Promotion of physical fitness and prevention of secondary conditions for children with cerebral palsy: section on pediatrics research summit proceedings

Stakeholder Perspectives on Physical Activity in Youth With Developmental Disabilities: A Mixed Methods Study

We explored factors associated with physical activity (PA) engagement in youth with developmental disabilities (DD) as they transition out of school. We conducted focus group discussions with 44 youth, families, special educators, and therapists to obtain information on PA levels, barriers to being active, and recommendations to improve PA among youth. Youth preferred activities that are fun, not too challenging, noncompetitive, and promoted interactions with neurotypical peers. Families face the burden of sustaining PA in their adult children after school age and experience barriers related to accessibility and affordability of adult-oriented programs, availability of trained personnel, and challenges in balancing multiple work and family-related commitments. Our findings can inform the design of programs to promote PA among youth with DD.

Utilization of special services among children and youth with special healthcare needs: A time-to-event analysis of the national survey of children's health data, 2016-2022

BACKGROUND

Special services including physical, occupational, speech, or behavioral therapies are associated with enhanced long-term functioning and well-being of children and youth with special healthcare needs (CYSHCN). Yet, there is a lack of recent evidence on the utilization of these services, and the age at which CYSHCN first receive them.

OBJECTIVE

This study assessed the distribution, timing, and determinants of special services utilization across different types of special healthcare needs.

METHODS

Data from 63,734 caregivers of CYSHCN aged 0-17 years from the 2016-2022 National Survey of Children's Health were analyzed using Rao-Scott Chi-Square, Log-rank, and Cox proportional hazard tests.

RESULTS

Overall, 41.9 % of CYSHCN ever received special services, including 91.4 %, 90.3 %, 88.0, and 34.1 % of children and youth with Down syndrome, cerebral palsy, autism, and other special healthcare needs (OSHCN), respectively. Children with Down syndrome and cerebral palsy received special services earlier than those with autism or OSHCN. Utilization of special services was higher among male children and youth (aHR 1.41; 95 % CI: 1.33-1.49), aged 0-5 years (aHR: 4.70; 95 % CI: 4.32-5.11), second or later born children (aHR: 1.18; 95 % CI: 1.10-1.26), from families with low-income (aHR: 1.14; 95 % CI: 1.04-1.24), living with married parents (aHR: 1.11; 95 % CI: 1.04-1.19), consistently insured (aHR: 1.24; 95 % CI: 1.08-1.42), and with a more complex health condition (aHR: 3.40; 95 % CI: 3.13-3.70) compared to their counterparts.

CONCLUSIONS

These findings highlight the necessity of adopting tailored approaches for children with different special healthcare needs to optimize and sustain the utilization of special services.

Co-Construction of a Dance Class Adapted for Adolescents with Cerebral Palsy

AIM

To co-construct a dance class adapted for adolescents with cerebral palsy (CP).

METHOD

A three phase co-construction process with study collaborators was used to (1) define the objectives and the obstacles and opportunities related to offering a dance class in the community through three focus groups with adolescents, their parents and study partners; (2) co-create the dance class based on the results of step 1, the expertise of the research team and the logic model of the dance class; and (3) test the dance class to evaluate its effects in relation to the defined objectives.

RESULTS

Three objectives were identified: to have fun, promote movement, and social interaction. A weekly dance class (60 min./10 wk) was continuously tested on the adolescents and adapted by the dance facilitators.

CONCLUSION

To improve practices and support the implementation of dance classes for young people with CP, eight recommendations are proposed relating to the creation of adapted classes and the evaluation of their desired effects.

Investigating physiological symptoms associated with mental health symptoms in youth with cerebral palsy: An observational study

Over 50 % of children and youth with cerebral palsy (CP) experience mental health challenges, with anxiety and depression most common. Youth with CP also experience several physiological symptoms such as fatigue, pain, sedentary lifestyle, and sleep disturbances that impact their daily living; however, little is known about the impact of these symptoms on mental health outcomes in these youth. This study addressed this gap and examined the individual and cumulative impacts of physiological symptoms on anxiety and depression symptoms in youth with CP. Forty youth with CP aged 8 to 18 years, and their caregiver, participated in this cross-sectional observational study. Pain, fatigue, anxiety, and depressive symptoms were measured using caregiver- and self-reported questionnaires and participants wore accelerometers for seven consecutive days, providing non-invasive physical activity and sleep pattern data. Youth with CP experienced substantial physiological symptoms and elevated anxiety and depression symptoms. Linear regression models determined that all physiological factors were predictive of caregiver-reported youth anxiety (R2 = 0.23) and youth depressive symptoms (R2 = 0.48). Fatigue, pain severity, sleep efficiency, and physical activity outcomes individually and cumulatively contributed to caregiver-reported youth anxiety and depression symptoms. These findings highlight the important role of physiological symptoms as potential risk factors and potential targets for intervention for mental health issues for in youth with CP.

Measuring Physical Activity in Children Who Do Not Walk and With Cerebral Palsy: An Exploratory Case Series

AIM

The purpose of this case series was to describe physical activity (PA) amount and intensity in the home and school environment. Accelerometers and heart rate (HR) monitors are reliable and valid measures of PA in children with cerebral palsy (CP) who can walk. There is limited research on PA measures in children with CP who cannot walk.

METHODS

Three 9-year-old boys with CP, Gross Motor Function Classification System levels IV and V, participated in a 1-week measurement period wearing waist- and wrist-worn triaxial accelerometers to measure PA counts and a wrist-worn HR monitor to measure PA intensity. PA intensity was calculated using an estimated HR max. Accelerometer counts were reported. Parents and school staff completed activity and eating journals.

RESULTS

Six days of PA and HR data were analyzed. Two participants spent more time in moderate/vigorous PA intensity during school compared to at home. Activities with greatest PA intensity included oral eating, communication, and social engagement. Higher activity counts were recorded from the wrist compared with the waist accelerometers. PA and eating journal adherence were high in both settings.

CONCLUSION

The findings provide preliminary data to evaluate PA amount and intensity in children with CP who have little walking ability. It is important to consider PA levels in daily activity for youth with CP when designing plans of care.

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.

The SPORTS Participation Framework: illuminating the pathway for people with disability to enter into, participate in, and excel at sport

BACKGROUND

Sports participation for people with disabilities exists at the intersection of health, sport, and education sectors. However, no common framework and language exist to describe the stages of sports participation.

OBJECTIVE

To present the background to the SPORTS Participation Framework, and how it can be used to illuminate the path that people with disability may travel to enter into, participate in, and enjoy and excel at all levels of sport.

METHOD

The SPORTS Participation Framework includes six stages drawn from mainstream sports pathways and models used to classify barriers to sports participation for people with disabilities: (S) Screening, goal setting and individual preparation, (P) Practitioner led, peer-group sports interventions, (O) Organised junior entry-point sports programs, (R) Recreational sport (non-competitive), (T) Team competition (school/club representation), and (S) State, National, and International competition.

