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Exercise and Physical Activity Recommendations for People with Cerebral Palsy
Developmental Medicine & Child Neurology
Abstract
Physical activity and its promotion, as well as the avoidance of sedentary behaviour, play important roles in health promotion and prevention of lifestyle-related diseases. Guidelines for young people and adults with typical development are available from the World Health Organisation and American College of Sports Medicine. However, detailed recommendations for physical activity and sedentary behaviour have not been established for children, adolescents, and adults with cerebral palsy (CP). This paper presents the first CP-specific physical activity and exercise recommendations. The recommendations are based on (1) a comprehensive review and analysis of the literature, (2) expert opinion, and (3) extensive clinical experience. The evidence supporting these recommendations is based on randomized controlled trials and observational studies involving children, adolescents, and adults with CP, and buttressed by the previous guidelines for the general population. These recommendations may be used to guide healthcare providers on exercise and daily physical activity prescription for individuals with CP.
... At the end of the study, participants reported a mean exercise duration of 23.5 minutes per session, higher than their mean duration of 16.9 minutes when they first commenced the home-based programme. Nevertheless, the SHEP is a program composed of alternating aerobic and strengthening exercises program, which may not exactly conform to the current exercise recommendation for children with CP where a minimum of 20 minutes per session of aerobic exercise is recommended [24]. ...
... OMNI-RPE was selected because it is more feasible, reliable and practical than HR monitoring when performed at home under caregiver supervision. Moderate intensity training is suggested, given that children with CP are capable of and will benefit from engaging in progressively intense aerobic exercise similar to the extent recommended for their peers with typical development [24]. ...
... The findings from our study suggest that exercise is an important daily physical activity that improves the walking ability of ambulant children with CP. A recently published guideline for exercise and physical activity recommended that healthy lifestyle and physical activity should be encouraged and added as part of therapy for children with CP as they transition into adulthood [24]. Therefore, in the clinical context, SHEP can serve as an introductory tool to physical activity for young people with CP and may be potentially used as a structured and rapid exercise intervention to improve walking ability, particularly walking speed, for a short period of 8 weeks when added to standard care. ...
Objective:
To investigate outcomes after 8 weeks of a structured home-based exercise program (SHEP) for improving walking ability in ambulant children with cerebral palsy (CP).
Method:
Eleven children participated in this study (7 males and 4 females, mean age 10 years 3 months, standard deviation (SD) 3y) with Gross Motor Function Classification System (GMFCS) I-III. This study used a prospective multiple assessment baseline design to assess the effect of SHEP upon multiple outcomes obtained in three different phases. Exercise intensity was quantified by OMNI-RPE assessed by caregivers and children. Outcome assessments of walking speed, GMFM-66 and physiological cost index (PCI) were measured four times at pre-intervention (Phase 1) and at 3-weekly intervals over eight weeks during intervention (Phase 2). Follow-up assessments were performed at one month and three months after intervention (Phase 3). Statistical analyses were repeated measures ANOVA and Wilcoxon signed-rank test.
Results:
SHEP improved walking ability in children with CP, particularly for their walking speed (p= 0.01, Cohen's d= 1.9). The improvement of GMFM-66 scores during Phase 2 and Phase 3 had a large effect size, with Cohen's d of 1.039 and 1.054, respectively, compared with that during Phase 1 (p< 0.017). No significant change of PCI was observed (Cohen's d= 0.39).
Conclusion:
SHEP can be a useful intervention tool, given as a written, structured, and practical exercise program undertaken at home to achieve short term goals for improving walking ability when added to standard care.
... The study involved 18 participants with CP (13 males,[9][10][11][12][13][14][15][16][17][18][19][20][21][22] mean 14.2 ± 4.4) and 17 TDs (12 males,[9][10][11][12][13][14][15][16][17][18][19][20][21][22] year, mean 14.6 ± 4.3). At baseline, participants with CP had a 1.0 (95% confidence interval (CI) [-2.0, -0.0]) kg/ m 2 lower skeletal muscle mass index than TDs. ...
