of life of the study population. The T-EASE had good test-retest reliability (ICC = 0.996), internal consistency (α = 0.903), higher construct validity approved by confirmatory factor analysis, and criterion validity supported by the weak-to-strong correlations between T-EASE and GMFCS, and PODCI. The T-EASE scores were significantly different between GMFCS levels (p < .05). The T-EASE was found to be valid and reliable to determine the endurance for physical activity of Turkish pre-school children with CP with the sensitivity to changes in motor function levels.

Growth in infants, children and adolescents with unilateral and bilateral cerebral palsy

To compare growth patterns during infancy, childhood and adolescence in children with unilateral and bilateral cerebral palsy (CP) phenotype and to assess the association with gross motor impairment, dysphagia and gestational age. We retrospectively studied 389 children with CP from a single center population in Munich, Germany. 1536 measurements of height and weight were tabulated and z-scored from 6 to 180 months of age. Generalized linear mixed model were used to examine the association between growth, GMFCS, dysphagia and gestational age by CP phenotype. Children with unilateral CP tend to grow similarly to their typically developed peers. In the main effect model, bilateral CP phenotype was significantly associated with decreased mean z-scores for height (β [95% CI] - 0.953 [- 1.145, - 0.761], p < 0.001), weight (- 0.999 [- 1.176, - 0.807], p < 0.001) and BMI (β [95% CI] - 0.437 [- 0.799, - 0.075]), compared with unilateral CP phenotype. This association remained significant in the interaction models. The height-for-age z-scores, weight-for-age decreased z-scores and BMI-for-age z-scores of children with bilateral CP and GMFCS III-V or dysphagia decreased more significantly than those of children with unilateral CP. Preterm birth was not significantly associated with decreased growth in height, weight and BMI. Reduced growth in children with bilateral CP was strongly associated with moderate to severe impairment in gross motor function (GMFCS III-V) and dysphagia.

Glycine receptor subunit-ß -deficiency in a mouse model of spasticity results in attenuated physical performance, growth and muscle strength

Spasticity is the most common neurological disorder associated with increased muscle contraction causing impaired movement and gait. The aim of this study was to characterize the physical performance, skeletal muscle function, and phenotype of mice with a hereditary spastic mutation (B6.Cg-Glrb^spa/J). Motor function, gait, and physical activity of juvenile and adult spastic mice and the morphological, histological, and mechanical characteristics of their soleus and gastrocnemius medialis muscles were compared with those of their wild-type (WT) littermates. Spastic mice showed attenuated growth, impaired motor function, and low physical activity. Gait of spastic mice was characterized by a typical hopping pattern. Spastic mice showed lower muscle forces, which were related to the smaller physiological cross-sectional area of spastic muscles. The muscle-tendon complex length-force relationship of adult gastrocnemius medialis was shifted toward shorter lengths, which was explained by attenuated longitudinal tibia growth. Spastic gastrocnemius medialis was more fatigue resistant than WT gastrocnemius medialis. This was largely explained by a higher mitochondrial content in muscle fibers and relatively higher percentage of slow-type muscle fibers. Muscles of juvenile spastic mice showed similar differences compared with WT juvenile mice, but these were less pronounced than between adult mice. This study shows that in spastic mice, disturbed motor function and gait is likely to be the result of hyperactivity of skeletal muscle and impaired skeletal muscle growth, which progress with age.

Sedentary behaviour in non-ambulant children and young people with physical disabilities: a systematic search and review protocol

INTRODUCTION

Non-ambulant children and young people with physical disabilities are at high risk of experiencing negative health outcomes associated with sedentary time. A previous scoping review summarising evidence relating to sedentary behaviours of children with physical disabilities identified the need for validated methods of measuring physical activity of children who use wheelchairs and evaluation of interventions to reduce sedentary time. The scoping review did not assess the quality of evidence relating to this topic, therefore its validity remains unclear. No reviews focussing on non-ambulant children and young people up to the age of 25 years have been undertaken.The objectives of this systematic search and review are to:Identify all peer-reviewed articles relating to sedentary behaviour of non-ambulant children and young people.Categorise the articles according to study design and four subquestions relating to (i) measurement, (ii) patterns, (iii) associated risks and (iv) interventions to reduce sedentary time or behaviour.Critically appraise quality of the articles using established critical appraisal tools.Summarise the evidence for each subquestion. Describe its cumulative strength and identify knowledge gaps.

METHODS AND ANALYSIS

This protocol was developed using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. The research questions, inclusion/exclusion criteria and search terms have been developed a priori using the 'Population, Concept and Context' framework. Online databases will be systematically searched to identify peer-reviewed articles published between 1996 and 2021. Two reviewers will screen, categorise and critically appraise the articles. Data extraction and analysis will be verified by the second reviewer.Results will be reported as a best evidence synthesis, with reference to the PRISMA checklist.