RESULTS

For each stage, this paper describes the content of sports activities, the context in which they are performed, key stakeholders, barriers to participation, available evidence, and case studies.

CONCLUSIONS

The SPORTS Participation Framework presents a structure to navigate the stages of introducing and promoting lifelong sports participation for people with disabilities. It scaffolds clear communication, governance, and policy across health, sport, and education sectors, and supports clinicians and researchers to address barriers to participation at each stage to improve individual and population-wide participation in sport for people with disabilities.

Exploring Physical Activity in Children and Adolescents with Disabilities: A Bibliometric Review of Current Status, Guidelines, Perceived Barriers, and Facilitators and Future Directions

BACKGROUND

Physical activity contributes to both physiological and psychosocial benefits for children and adolescents with disabilities. However, the prevalence of physical inactivity is notably higher among disabled young people compared to their healthy peers. Despite this, there is a lack of constructed knowledge structure, evolutionary path, research hotspots, and frontiers in studies related to physical activity in young people with disabilities.

METHODS

The literature related to the research of physical activity in children and adolescents with disabilities was retrieved from the core collection of the Web of Science. The annual publication numbers and the timing, frequency, and centrality of the co-occurrence network with respect to journals, countries, institutions, authors, references, and keywords were analyzed. Additionally, clustering analysis and burst analysis were performed on the references and keywords. All analyses were conducted using CiteSpace.

RESULTS

A total of 1308 related articles were included. The knowledge structure of research on the physical activity of disabled children and adolescents, including annual publication numbers, influencing journals, countries, institutions, authors, references, and keywords along with their respective collaborative networks, has been constructed. Furthermore, the research foundation, current hot topics, and research frontiers have been identified by analyzing references and keywords.

CONCLUSIONS

Current research hotspots include interventions, therapies, and programs aimed at enhancing specific skills, as well as addressing the satisfaction of competence to improve motivation and the effectiveness of physical activity. There is also a focus on the development of scales for quantitative studies. Future directions may be toward personalized interventions or programs to enhance physical activity levels among youth with disabilities.

Effects of 12-week aquatic exercises on gross motor function, swimming skills and walking ability in children with cerebral palsy

BACKGROUND

Cerebral palsy (CP) is the most common cause of physical disability in childhood defined as a group of permanent disorders of movement. The aim of this study was to determine the effects of 12-week aquatic exercise program on gross motor function, swimming skills, and walking ability in children with cerebral palsy.

METHODS

Eighteen children (mean±SD age: 12.3±3 years) with cerebral palsy classified at levels I, II and III on the Gross Motor Function Classification System were allocated to one group, where the first 12 weeks were a control period while another 12 weeks were an experimental period. The participants underwent the same battery of tests focusing gross motor function, swimming skills, and walking ability on three occasions.

RESULTS

Control period was stable with no significant changes in any of measurements. After the 12-week experimental program, a statistically significant improvement was determined in gross motor function (P=0.005), swimming skills (P=0.000), walking endurance and walking velocity (P=0.000). No significant differences (P>0.05) were observed for walking efficiency.

CONCLUSIONS

The 12-week aquatic exercise program (3/week, 60 minutes), combining Halliwick method, swimming and walking activities may improve the gross motor function, swimming skills, walking endurance and velocity in ambulatory children with cerebral palsy.

Journey to 1 Million Steps: A Retrospective Case Series Analyzing the Implementation of Robotic-Assisted Gait Training Into an Outpatient Pediatric Clinic

PURPOSE

To describe the implementation of an exoskeleton program in a rehabilitation setting using a Design Thinking framework.

METHODS

This is a retrospective case series of 3 randomly selected children who participated in skilled physical therapy using a pediatric exoskeleton that occurred on our journey to walking 1 000 000 steps in the exoskeleton devices. Participants ranged in age from 3 to 5 years, and all had neurologic disorders.

RESULTS

All participants improved toward achieving their therapy goals, tolerated the exoskeleton well, and had an increased number of steps taken over time.

CONCLUSION

The implementation of new technology into pediatric care and an established outpatient therapy clinic is described. The Design Thinking process applies to health care professionals and improves clinical care. Exoskeletons are effective tools for use in pediatric physical therapy.

Identifying Postural Instability in Children with Cerebral Palsy Using a Predictive Model: A Longitudinal Multicenter Study

Insufficient postural control and trunk instability are serious concerns in children with cerebral palsy (CP). We implemented a predictive model to identify factors associated with postural impairments such as spastic or hypotonic truncal tone (TT) in children with CP. We conducted a longitudinal, double-blinded, multicenter, descriptive study of 102 teenagers with CP with cognitive impairment and severe motor disorders with and without truncal tone impairments treated in two specialized hospitals (60 inpatients and 42 outpatients; 60 males, mean age 16.5 ± 1.2 years, range 12 to 18 yrs). Clinical and functional data were collected between 2006 and 2021. TT-PredictMed, a multiple logistic regression prediction model, was developed to identify factors associated with hypotonic or spastic TT following the guidelines of "Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis". Predictors of hypotonic TT were hip dysplasia (p = 0.01), type of etiology (postnatal > perinatal > prenatal causes; p = 0.05), male gender, and poor manual (p = 0.01) and gross motor function (p = 0.05). Predictors of spastic TT were neuromuscular scoliosis (p = 0.03), type of etiology (prenatal > perinatal > postnatal causes; p < 0.001), spasticity (quadri/triplegia > diplegia > hemiplegia; p = 0.05), presence of dystonia (p = 0.001), and epilepsy (refractory > controlled, p = 0.009). The predictive model's average accuracy, sensitivity, and specificity reached 82%. The model's accuracy aligns with recent studies on applying machine learning models in the clinical field.

Policy brief: adaptive cycling equipment for individuals with neurodevelopmental disabilities as durable medical equipment

- Durable medical equipment (DME) policies require that the equipment be medically necessary; however, adaptive cycling equipment (bicycles and tricycles) are usually not deemed medically necessary. - Individuals with neurodevelopmental disabilities (NDD) are at high risk for secondary conditions, both physical and mental, that can be mitigated by increasing physical activity. - Significant financial costs are associated with the management of secondary conditions. - Adaptive cycling can provide improved physical health of individuals with NDD potentially reducing costs of comorbidities. - Expanding DME policies to include adaptive cycling equipment for qualifying individuals with NDD can increase access to equipment. - Regulations to ensure eligibility, proper fitting, prescription, and training can optimize health and wellbeing. - Programs for recycling or repurposing of equipment are warranted to optimize resources.

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.

Systematic review: exercise training for equinus deformity in children with cerebral palsy

Background

Children with spastic cerebral palsy have motor deficits that can lead to joint contractures. Ankle equinus deformity is the most common foot deformity among children with CP. It is caused by spasticity and muscular imbalance in the gastrocnemius-soleus complex. Exercise enhances ankle function, improves gait in children with CP, and prevents permanent impairment. Therefore, there is a need to investigate the effectiveness of different types of exercise used in equine management. The aim of this review is to assess the evidence of the effectiveness of exercise training on equinus deformity in children with cerebral palsy.