... The study involved 18 participants with CP (13 males,[9][10][11][12][13][14][15][16][17][18][19][20][21][22] mean 14.2 ± 4.4) and 17 TDs (12 males,[9][10][11][12][13][14][15][16][17][18][19][20][21][22] year, mean 14.6 ± 4.3). At baseline, participants with CP had a 1.0 (95% confidence interval (CI) [-2.0, -0.0]) kg/ m 2 lower skeletal muscle mass index than TDs. ...
... Similar to the general population [14], high levels of sedentary time and low levels of physical activity have been recognized as risk factors for poor cardiometabolic health in adults with CP [15,16]. While regular exercise may be an effective tool to improve cardiorespiratory fitness and muscle mass and strength among people with CP [17], research is lacking on whether exercise training effectively reduces cardiometabolic risk, such as blood pressure or lipids, in children and young adults with CP. Strength training is especially effective in improving motor function, muscle mass, and strength [17,18]. ...
Background
Adults with cerebral palsy (CP) have a high risk of cardiometabolic diseases. It is unknown whether this risk is elevated in young people with CP and whether exercise can reduce this risk. Therefore, we investigated the effects of the EXErcise for Cerebral Palsy (EXECP) intervention on cardiometabolic risk in children and young adults with CP and compared this risk to typically developing children and young adults (TDs).
Methods
Ambulatory male and female participants with spastic CP, aged 9–24 years, and age- and sex-matched TDs without musculoskeletal disorders were recruited. Participants with CP were measured at baseline, after a three-month control period manifesting normal development, and after the three-month strength, gait, and flexibility training intervention. TDs were measured at baseline and after the control period. They did not attend the intervention. Cardiometabolic risk factors included body weight, body fat percentage, and skeletal muscle mass index assessed with bioimpedance; resting systolic and diastolic blood pressure and aortic pulse wave velocity assessed with a non-invasive oscillometric device; fasting plasma high-density and low-density lipoprotein cholesterol, triglyceride, and glucose levels. Data were analyzed with independent samples t-tests and linear mixed-effects models adjusted for sex and age.
Results
The study involved 18 participants with CP (13 males, 9–22 year, mean 14.2 ± 4.4) and 17 TDs (12 males, 9–22 year, mean 14.6 ± 4.3). At baseline, participants with CP had a 1.0 (95% confidence interval (CI) [-2.0, -0.0]) kg/m² lower skeletal muscle mass index than TDs. During the control period, no statistically significant between-group differences were observed in the change of any outcome. In the CP group, body weight (β = 1.87, 95% CI [1.04, 2.70]), fat percentage (β = 1.22 [0.07, 2.37], and blood glucose (β = 0.19, 95% CI [0.01, 0.37]) increased, while diastolic blood pressure (β=-2.31, 95% CI [-4.55, -0.06]) and pulse wave velocity (β=-0.44, 95% CI [-0.73, -0.16]) decreased. In the TD group, only body weight increased (β = 0.85, 95% CI [0.01, 1.68]) statistically significantly. In the CP group, no changes were observed during the intervention.
Conclusions
Young people with and without CP do not exhibit significant differences in most cardiometabolic risk factors. EXECP intervention may attenuate some adverse development trajectories occurring without the intervention but greater volume and intensity of aerobic exercise may be needed to reduce cardiometabolic risk.
Trial registration
ISRCTN69044459; Registration date 21/04/2017.
... Research has revealed that the hemodynamic responses of children with CP during walking are also crucial in terms of risk factors for chronic diseases at an advanced age (9,(11)(12)(13). There is a need for applicable and effective interventions to enhance the cardiorespiratory performance of children with CP by increasing their mobility (14). ...
... (Table 3). Children with CP are less physically fit due to their handicap, which is linked to the emergence of secondary illnesses such diabetes, obesity, and cardiovascular disease (9,11,13,24). In the current literature, it is remarkable that aerobic capacity training in children with CP is performed with adaptive cycling, arm ergometer, treadmill, aquatherapy, running, and swimming (10,15). ...
... Studies show that children with CP have significantly lower cardiorespiratory capacity than their peers (13,28). ...