ETHICS AND DISSEMINATION

Ethical approval is not required. The review will be submitted to an appropriate peer-reviewed journal.

REGISTRATION

The review is registered on the Open Science Framework database. DOI: https://doi.org/10.17605/OSF.IO/SQXJB. Any protocol amendments will be recorded in the Open Science Framework database.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Is Physical Activity-Related Self-Efficacy Associated with Moderate to Vigorous Physical Activity and Sedentary Behaviour among Ambulatory Children with Cerebral Palsy?

Purpose: To determine how physical activity-related self-efficacy is associated with physical activity and sedentary behaviour time among ambulatory children with cerebral palsy (CP). Method: Children with CP, Gross Motor Function Classification System (GMFCS) Levels I-III ( N = 26; aged 9–18 y), completed the task self-efficacy component of a self-efficacy scale and wore Actigraph GT3X+ accelerometers for 5 days. Correlations (Pearson and Spearman’s rank-order; a = 0.050) were conducted to evaluate the relationships among age, GMFCS level, self-efficacy, and both daily moderate-to-vigorous physical activity (MVPA) and sedentary time. Linear regression models were used to determine the relationships among the independent variables and MVPA and sedentary time. Results: Self-efficacy was positively associated with MVPA time ( r = 0.428, p = 0.015) and negatively correlated with sedentary time ( r = –0.332, p = 0.049). In our linear regression models, gross motor function (β = –0.462, p = 0.006), age (β = –0.344, p = 0.033), and self-efficacy (β = 0.281, p = 0.080) were associated with MVPA time ( R2 = 0.508), while GMFCS level (β = 0.439, p = 0.003) and age (β = 0.605, p < 0.001) were associated with sedentary time ( R2 = 0.584). Conclusions: This research suggests that self-efficacy, age, and gross motor function are associated with MVPA in children with CP. Additional research is needed to confirm these findings and further explore the influence of self-efficacy on sedentary behaviour.

Exploring participation in family and recreational activities among children with cerebral palsy during early childhood: how does it relate to motor function and parental empowerment?

PURPOSE

To explore participation in real-life activities during early childhood, compare children's participation based on motor function and investigate relationships between participation and parental empowerment.

METHODS

Data derived from the Cerebral Palsy Follow-up Program (CPOP) in Norway and the research registry Habilitation Trajectories, Interventions, and Services for Young Children with CP (CPHAB). Fifty-six children (12-56 months, GMFCS levels I-IV, MACS levels I-V) and their families were included. Frequency and enjoyment of participation were assessed by the Child Engagement in Daily Life Questionnaire and parental empowerment in family and service situations by the Family Empowerment Scale at least twice during the preschool years. Differences between groups based on motor function were explored by the Kruskal-Wallis tests. A linear mixed model was conducted to explore relationships between child participation and parental empowerment.

RESULTS

Similarities and differences in participation between children at different motor function levels varied between the activities explored. Fluctuations in frequency and stable enjoyment scores over time were most common. A statistically significant relationship was revealed between child participation and parental empowerment in family situations, but not in service situations.

CONCLUSIONS

Child participation appears as context-dependent and complexly influenced by both motor function and parental empowerment. This supports a focus on transactional processes when exploring and promoting child participation.Implications for RehabilitationFamily and recreational activities represent real-life contexts providing opportunities for interactions and experiences supporting development and learning.Children with CP appreciate a wide range of activities in the home and community, which emphasizes the importance of providing opportunities for such participation in order to fulfill their desires and interests.Child participation appears as complexly influenced by the unique activity setting, motor function and characteristics of the family environment, requiring attention to transactional processes when aiming to explore and promote participation.

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.

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.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

WHAT THIS PAPER ADDS

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

Longitudinal physical activity and sedentary behaviour in preschool-aged children with cerebral palsy across all functional levels

AIM

To investigate longitudinal changes of habitual physical activity (HPA) and sedentary time in children with cerebral palsy (CP) aged 1 year 6 months to 5 years across all functional abilities.

METHOD

At study entry, 95 children (62 males, 33 females) were classified using the Gross Motor Function Classification System (GMFCS) at levels I (50), II (9), III (16), IV (6), and V (14). Physical activity was recorded on a total of 159 occasions at four possible time points: 1 year 6 months to 2 years; 2 years 6 months to 3 years; 4 years; and 5 years using ActiGraph for 3 days. Mixed-effects regression models were used for analyses.