Methodology

The American Academy for Cerebral Palsy and Developmental Medicine and Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology were used to conduct this systematic review. Four databases (PubMed, Cochrane Library, Physiotherapy Evidence Database (PEDro), and Google Scholar) were searched till January 2022 using predefined terms by two independent reviewers. Randomized controlled trials published in English were included. This review included seven studies with 203 participants ranging in age from 5 to 18 years. Methodological quality was assessed using AACPDM, PEDro scale; also, levels of evidence adopted from modified Sacket’s scale were used for each study. Primary outcomes were dorsiflexion angle, plantar flexion angle, and plantar flexors strength.

Results

The quality of studies ranged from good (six studies) to fair (one study). The level of evidence was level 1 (six studies) and level 2 (one study) on modified Sacket’s scale. There is a low risk of bias in the included studies. Meta-analysis revealed a non-significant difference in plantar flexor strength, plantar flexion angle, and dorsiflexion angle between the study and control group.

Conclusions

There is a need for high-quality studies to draw a clear conclusion as the current level of evidence supporting the effectiveness of various types of exercises on equinus deformity in children with cerebral palsy is still weak.

Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy

Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.

Physiological Response to the 6-Minute Frame Running Test in Children and Adults With Cerebral Palsy

PURPOSE

To determine the physiological response and association to peak oxygen uptake of the 6-minute Frame Running test (6-MFRT) in persons with cerebral palsy (CP).

METHODS

Twenty-four participants with CP, Gross Motor Function Classification System II/III/IV, performed the 6-MFRT. Distance, peak heart rate (HR peak ), peak respiratory exchange ratio (RER peak ), and peak oxygen uptake ( O 2peak ) were measured.

RESULTS

HR peak ranged from 146 to 201 beats per minute, RER peak from 0.94 to 1.49, 6-MFRT distance from 179 to 1220 m and O 2peak from 0.62 to 2.18 L/min. HR peak was achieved in 63%, RER peak in 71%. A strong correlation was observed between 6-MFRT and O 2peak .

CONCLUSIONS

The 6-MFRT represented a (near) maximum effort for 75% of the participants and the 6-MFRT can be used to estimate oxygen consumption on an individual basis.

The Experience of Physical Activity in Adolescents With Cerebral Palsy

For adolescents with cerebral palsy (CP), participating in physical activity (PA) can be difficult due to functional limitations that not only affect an adolescent's ability or willingness to participate in PA but also create particular social concerns. Research in the area of PA and adolescents with CP is limited. This research study utilized hermeneutic phenomenology to gain a more comprehensive understanding of the lived experiences of 14 adolescents with CP who participated in PA. The interpretations of each participant offered common understandings and themes to be identified and warranted as valid by the interpretive team. Common understandings identified were (a) developmental tasks of typical adolescents, (b) place of friends, (c) purpose of PA, (d) importance of support, and (e) wanting to be like the primary researcher. Most of the 14 participants had similar experiences within the identified common understandings and themes. Physical activity, in part, helps adolescents find out about themselves and their place within their community. The experiences of adolescents with CP and PA show that participation in PA is a way to connect with friends, meet new people, and gain a feeling of freedom from their disability. We offer healthcare providers a starting point to talk about PA and to help adolescents with CP find activities within their community.

Mental Health Benefits of Physical Activity in Youth with Cerebral Palsy: A Scoping Review

AIMS

Children and adolescents with cerebral palsy (CP) are at heightened risk for mental health problems. Physical activity is an effective strategy to promote quality of life (QoL) and reduce mental health symptoms along with evidence-based therapies. This study described existing literature examining the mental health outcomes (e.g., QoL, well-being, anxiety, and depression) of physical activity interventions in children and adolescents with CP to help inform the implementation of physical activity interventions for this population.

METHODS

Ascoping review framework was used to map the existing quantitative literature.

RESULTS

The search returned 243 articles; after titles, abstracts, and full manuscripts were reviewed, 21 articles were included. The association between physical activity and QoL was examined in most studies (n = 17) with mixed findings. Eight studies documented at least one significant positive association between physical activity and QoL, and four found that physical activity interventions were highly enjoyable. Only one study assessed anxiety and/or depression following a PA intervention.

CONCLUSIONS

Physical activity may benefit aspects of QoL and mental health symptoms; however, this was not a consistent finding in the existing literature. Along with other therapies, physical activity interventions may be valuable in improving QoL, and in turn, the mental health symptoms of children with CP.

The Impact of Frame Running on Quality of Life in Young Athletes With Mobility Limitations

Purpose

The para-athletic sport Frame Running is developed for persons with neurological impairments causing severe limitations of walking ability. Participating in sports can contribute to a better quality of life (QoL). It is unknown if participation in Frame Running contributes to QoL in children with mobility limitations. This study aims to explore the changes in QoL in children and youth who started Frame Running.

Materials and Methods

We conducted a cross-sectional study amongst young Frame Running athletes with mobility limitations due to various underlying causes, aged 6–19 years, who are members of one of the Frame Running groups in the Netherlands. For 62 athletes, parents completed the Psychosocial Impact of Assistive Devices Scale (PIADS) questionnaire (subscales: competence, adaptability, and self-esteem). For six athletes, parents were interviewed to obtain more in-depth insight in the perceived changes in the QoL of their children.

Results

Parents (of 58% boys, mean age 12 years 4 months; SD 3 years 3 months; 52% supported walkers) reported a significant positive change on all three subscales of the PIADS questionnaire since their children started Frame Running. Most change was experienced in the items performance, the ability to participate, happiness and self-confidence. Quotes of the parents who were interviewed elucidated these changes.

Conclusion

Frame Running increased QoL in young athletes with a mobility limitation. Frame Running may therefore be advised for these children and youth to improve QoL.

The SIT-PT Trial Protocol: A Dose-Matched Randomized Clinical Trial Comparing 2 Physical Therapist Interventions for Infants and Toddlers With Cerebral Palsy

OBJECTIVE

Although early intervention for infants at risk for cerebral palsy is routinely recommended, the content of intervention is poorly described, varies widely, and has mixed supporting evidence. The purpose of this study was to compare efficacy of 2 interventions grounded in differing domains of the International Classification of Functioning, Disability and Health on developmental outcomes of infants with or at high risk of cerebral palsy.