This study aimed to determine the effects of MPE and neurodevelopmental therapy (NDT) on hemodynamic responses in children with Cerebral Palsy (CP). Materials and Methods: 18 children with CP between expanded&revised gross motor function classification system (GMFCS-E&R) I-III were randomized into two groups as study (MPE) and control (NDT). Pressure Biofeedback Unit Test (PBU), 6-minute walk test (6MWT), core stability tests were performed. Hemodynamic responses (heart rate (HR), respiratory rate (RR), blood pressure (BP)) were measured before and after the 6MWT and physiotherapy sessions (PS). Results: Significant difference was found in the abdominal fatigue test (AFT) (p=0.014), modified side bridge (MSBT) test (p
... PA benefits children with CP by improving cardiorespiratory endurance, muscle strength and functional mobility while reducing SB and associated health risks. Additionally, it enhances bone health, posture and psychological well-being, contributing to a better quality of life (Verschuren et al. 2016). However, research reveals that children with CP report a high frequency of participation in sedentary activities and low participation in leisure-time PA (Vila-Nova et al. 2020;Souto et al. 2023). ...
... The checklist applies to all levels of functioning, promoting a 24-h activity framework for both ambulant (GMFCS I-III) and nonambulant (GMFCS IV and V) children with CP. Clinicians should consider that although opportunities for vigorous PA are limited for nonambulant children (e.g., framerunning), incorporating supported weight-bearing activities and transitions from sitting to standing, alongside reduced SB and optimized sleep, can contribute to increased energy expenditure and overall health (Verschuren et al. 2016). Furthermore, the checklist allows comments and questions, providing an opportunity for parents to express their concerns and seek advice. ...
Background
The importance of 24‐h movement behaviour, including sleep, physical activity (PA) and sedentary behaviour (SB), has gained prominence due to its significant impact on the health and development of children, including those with cerebral palsy (CP). The 24‐h activity checklist for CP, a tool developed in the Netherlands to monitor the activity in CP paediatric population, requires translation and cultural adaptation to Portuguese for use in Brazil and Portugal.
Methods
This cross‐sectional methodological study involved translating and culturally adapting the 24‐h activity checklist for CP into Brazilian Portuguese (BP) and European Portuguese (EP) languages. The process included forward translation, synthesis and backward translation, expert panel evaluation and pretesting. Brazilian and Portuguese experts appraised content validity, assessed by the individual item (I‐CVI) and scale level content validity index scores (S‐CVI/Ave). Sixty parents of children with CP participated in the test–retest analysis, reported with the Intraclass Correlation Coefficients (ICCs).
Results
I‐CVI scores were higher than 0.78 for both versions. S‐CVI/Ave scores were considered excellent for BP (0.91) and EP version (1.0). Expert's appraisal results in the inclusion of a question about sleep‐related time indicators and the split of sleep, PA, and screen time questions for weekdays and weekends. Brazilian and Portuguese parents of children with CP reported understanding on instructions, questions, and answer options. The ICC values range from 0.81 to 0.99 and 0.6 to 0.98, for BP and EP, respectively.
Conclusions
The BP and EP versions of 24‐h activity checklist for CP demonstrated good content validity and test–retest reliability, supporting its use in Brazil and Portugal. This tool can contribute to improving communication between families and healthcare professionals to monitor and develop tailored interventions for healthy movement behaviours in children with CP.
... These features are driven by several factors, such as changes in body composition (e.g., increased body fat and prominent sarcopenia), decreased physical activity, and impaired nutrition intake. Evidence suggests that growth patterns in CP differ according to level of function based on the GMFCS, and more severe motor impairments are associated with increased growth impairment [11]. These growth trends are important to identify proper dietary interventions. ...
... It is important to understand these variations when providing adequate nutritional support. In children with CP, equations have been developed that consider GMFCS levels as well as the particular movement patterns and used to predict energy needs with greater accuracy [9][10][11][12]. ...
Cerebral palsy (CP) is a neurodevelopmental disorder with marked heterogeneity that broadly affects motor function and quality of life in the paediatric population. This narrative review purposes the role of synergism between nutritional interventions and physiotherapy in paediatric CP. Using a review of contemporary relevant literature and clinical evidence, we discuss the possible advantageous role of structuring individualised nutritional inputs in conjunction with specifically structured physiotherapy programs, to enhance outcomes including gross motor function, strength and overall functional capacity. There is a need for integrated approaches for CP management and the review demonstrates how attention to nutritional status can enhance the benefit of physiotherapy treatment and how physiotherapy can enhance nutritional status through improved feeding ability and general metabolic function. We present data to support the notion that these interventions are synergistic and offer clinical recommendations for implementation. A more successful integrating approach to the underlying causes of CP in children will enable health professionals to develop more effective treatment strategies.