RESULTS

Participants classified at GMFCS levels I and II had stable HPA as they aged. HPA significantly decreased at 5 years in children classified at GMFCS levels III to V. Sedentary time significantly increased at 4 years and 5 years in all participants. Annual HPA significantly reduced in children classified at GMFCS levels III to V (-123 counts/min, 95% confidence interval [CI] -206 to -40) while annual sedentary time significantly increased in all participants (GMFCS levels I-II: 2.4%, 95% CI 0.7-4.1; GMFCS levels III-V: 6.9%, 95% CI 4.6-9.2).

INTERPRETATION

Children with CP at all GMFCS levels should be encouraged to be physically active from early childhood as HPA levels start to decline from 4 years. Breaks in sedentary time are required for all children with CP from the age of 3 years.

Body composition, diet, and physical activity: a longitudinal cohort study in preschoolers with cerebral palsy

BACKGROUND

Altered body composition in children with cerebral palsy (CP) could be due to differences in energy intake, habitual physical activity (HPA), and sedentary time.

OBJECTIVE

We investigated the longitudinal relation between the weight-for-age z score (WZ), fat-free mass (FFM), percentage of body fat (%BF), and modifiable lifestyle factors for all Gross Motor Function Classification System (GMFCS) levels (I-V).

DESIGN

The study was a longitudinal population-based cohort study of children with CP who were aged 18-60 mo (364 assessments in 161 children; boys: 61%; mean ± SD recruitment age: 2.8 ± 0.9 y; GMFCS: I, 48%; II, 11%; III, 15%; IV, 11%; and V, 15%). A deuterium dilution technique or bioelectrical impedance analysis was used to estimate FFM, and the %BF was calculated. Energy intake, HPA, and sedentary time were measured with the use of a 3-d weighed food diary and accelerometer wear. Data were analyzed with the use of a mixed-model analysis.

RESULTS

Children in GMFCS group I did not differ from age- and sex-specific reference children with typical development for weight. Children in GMFCS group IV were lighter-for-age, and children in GMFCS group V had a lower FFM-for-height than those in GMFCS group I. Children in GMFCS groups II-V had a higher %BF than that of children in GMFCS group I, with the exception of orally fed children in GMFCS group V. The mean %BF of children with CP classified them as overfat or obese. There was a positive association between energy intake and FFM and also between HPA level and FFM for children in GMFCS group I.

CONCLUSIONS

Altered body composition was evident in preschool-age children with CP across functional capacities. Gross motor function, feeding method, energy intake, and HPA level in GMFCS I individuals are the strongest predictors of body composition in children with CP between the ages of 18 and 60 mo.

Exploring the feasibility and use of accelerometers before, during, and after a camp-based CIMT program for children with cerebral palsy

PURPOSE

The aim of this pilot study was to determine the feasibility and use accelerometers before, during, and after a camp-based constraint-induced movement therapy (CIMT) program for children with hemiplegic cerebral palsy.

METHODS

A pre-test post-test design was used for 12 children with CP (mean = 4.9 yrs) who completed a 30-hour camp-based CIMT program. The accelerometer data were collected using ActiGraph GT9X Link. Children wore accelerometers on both wrists one day before and after the camp and on the affected limb during each camp day. Three developmental assessments were administered pre-post CIMT program.

RESULTS

Accelerometers were successfully worn before, during, and directly after the CIMT program to collect upper limb data. Affected upper limb accelerometer activity significantly increased during the CIMT camp compared to baseline (p< 0.05). Significant improvements were seen in all twelve children on all assessments of affected upper limb function (p< 0.05) measuring capacity and quality of affected upper limb functioning.

CONCLUSION

Accelerometers can be worn during high intensity pediatric CIMT programs to collect data about affected upper limb function. Further study is required to determine the relationship between accelerometer data, measure of motor capacity, and real-world performance post-CIMT.

Habitual Physical Activity in Children With Cerebral Palsy Aged 4 to 5 Years Across All Functional Abilities

PURPOSE

To compare ambulatory status in children with cerebral palsy aged 4 to 5 years with their habitual physical activity and time spent sedentary, and to compare their activity with physical activity guidelines.

METHODS

Sixty-seven participants-independently ambulant, marginally ambulant, and nonambulant-wore accelerometers for 3 days. Time spent sedentary as a percentage of wear time and activity counts were compared between groups.

RESULTS

There were significant differences in time spent sedentary and activity counts between groups. Children who were independently ambulant were more likely to meet physical activity guidelines.

CONCLUSION

Children with cerebral palsy spent more than half of their waking hours in sedentary time. Interventions to reduce sedentary behavior and increase habitual physical activity are needed in children with cerebral palsy at age 4 to 5 years.