METHODS

Infants who meet inclusion criteria will be randomized into either Sitting Together and Reaching To Play or Movement, Orientation, Repetition, Exercise Physical Therapy groups. Both groups will receive intervention twice weekly for 3 months and follow-up at 3, 6, 9, and 12 months from baseline. The primary objectives compare changes over time and between groups in sitting, gross motor, and cognitive development. The setting is the infant's home unless the caregiver requests otherwise. One hundred and fifty infants between 8 and 24 months of age will be enrolled in 3 geographically, racially, and ethnically diverse sites: Los Angeles, California; Omaha, Nebraska; and Seattle, Washington. Enrolled infants will demonstrate motor delays, emerging sitting skills, and signs of neurologic impairment. Sitting Together and Reaching To Play targets activities including sitting, reaching, and motor-based problem solving to improve global development. In contrast, Movement, Orientation, Repetition, Exercise Physical Therapy focuses on strengthening and musculoskeletal alignment while encouraging repeated movement practice. Outcome measures include the Gross Motor Function Measure, Bayley Scales of Infant Development-IV, Assessment of Problem Solving in Play, and a Parent Child Interaction assessment. Enrolled children will maintain usual intervention services due to ethical concerns with intervention withdrawal.

IMPACT

This will be the first study, to our knowledge, comparing efficacy of early physical therapy with dose-matched interventions and well-defined key principles. The outcomes will inform selection of key principle of intervention in this population.

Leisure Time Physical Activity in Children and Young People With Cerebral Palsy: A Population-Based Study

PURPOSE

To describe leisure time physical activity in children and young people with cerebral palsy and identify barriers and facilitators to participation.

METHODS

Leisure time physical activity participation was derived from a national cerebral palsy register and associated factors were analyzed. Barriers and facilitators to participation were investigated through a survey.

RESULTS

Leisure time physical activity participation was recorded. Outcomes of participation decreased with increasing Gross Motor Function Classification System level. Leisure time physical activity "not in club" for 11- to 18-year-olds was significantly lower than for those aged 5 to 10 years for Gross Motor Function Classification System level II. The survey supported that disability and disliking help were common barriers and parental encouragement and enjoyment were common facilitators.

CONCLUSIONS

Data from the register and survey provide insight into factors influencing leisure time physical activity participation in young people with cerebral palsy and how to increase.

Effect of Equine-Assisted Activities and Therapies on Cardiorespiratory Fitness in Children with Cerebral Palsy: A Randomized Controlled Trial

Abstract Objectives: To determine the effects of an equine-assisted activities and therapies (EAAT) program on cardiorespiratory fitness (CRF) in children with cerebral palsy (CP). Design: An evaluator-blinded, parallel, two-arm, randomized controlled clinical trial with 1:1 randomization. Settings/Location: A tertiary university hospital and a local arena. Subjects: Forty-six children with CP (24 boys and 22 girls) classified as Gross Motor Function Classification System levels I, II, or III were included. Interventions: The EAAT program was conducted for 40 min twice a week for 16 weeks (32 lessons). Outcome measures: Clinical global impression scales, motor capacity, cardiopulmonary fitness, and habitual physical activity was measured on both groups before and after the 16-week period. Results: Changes in the Clinical Global Impression-Severity scale and Clinical Global Impression-Improvement scale scores were not different between the groups after the intervention. Analysis of covariance revealed statistically significant differences in Gross Motor Function Measure 66 (GMFM 66) (p < 0.05) and Pediatric Balance Scale (p < 0.001) in motor capacity and resting heart rate (HRrest) (p < 0.001) in CRF, between the EAAT group and the control group. Subgroup analysis using multiple linear regression analysis revealed that the GMFM 66 changes had a statistically significant effect on the HRrest changes in the EAAT group (p < 0.05). Conclusions: The present study showed decreased HRrest in children with CP after completing the 16-week EAAT program. This improvement was explained by the improvement of GMFM 66 in the EAAT group. Thus, EAAT may be among the endurance training programs that could be offered to children with CP to improve their CRF. Clinical Trial Registration number: NCT03870893.

Non-pharmacological and non-surgical treatment of pain in children and adolescents with cerebral palsy: A scoping review

PURPOSE

To explore the existing literature on non-pharmacological and non-surgical pain management in children and adolescents with cerebral palsy (CP).

METHODS

Databases (Cochrane Library, PubMed MEDLINE, Ovid Embase, and PsycINFO) were systematically searched to identify literature on non-pharmacological and non-surgical interventions for relieving pain in children with CP or similar conditions.

RESULTS

Thirteen publications met the inclusion criteria. Based on study designs, the overall level of evidence of the included studies was low, justifying the use of a scoping review. Only three were randomized controlled trials. Pain reduction was reported in 8 of the 13 studies from following interventions: physiotherapy/rehabilitation, massage, cranial osteopathy, swimming and aquatics, and assistive devices. These complementary strategies should not omit conventional treatment, and a multidisciplinary approach using multifaceted treatment of pharmacological and non-pharmacological therapy is recommended to increase the pain-relieving effect.

CONCLUSION

The results indicate that physiotherapy, massage, swimming exercise, and various assistive devices can have pain-relieving effects. We found limited evidence on the topic of non-pharmacological and non-surgical treatment of pain in children with CP. Due to the lack of power in the included studies, no true evidence-based recommendations can be made from the collected articles; thus, further studies with larger cohorts and more power are needed to substantiate evidence-based treatment of pain in children and adolescents with CP.

Physical activity intention and attendance behaviour in Finnish youth with cerebral palsy - results from a physical activity intervention: an application of the theory of planned behaviour

Physical activity is associated with better health in individuals with cerebral palsy (CP). Numerous physical activity interventions have been designed to promote physical activity among youth with CP. No previous studies have explored the factors contributing to the intention to participate and predicting attendance behaviour for these interventions. Using theory of planned behaviour (TPB), this study explored the prediction of physical activity intention and attendance behaviour in a physical activity intervention aiming to promote physical activity in a sample of young individuals with CP. Males with CP aged 9-21 years were asked to complete measures of attitude, subjective norms, perceived behavioural control and, intentions towards a physical activity intervention. Participants had no cognitive impairments to understand and follow instructions, were categorised into Gross Motor Function Classification System I-III, did not receive any specific lower limbs' medical treatment, or did not participate in a strength training program for lower limbs within 6 months before the study. Subjective norms were found to be the only significant predictor of intention, accounting for 83% of variance in intention. Intention and perceived behaviour control were found to be a nonsignificant predictor of attendance behaviour in youth with CP. The results show that TPB is a relevant tool in the prediction of intention towards a physical activity intervention in Finnish youth with CP.

Aerobic Responses to FES-Assisted and Volitional Cycling in Children with Cerebral Palsy

Recumbent stationary cycling is a potential exercise modality for individuals with cerebral palsy (CP) that lack the postural control needed for upright exercises. Functional electrical stimulation (FES) of lower extremity muscles can help such individuals reach the cycling intensities that are required for aerobic benefits. The aim of this study was to examine the effect of cycling with and without FES assistance to that of a no-intervention control group on the cardiorespiratory fitness of children with CP. Thirty-nine participants were randomized to a FES group that underwent an 8-week FES-assisted cycling program, the volitional group (VOL), who cycled without FES, or a no-intervention control group (CON) (15 FES, 11 VOL, 13 CON). Cadence, peak VO₂, and net rise in heart rate were assessed at baseline, end of training, and washout (8-weeks after cessation of training). Latent growth curve modeling was used for analysis. The FES group showed significantly higher cycling cadences than the VOL and CON groups at POST and WO. There were no differences in improvements in the peak VO₂ and peak net HR between groups. FES-assisted cycling may help children with CP attain higher cycling cadences and to retain these gains after training cessation. Higher training intensities may be necessary to obtain improvements in peak VO₂ and heart rate.