... Recently, interventions for children with CP have shifted from a focus on improved attainment of developmental milestones for motor skills to include improved PA (Damiano, 2006;Rowland et al., 2015;Verschuren et al., 2016). PA guidelines for people with CP were launched to promote healthy lifestyles and prevent the risk of cardiovascular and metabolic diseases (Verschuren et al., 2016). ...
... Recently, interventions for children with CP have shifted from a focus on improved attainment of developmental milestones for motor skills to include improved PA (Damiano, 2006;Rowland et al., 2015;Verschuren et al., 2016). PA guidelines for people with CP were launched to promote healthy lifestyles and prevent the risk of cardiovascular and metabolic diseases (Verschuren et al., 2016). Regarding children with neurodevelopmental disabilities, a systematic review reported that engaging in active physical leisure activities such as cycling or horse riding was positively associated with better QoL. ...
Aims:
To measure the quality of life in children with impaired walking who receive a mobility assistance dog (MAD).
Methods:
The parents of ten children who received a MAD completed the cerebral palsy quality of life questionnaire, before receiving their dog and at one, three, and six-month follow-up. Data were analyzed to assess changes for each participant and to the group.
Results:
The group showed a positive change in the domains of social well-being and acceptance, feelings about functioning, and emotional well-being and self-esteem after six months. Children with less impairment (GMFCS I-II) showed a change in social-wellbeing and acceptance, feelings about functioning, participation, physical health, and emotional-wellbeing and self-esteem after six months. Children with more impairment (GMFCS III-IV) showed no change at any timepoint measured.
Conclusions:
This novel therapeutic area of receiving a MAD demonstrated some positive quality of life changes after six months for a small group of children with impaired walking. These are preliminary findings in a small sample and this intervention would benefit from further study.
... CP is the most common form of childhood disability, and measures are needed to combat the neuromuscular impairments and the resulting secondary musculoskeletal challenges, including inactivity, muscle weakness and altered muscle geometry (2). Training recommendations for patients with CP have been formulated, proposing a combination of high-intensity resistance and endurance training (12). These guidelines however have no proof-of-concept and present a myriad of barriers which hinders effective participation, expanding from emotional and environmental to economic factors (13). ...
... Exercise recommendations for CP populations aim at increasing muscle mass and strength to increase independence and movement in daily life while simultaneously reducing physical limitations and secondary health issues (12). Despite attending the training sessions, the CP trained population still show low levels of moderate-to-vigorous activity levels (194 min/week) compared with the TD trained group (503 min/week). ...
Background
This cross-sectional study examined whether exposure to long-term resistance and endurance training can counteract muscular weakness on a functional, neurological and structural level in adolescents with cerebral palsy (CP) compared with typically-developed peers (TD) in dependence of training status.
Methods
Five trained (4 males; mean age: 19.8) and four untrained adolescents with CP (3 males; 20.2) were compared with nine age- and sex-matched TD trained (7 males; 19.8) and nine untrained TD peers (7 males; 20.3). Isometric and isokinetic measurements assessed strength in knee flexion and extension, voluntary activation (VA) was assessed by the twitch interpolation technique and ultrasound imaging of the m. quadriceps was performed to assess anatomical cross sectional area (ACSA). Both legs were assessed in all participants.
Results
CP trained showed lower absolute isometric strength (dominant: -18% [-48; 11]; non-dominant: -35% [-58; -11]) than TD untrained while CP untrained showed between 29% and 33% lower strength than TD untrained. VA in CP trained (dominant: -13% [-23; -3]; non-dominant: -10% [-30; 11]) and CP untrained (dominant: -14% [-23; -4]; non-dominant: -8% [-29; 13]) showed similar deficits compared with TD untrained. CP trained showed higher ACSA than TD untrained in the dominant leg of the m. vastus lateralis (+ 16% [-7; 38]), while the non-dominant side showed lower values (-18% [-45; 9]).
Conclusion
Exposure to long-term resistance and endurance training is associated with a smaller gap in maximum strength and muscle volume in the dominant leg of adolescents with CP while neural drive does not seem to be affected by training exposure.
Trial registration
ClinicalTrials.gov Identifier NCT05859360 / Registration date May 4, 2023
... Maltais et al. further found that individuals who engage in at least 30 minutes of moderate-intensity exercise (i.e., 60-75% of HR max or 50% of VO2 peak uptake) have improved cardiac output, compared to their pre-exercise levels [7]. An eight-week physical fitness intervention in children with GMFCS levels I and II resulted in a 23% increase in their cardiorespiratory endurance [7], and a threemonth intervention led to a 15% increase in cardiorespiratory endurance in those with GMFCS levels II and III [8]. ...
... Unlike previous research primarily focused on typically developing individuals, this study addresses the unique physical characteristics and capabilities of children with CP, filling a critical gap in the literature [8]. However, this study specifically examines the response of children with CP to cardiovascular endurance training and its impact on their fatigue levels. ...
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.
... Contrary to what was described in able-bodied football players aged > 30 years, who presented a lower physical performance compared to younger ager groups (13)(14)(15), the present results seem to suggest that age does not influence components such as vertical jump, sprint capacity, change of direction ability and dribbling. Possibly, the absence of differences between age groups could be due to less and later access to sport participation in para-athletes, for who rehabilitation therapies are an important part of children and adolescents' lives, and the transition between traditional rehabilitation and community-based sports activity programs could influence the competitive development process [34,35]. A prior research in elite youth players without disability suggests that for talent identification is necessary to consider maturity status and performance variables as tactical position-specific, reinforcing the multifactorial nature of the sport and opening the door to explore this aspect in players with CP [36]. ...
... Another feature to take into account in adults with CP includes early declines in motor function, which may start earlier than adulthood, conditioned by a potential mechanism associated with the secondary consequences of the primary neurological insult with an accelerated progression of muscle pathology [38,39]. The non-significant differences between age groups could reflect the benefit from the systematic sport participation on the evaluated player's physical fitness, although further research is needed to confirm the effect of football practice in the prevention of long-term health risks in football players with CP [34]. ...
... Specifically, the majority of children and adolescents with CP are insufficiently active for good health 5 and, compared with those who are ambulant, those with CPHSN are more sedentary and less physically active. 6 It is plausible that the relatively greater gross motor decline of adolescents with CPHSN is caused, at least in part, by their relatively low levels of habitual physical activity. ...
... Finally, free-living physical activity was not measured during the baseline or withdrawal periods. Although people with CPHSN typically accumulate low volumes of daily activity 6 and no training was conducted during these periods, we did not control for this effect. ...
Objective
This study aims to evaluate the effect of a performance-focused swimming programme on motor function in previously untrained adolescents with cerebral palsy and high support needs (CPHSN) and to determine whether the motor decline typical of adolescents with CPHSN occurred in these swimmers.
Methods
A Multiple-Baseline, Single-Case Experimental Design (MB-SCED) study comprising five phases and a 30-month follow-up was conducted. Participants were two males and one female, all aged 15 years, untrained and with CPHSN. The intervention was a 46-month swimming training programme, focused exclusively on improving performance. Outcomes were swim performance (velocity); training load (rating of perceived exertion min/week; swim distance/week) and Gross Motor Function Measure-66-Item Set (GMFM-66). MB-SCED data were analysed using interrupted time-series simulation analysis. Motor function over 46 months was modelled (generalised additive model) using GMFM-66 scores and compared with a model of predicted motor decline.
Results
Improvements in GMFM-66 scores in response to training were significant (p<0.001), and two periods of training withdrawal each resulted in significant motor decline (p≤0.001). Participant motor function remained above baseline levels for the study duration, and, importantly, participants did not experience the motor decline typical of other adolescents with CPHSN. Weekly training volumes were also commensurate with WHO recommended physical activity levels.