Predictors of physical activity levels in children and adolescents with cerebral palsy: clinical cohort study protocol

INTRODUCTION

Children and adolescents with cerebral palsy may be trapped in a vicious circle of low physical fitness, resulting in deconditioning that causes a further decrease in physical activity (PA), a lower quality of life and an increased risk of developing non-communicable diseases. Therefore, establishing a healthy and active lifestyle during childhood is even more important for individuals with a disability. However, the factors that influence habitual PA in children and adolescents with cerebral palsy remain unknown.The present protocol outlines a prospective cohort study with the aim of investigating potential predictors of habitual PA in children and adolescents with cerebral palsy in order to provide evidence for optimising PA levels and associated overall health.

METHODS AND ANALYSIS

This prospective cohort study will enrol participants with cerebral palsy between the ages of 8 and 15 years at Gross Motor Function Classification System levels I-III. Using a modified version of the International Classification of Functioning, Disability and Health model as a conceptual analytical framework, the analysis will be divided into six components and will provide predictors for habitual PA measured by accelerometry. The potential predictive variables are registry data on physical function (Danish Cerebral Palsy Follow-Up Programme); validated proxy-reported questionnaires on quality of life (Paediatric Quality of Life Inventory), overall health, pain and participation in daily activities (Paediatric Outcomes Data Collection Instrument) and supplementary questions regarding sleep, screen time and socioeconomic status.

ETHICS AND DISSEMINATION

The project is approved by the Danish Data Protection Agency (19/16396) and has been declared not notifiable by the Regional Committee on Health Research Ethics, cf. Committee Act Art. 14, paragraph 1 (S-20192000-23). The study results will be published in international peer-reviewed journals, presented at international conferences, and published in a PhD dissertation.

TRIAL REGISTRATION NUMBER

NCT04614207.

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

PURPOSE

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

METHODS

A descriptive multiple-case study.

RESULTS

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

CONCLUSIONS

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

Postural mechanisms in moderate-to-severe cerebral palsy

People with moderate-to-severe cerebral palsy (CP) have the greatest need for postural control research yet are usually excluded from research due to deficits in sitting ability. We use a support system that allows us to quantify and model postural mechanisms in nonambulatory children with CP. A continuous external bench tilt stimulus was used to evoke trunk postural responses in seven sitting children with CP (ages 2.5 to 13 yr) in several test sessions. Eight healthy adults were also included. Postural sway was analyzed with root mean square (RMS) sway and RMS sway velocity, along with frequency response functions (FRF, gain and phase) and coherence functions across two different stimulus amplitudes. A feedback model (including sensorimotor noise, passive, reflexive, and sensory integration mechanisms) was developed to hypothesize how postural control mechanisms are organized and function. Experimental results showed large RMS sway, FRF gains, and variability compared with adults. Modeling suggested that many subjects with CP adopted "simple" control with major contributions from a passive and reflexive mechanism and only a small contribution from active sensory integration. In contrast, mature trunk postural control includes major contributions from sensory integration and sensory reweighting. Relative to their body size, subjects with CP showed significantly lower damping, three to five times larger corrective torque, and much higher sensorimotor noise compared with the healthy mature system. Results are the first characterization of trunk postural responses and the first attempt at system identification in moderate-to-severe CP, an important step toward developing and evaluating more targeted interventions.NEW & NOTEWORTHY Cerebral palsy (CP) is the most common cause of motor disability in children. People with moderate-to-severe CP are typically nonambulatory and have major impairments in trunk postural control. We present the first systems identification study to investigate postural responses to external stimulus in this population and hypothesize at how the atypical postural control system functions with use of a feedback model. People with moderate-to-severe CP may use a simple control system with significant sensorimotor noise.

Effectiveness of Robot-Assisted Gait Training on Functional Skills in Children with Cerebral Palsy

This study was aimed to investigate the effects of robot-assisted gait training (RAGT) on motor functions, spasticity status, balance, and functionality in children with cerebral palsy (CP). A total of 26 patients who were diagnosed with CP (diplegic, with gross motor function classification system [GMFCS] levels of 2–5) and who regularly participated in a rehabilitation program were recruited in the study after obtaining approval from their parents. The patients were randomly assigned to two groups. Group 1 (n = 13) received conventional physical therapy (65 minutes, 2 days/week × 8) and group 2 (n = 13) received 25 minutes of RAGT (RoboGait) in addition to conventional therapy (CT; 40 minutes, 2 days/week × 8). GMFCS was used to evaluate motor functions and the Modified Ashworth Scale was used to evaluate spasticity. The pediatric Berg balance scale, pediatric functional independence measure, and timed up and go tests were employed to assess balance and functional status. The evaluations were performed at baseline and after 8 weeks of therapy. Both rehabilitation methods led to a statistically significant decrease in spasticity (p < 0.05); however, there was no difference in this improvement of spasticity between the groups (p > 0.05). Both groups exhibited significant improvements in functional independence, balance, and performance at the end of therapy (p < 0.05), and there was no significant difference between the groups (p > 0.05). The results of this study show that addition of RAGT to CT for 8 weeks is not superior to CT alone in children with CP.

Development of Lower Extremity Strength in Ambulatory Children With Bilateral Spastic Cerebral Palsy in Comparison With Typically Developing Controls Using Absolute and Normalized to Body Weight Force Values

This cross-sectional study aimed to examine the development of lower limb voluntary strength in 160 ambulatory patients with bilateral spastic cerebral palsy (CP) (106 diplegics/54 quadriplegics) and 86 typically developing (TD) controls, aged 7–16 years. Handheld dynamometry was used to measure isometric strength of seven muscle groups (hip adductors and abductors, hip extensors and flexors, knee extensors and flexors, and ankle dorsiflexors); absolute force (AF) values in pounds were collected, which were then normalized to body weight (NF). AF values increased with increasing age (p < 0.001 for all muscle groups), whereas NF values decreased through adolescence (p < 0.001 for all muscle groups except for hip abduction where p = 0.022), indicating that increases in weight through adolescence led to decreases in relative force. Both AF and NF values were significantly greater in TD subjects when compared with children with CP in all muscle and all age groups (p < 0.001). Diplegics and quadriplegics demonstrated consistently lower force values than TD subjects for all muscle groups, except for the hip extensors where TD children had similar values with diplegics (p = 0.726) but higher than quadriplegics (p = 0.001). Diplegic patients also exhibited higher values than quadriplegics in all muscles, except for the knee extensors where their difference was only indicative (p = 0.056). The conversion of CP subjects' force values as a percentage of the TD subjects' mean value revealed a pattern of significant muscle strength imbalance between the CP antagonist muscles, documented from the following deficit differences for the CP muscle couples: (hip extensors 13%) / (hip flexors 32%), (adductors 27%) / (abductors 52%), and (knee extensors 37%) / (knee flexors 53%). This pattern was evident in all age groups. Similarly, significant force deficiencies were identified in GMFCS III/IV patients when compared with TD children and GMFCS I/II patients. In this study, we demonstrated that children and adolescents with bilateral CP exhibited lower strength values in lower limb muscles when compared with their TD counterparts. This difference was more prevalent in quadriplegic patients and those with a more severe impairment. An important pattern of muscle strength imbalance between the antagonist muscles of the CP subjects was revealed.

Physical therapist-led swimming lessons for children with cerebral palsy: a report of 2 cases

[Purpose] The purpose of this study was to report that a physical therapist qualified for swimming instruction can provide swimming instruction to children with spastic paraplegia due to cerebral palsy. We examined the role of the physical therapist in the support. [Participants and Methods] Two elementary school children with cerebral palsy participated in this study. The swimming program consisting of 6 sessions was performed over 6 months in an indoor swimming pool. Each session lasted for 30 minutes and was instructed by a trained physical therapist. The 5 categories for evaluation were motor function, muscle tone, activities of daily living, swimming skill, and satisfaction level. [Results] Case A showed improvement in streamline floating distance and 15-m time. Case B could not swim 15 m in the first session but completed 15 m within 102 s in the last session. The 3 other categories besides swimming skills did not improve. [Conclusion] With a skilled physical therapist’s instruction, children with cerebral palsy may improve their swimming skills over a limited number of sessions without any adverse events.

Physical Activity, Medical Home, and Health Behavior Counseling Among Adolescents with Special Health Care Needs: NSCH 2016-2017

OBJECTIVES

Aim 1 was to establish updated prevalence estimates for meeting national physical activity (PA) guidelines among adolescents with and without special healthcare needs (SHCN), 12-17 years old. To identify at-risk subgroups, our sub-aim was to compare the distribution of prevalence estimates across PA levels by SHCN subtypes, and in reference to peers without SHCN. Aim 2 was to examine the association between meeting PA guidelines, having a medical home, and receiving positive health behavior counseling in this population.

METHODS

Weighted prevalence estimates for meeting the 2018 National PA Guidelines (inactive, insufficiently active, sufficiently active: guidelines met) were calculated from a secondary analysis of the National Survey of Children's Health 2016-2017 ( n = 16,171, 27% SHCN). Adjusted odds ratios and 95% CIs were estimated from logistic regression models to measure the association between PA, medical home, and postive health behavior counseling.

RESULTS

Of adolescents with SHCN, 15% were reported to be meeting PA guidelines compared to 19% of peers without SHCN peers. Among adolescents with a medical home, regardless of SHCN status, those receiving positive health behavior counseling had 1.70 times the adjusted odds of meeting PA guidelines compared to peers without counseling.

CONCLUSIONS FOR PRACTICE

Adolescents with and without SHCN were more likely to meet PA guidelines if they had a medical home and received positive health behavior counseling, highlighting the value of comprehensive healthcare practices for PA promotion.

The use and perception of support walkers for children with disabilities: a United Kingdom survey

BACKGROUND

Support walkers are a type of assistive device that may enable non-ambulant children with disabilities to walk independently and promote improvements in bowel function, bone mineral density (BMD), mobility, independence, participation and social function. However, there is little evidence to support these benefits and there is a lack of research describing the use of support walkers in clinical practice. This study aimed to examine the use of support walkers for children with disabilities in clinical practice.

METHOD

A survey was distributed via professional organisations, charities and schools associated with paediatric disabilities in the UK. Participants were recruited between January and March 2018. Populations of interest were those who prescribe support walkers to children with disabilities and those who work with children who use them.

RESULTS

In total, 125 people were included in the analysis; 107 responders prescribed support walkers and 18 responders worked with children who used support walkers. The population of children who use support walkers ranged from 6 months to 18 years and included children with cerebral palsy, chromosomal abnormalities and other medical conditions. Use of these devices was also reported in schools, at home and in the community for varying lengths of time. Numerous perceived benefits were noted, most frequent of which were increases in physical activity and enjoyment. By comparison, fewer perceived problems were identified but centred on lack of space and difficulty with transfers.

CONCLUSIONS

This study provides insight into the use of support walkers in the UK, particularly surrounding current practices, which may help to improve consistency in clinical settings. Perceived benefits and problems may provide a basis for identification of appropriate outcome measures to monitor effectiveness. These results should also provide a basis for designing future studies to examine effectiveness of support walkers for paediatric disabilities.

Strength Training to Improve Performance in Athletes With Cerebral Palsy: A Systematic Review of Current Evidence

Fleeton, JRM, Sanders, RH, and Fornusek, C. Strength training to improve performance in athletes with cerebral palsy: A systematic review of current evidence. J Strength Cond Res 34(6): 1774-1789, 2020-Persons with cerebral palsy (CP) can partake in many different forms of organized sport including elite competition at state and international levels. There is limited evidence on how CP athletes should train to enhance performance. The purposes of this article were to conduct a systematic review of the current evidence on ambulatory individuals with CP for (a) strength and functional improvement through strength training; (b) potential sports performance improvement through strength training; (c) the identification of risk and special considerations associated with strength and conditioning for this population, and; (d) the identification of future research foci to educate strength and conditioning coaches on specific program design for elite CP athletes. Seven electronic databases were searched for studies investigating resistance training interventions. The databases were also searched for training interventions or investigations into sports performance in athletes with CP competing at regional level or above. Thirty articles were included in the systematic review of strength training, and 23 articles included in the narrative review of training for sports performance. High-quality evidence indicates that resistance training can improve muscular strength in individuals with CP, with some preliminary evidence of structural and neurological adaptations. However, there is limited evidence for functional improvements. Limited research has examined the performance capacity of athletes with CP, and no training interventions have been conducted. Coaches should employ existing guidelines when designing programs while considering specific athlete limitations. Initially, the focus should be increasing athlete muscular strength before considering specific sport demands.

Multidimensional Measures of Physical Activity and Their Association with Gross Motor Capacity in Children and Adolescents with Cerebral Palsy

The current lack of adapted performance metrics leads clinicians to focus on what children with cerebral palsy (CP) do in a clinical setting, despite the ongoing debate on whether capacity (what they do at best) adequately reflects performance (what they do in daily life). Our aim was to measure these children’s habitual physical activity (PA) and gross motor capacity and investigate their relationship. Using five synchronized inertial measurement units (IMU) and algorithms adapted to this population, we computed 22 PA states integrating the type (e.g., sitting, walking, etc.), duration, and intensity of PA. Their temporal sequence was visualized with a PA barcode from which information about pattern complexity and the time spent in each of the six simplified PA states (PAS; considering PA type and duration, but not intensity) was extracted and compared to capacity. Results of 25 children with CP showed no strong association between motor capacity and performance, but a certain level of motor capacity seems to be a prerequisite for the achievement of higher PAS. Our multidimensional performance measurement provides a new method of PA assessment in this population, with an easy-to-understand visual output (barcode) and objective data for clinical and scientific use.

Clinical gait analysis and physical examination don't correlate with physical activity of children with cerebral palsy. Cross-sectional study

Gait analysis and physical clinical measures are usually performed in children with cerebral palsy to help the surgeons make therapeutic decision. However, the level of physical activity in daily life is not systematically assessed. The aim of this cross sectional study was to examine the correlations between: three-dimensional gait analysis kinematic and spatiotemporal parameters, clinical measures and physical activity. Participants were 30 children with cerebral palsy (10–18 y), with GMFCS I–III. Daily physical activity was measured with an Actigraph GT3X accelerometer in free living environment during seven consecutive days. The percent of time spent in sedentary, in moderate to vigorous physical activity and the number of steps per day were computed from the accelerometer data. Kinematics parameters did not correlate with physical activity. Moderate correlations were found between spatio-temporal parameters and physical activity, for instance timing of toe-off (r = −0.40, p = 0.03). Few physical examination parameters were correlated with physical activity, such as the hip flexors selective motor control (r = 0.69 with moderate to vigorous activity and r = 0.70 with steps per day, p < 0.05). The physical activity profile cannot be sufficiently determined by a combination of clinical measures.

Machine learning to quantify habitual physical activity in children with cerebral palsy

AIM

To investigate whether activity-monitors and machine learning models could provide accurate information about physical activity performed by children and adolescents with cerebral palsy (CP) who use mobility aids for ambulation.

METHOD

Eleven participants (mean age 11y [SD 3y]; six females, five males) classified in Gross Motor Function Classification System (GMFCS) levels III and IV, completed six physical activity trials wearing a tri-axial accelerometer on the wrist, hip, and thigh. Trials included supine rest, upper-limb task, walking, wheelchair propulsion, and cycling. Three supervised learning algorithms (decision tree, support vector machine [SVM], random forest) were trained on features in the raw-acceleration signal. Model-performance was evaluated using leave-one-subject-out cross-validation accuracy.

RESULTS

Cross-validation accuracy for the single-placement models ranged from 59% to 79%, with the best performance achieved by the random forest wrist model (79%). Combining features from two or more accelerometer placements significantly improved classification accuracy. The random forest wrist and hip model achieved an overall accuracy of 92%, while the SVM wrist, hip, and thigh model achieved an overall accuracy of 90%.

INTERPRETATION

Models trained on features in the raw-acceleration signal may provide accurate recognition of clinically relevant physical activity behaviours in children and adolescents with CP who use mobility aids for ambulation in a controlled setting.

WHAT THIS PAPER ADDS

Machine learning may assist clinicians in evaluating the efficacy of surgical and therapy-based interventions. Machine learning may help researchers better understand the short- and long-term benefits of physical activity for children with more severe motor impairments.

Effect of Functional Progressive Resistance Exercise on Lower Extremity Structure, Muscle Tone, Dynamic Balance and Functional Ability in Children with Spastic Cerebral Palsy

The purpose of this study was to investigate the effects of functional progressive resistance exercise (FPRE) on muscle tone, dynamic balance and functional ability in children with spastic cerebral palsy. Twenty-five subjects were randomized into two groups: the FPRE group (n = 13) and the control group (n = 12). The experimental group participated in an FPRE program for 30 min per day, three times per week for six weeks. Knee extensor strength, rehabilitative ultrasound imaging (RUSI), muscle tone, dynamic balance, and functional ability was evaluated. The results showed statistically significant time × group interaction effects on the dominant side for knee extensor strength and cross-sectional area (CSA) in RUSI (p < 0.05). On both sides for thickness of the quadriceps (TQ) in RUSI, muscle tone and dynamic balance were statistically significant time × group interaction effects (p < 0.05). Additionally, knee extensor strength, CSA, TQ in RUS, muscle tone, dynamic balance and gross motor function measure (GMFM) in functional ability were significantly increased between pre- and post-intervention within the FPRE group (p < 0.05). The results suggest that FPRE is both feasible and beneficial for improving muscle tone, dynamic balance and functional ability in children with spastic cerebral palsy.

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.

Correlation between Accelerometer and Questionnaire-Based Assessment of Physical Activity in Patients with Cerebral Palsy

Background

Precise measuring and monitoring of physical activity (PA) in patients with cerebral palsy (CP) are critical for assessing their PA participation and its potential health benefits. Accelerometer-based assessment of PA has been considered valid, reliable, and practical in children with CP. Therefore, we investigated the correlation between accelerometer- and questionnaire-based assessment of PA in CP patients.

Methods

Nineteen patients with CP who were classified as Gross Motor Function Classification System level I–III and 84 normally developed participants were included in the study. Study participants wore an accelerometer for seven days, after which they visited the hospital and completed the International Physical Activity Questionnaire (IPAQ). CP patients and their caregivers completed the Pediatric Outcomes Data Collection Instrument (PODCI) and the Caregiver Priorities and Child Health Index of Life with Disabilities, respectively. The concurrent validity of the questionnaires was assessed.

Results

In the accelerometer-based assessment, time spent in PA was significantly shorter at every intensity level in CP patients than in normally developed participants. However, PA assessed by the IPAQ was significantly higher in patients with CP, indicating that they tend to exaggerate their participation in PA. On the correlation of the assessment by the accelerometer and by the PODCI, transfer/basic mobility, sports/physical function, and happiness increased significantly as the number of steps taken and the distance travelled increased.

Conclusions

In patients with CP, happiness and quality of life are associated with higher levels of PA. Thus, programs for patients with CP should focus on improving their PA.

Walking Performance, Physical Activity, and Validity of the Early Activity Scale for Endurance in Young Children with Cerebral Palsy

AIMS

To describe the walking performance and physical activity of children with cerebral palsy (CP) by Gross Motor Function Classification System (GMFCS) level, age, sex, and geographical location; and, to examine the concurrent validity of the 4-item Early Activity Scale for Endurance (EASE) to walking performance and physical activity scores.

METHODS

Seventy-nine children with CP participated. Parents completed the 4-item EASE. All children wore an Actigraph monitor (n = 79), and children in GMFCS levels I - III also wore a StepWatch monitor (n = 50), for seven days.

RESULTS

Only GMFCS level yielded significant differences in average strides taken per day, in strides per day taken faster than 30 strides per minute, in average physical activity counts per minute, and in minutes per day spent in moderate to vigorous physical activity. The 4-item EASE findings were moderately correlated with average physical activity counts per minute (.61, p< .001) and minutes per day spent in moderate to vigorous physical activity (.62, p < .001).

CONCLUSIONS

GMFCS level is predictive of both walking performance and physical activity in children with CP. The 4-item EASE may provide a quick and valid way to monitor physical activity in children with CP.

Barriers to and facilitators of physical activity for children with cerebral palsy in special education

AIM

To explore the barriers to and facilitators of physical activity for young people with cerebral palsy in specialist schools.

METHOD

Eleven focus groups involving 73 participants (10 young people with cerebral palsy, 13 parents of children with cerebral palsy, 27 teachers, 23 therapists) were held at two specialist schools. Focus groups were audio-recorded and transcribed verbatim. Transcripts were analysed using inductive thematic analysis by two researchers, independently.

RESULTS

Four main themes emerged from the focus groups: school priorities; student factors; staffing and environment; and roles and relationships. Physical activity was promoted when academic work and physical activity were seen as equally important school priorities. Student factors that reduced physical activity included fluctuating health, school absences, and protracted rehabilitation after surgery. The staffing and environment unique to specialist schools played a pivotal role in assisting students to be active, as was the importance of collaborative, relationship-based care.

INTERPRETATION

Physical activity programmes developed in specialist schools need to take into consideration complexities associated with the age, developmental stage, and academic requirements of young people with cerebral palsy. Particularly for adolescents, motivation was discussed as having a substantial influence on physical activity participation. These findings may assist school leadership teams, clinicians, and teachers in planning physical activity interventions.

WHAT THIS PAPER ADDS

Specialist schools offer custom-built environments that promote physical activity and inclusion for students with physical impairments. Therapists and teaching staff work creatively and collaboratively to incorporate an 'all-day' approach to providing physical activity opportunities. Balancing time spent on physical activity versus academic work can cause tension.

Adaptive Sports, Arts, Recreation, and Community Engagement

Adaptive sports and recreation have an important role in the lifestyle of individuals with cerebral palsy (CP). This article discusses the history of adaptive sports and the benefits of adaptive sports and recreation. Barriers and medical challenges are also thoroughly discussed, including common musculoskeletal issues, methods to prevent musculoskeletal injury, pain, fatigue, maximal exertion, and other medical comorbidities and illness. The role of health care providers such as physiatrists is emphasized to provide support to individuals with CP who either are interested in starting exercise or a sport or are already an athlete.

Informal Dance Intervention Improves BMI and Functional Gait in an Adolescent With Cerebral Palsy: A Case Report

PURPOSE

This case study examined the effects of incorporating Informal Dance Intervention into traditional therapy sessions on body mass index and functional walking in an adolescent girl with cerebral palsy.

CASE DESCRIPTION

A 15-year-old adolescent girl, Gross Motor Function Classification System Level II, participated in Informal Dance Intervention twice weekly in 2, 16 session phases. Sixty-minute sessions focused on waltzing, contra dancing, square dancing, and belly dancing to improve timing, endurance, vestibular functioning, and core strength.

CONCLUSIONS

Waist circumference decreased, walking speed increased on the 6-Minute Walk Test and Timed Up and Down Stairs, balance confidence increased per the Activities-specific Balance Confidence Scale, and vestibular functioning improved per changes in the Functional Gait Assessment.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Incorporating Informal Dance Intervention, in conjunction with therapy, may be motivating and improve overall health for adolescents with cerebral palsy to combat their tendency of increased sedentary lifestyle.

Dance and rehabilitation in cerebral palsy: a systematic search and review

AIM

To conduct a review of research literature on the use of dance and movement with music (rhythmic auditory stimulation [RAS]) in the neurorehabilitation of children and adults with cerebral palsy (CP).

METHOD

We conducted a systematic search and quality appraisal of the research literature on dance and RAS in CP. Additionally, we linked the research outcomes to the International Classification of Functioning, Disability and Health (ICF) framework.

RESULTS

Studies showed preliminary evidence of the benefits of dance and RAS on body functions, particularly balance, gait, walking, and cardiorespiratory fitness for individuals with CP. Research gaps are evident across all domains of the ICF, particularly in the participation and environment domains.

INTERPRETATION

To facilitate translation of quantitative research outcomes to the clinical classification of the ICF, a table was constructed that links traditional areas of quantitative rehabilitation research with the ICF categories highlighting areas of research strengths and areas where increased rigor is desirable. The potential for dance and RAS to have positive impacts on body functions, emotional expression, social participation, and attitudinal change are indicated areas for consideration in future research.

WHAT THIS PAPER ADDS

The potential for dance and movement to music help balance, gait, and walking in children and adults with cerebral palsy. Research gaps are evident across International Classification of Functioning, Disability and Health domains, particularly participation and environment domains.

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.

Developmental Trajectories and Reference Percentiles for the 6-Minute Walk Test for Children With Cerebral Palsy

PURPOSE

The purposes of this study were to document longitudinal developmental trajectories in 6-minute walk test (6MWT) distances and to develop age-specific reference percentiles for children across different Gross Motor Function Classification System (GMFCS) levels.

METHODS

A TOTAL OF: 456 children with cerebral palsy ages 3 to 12 years of, GMFCS levels I to III participated. Children's motor function was classified on the GMFCS, and children completed the 6MWT 2 to 5 times in 2 years.

RESULTS

Longitudinal developmental trajectories support that 6MWT distances increase with age followed by a tapering, as children approach their functional limit relative to their GMFCS level. Reference percentile graphs were created to monitor change over time.

CONCLUSIONS

The 6MWT longitudinal developmental trajectories, reference percentiles, and interpretation of percentile change should assist collaborative and proactive intervention planning relative to functional walking capacity for children with cerebral palsy.

Evidence-based Approach to Physical Therapy in Cerebral Palsy

Physiotherapy plays a key role in the management of cerebral palsy (CP) and comprises of various therapeutic interventions in enhancing the various physiological and functional outcomes. Though physiotherapy is used widely and recommended by all members of the health-care team, the effectiveness of physiotherapy is inconsistent. The objective of this review was to summarize and evaluate the effectiveness of physiotherapy interventions in children with CP. PubMed and Cochrane database were searched from January 2006 to April 2017 using the Medical Subject Heading and general keywords. Only systematic reviews and meta-analysis on PT interventions in children diagnosed with CP were included. Two reviewers independently assessed the methodological quality and retrieved the results. Thirty-four systematic reviews were identified that distinguished 15 different interventions. Moderate evidence of effectiveness was found for constraint-induced movement therapy for upper limb recovery, goal-directed/functional training, and gait training to improve gait speed. Conflicting evidence was found for the role of exercises on strength training and cardiorespiratory training. Intervention such as neurodevelopmental therapy (NDT) was found ineffective. This review suffer from limitations such as including reviews that had small sample size and that had considered heterogeneity of treatment interventions. Hence, the effectiveness of most PT interventions is found to be limited. On the basis of the present evidence, functional goal-oriented approaches are found to be effective and future research is required to determine the best ways to improve functional outcomes in children with CP.