Conclusions
Results suggest that adolescents with CPHSN who meet physical activity guidelines through participation in competitive swimming may prevent motor decline. However, this population is clinically complex, and in order to permit safe, effective participation in competitive sport, priority should be placed on the development of programmes delivered by skilled multiprofessional teams.
Trial registration number
ACTRN12616000326493.
... In addition, recent research has highlighted the unmet health service needs for this population, particularly related to physiotherapy [11]. Facilitating adults with disability to exercise in community settings helps to promote self-management of their condition and may subsequently reduce their needs for healthcare services, in addition to reducing long-term health risks and slowing deterioration in mobility [12][13][14]. ...
... A physical activity referral programme for adults with childhood-onset disability in tandem with appropriate adaptations and support may also help to address unmet health service needs [11], and facilitate this population to take more ownership in managing their condition and maintaining their mental wellbeing. Whilst subsequent implementation and evaluation of such a programme requires dedicated and sustained funding, it has potential to reduce burden on health service resources in the long term [49] by reducing the risk of developing other chronic conditions and slowing the decline in mobility associated with age [12][13][14]. It also aligns to this population's desire to move away from physical activity within traditional therapy settings [50]. ...
Purpose:
Explore community-based gym exercise for non-ambulant adults with childhood-onset disability.
Materials and methods:
Non-ambulant adults with childhood-onset disability participated in four, weekly gym sessions co-facilitated by physiotherapists and exercise professionals. Practicalities of participating in the sessions were recorded via uptake and attrition, weekly surveys, and focus groups. Perspectives of those who designed/delivered the study were gathered via weekly debrief meetings. Quantitative data were analysed descriptively, qualitative data were analysed thematically.
Results:
Ten non-ambulant adults with childhood-onset disability participated; 70% completed all exercise sessions. Focus groups identified three themes. "I wouldn't be able to exercise…there's no option for a community-based setting" described the lack of opportunities for exercise in gyms. "You don't realise the benefit of coming here" highlighted benefits of exercise. "We can do better" had two sub-themes: problem solving and ingredients for community-based gym exercise. Weekly feedback and debrief meetings identified practicalities related to equipment, exercises, and collaborative working between facilitators.
Conclusions:
Whilst there is an interest in community-based gym exercise for non-ambulant adults with childhood-onset disability, there remains a lack of inclusive gyms. Co-design of inclusive gym guidelines and condition-specific physical activity referral scheme may enhance opportunities for participation in gym exercise for adults with childhood-onset disability.
... The WHO physical activity guidelines for children and adolescents with disabilities do not differ from those for children and adolescents without disabilities. Further disease-specific recommendations for children with cerebral palsy (CP) are provided by Verschuren et al. [4], who found a positive effect of exercising at an intensity of 60-95% of maximum heart rate at least two to three times per week. Contrary to long-standing concerns about the potential risks of cardiorespiratory exercise for children with CP, their results indicated a low incidence of injury. ...
Background/Objectives: The GO-TRYKE® Kid (GTK®) is an arm- and leg-powered tricycle which, in addition to promoting strength, endurance, and coordination, aims to reactivate the central pattern generators of the spine for locomotion through cyclical movements. The present study investigated the effects of GTK® training on walking ability, GTK® riding performance, and health-related quality of life in children with walking disabilities. Methods: Nine children trained with the device twice a week for nine weeks. Short- and long-term effects on walking ability were measured using the timed up and go test (TUG) and the two-minute walk test (2MWT). GTK® riding performance and health-related quality of life were compared before and after the intervention period. Results: While no long-term effect on walking was found, a significant short-term effect on functional walking ability was observed (p = 0.009). GTK® riding performance improved significantly over the training period (p = 0.004). There were no significant changes in health-related quality of life. Conclusions: GTK® enables children with walking disabilities to participate in cycling as part of play and sport. Further research is required to investigate its functional and participatory effects, as there is significant potential to improve physical activity and overall well-being in this population.
... We have three pre-determined categories, which may be rather low compared to the number of activities from the protocol. Combining the activity standing with sitting and lying activities in one category 'stationary' activities can be criticized because among children with more severe mobility impairments, standing and transitions represent significant movement targets in therapy [60]. After careful consideration, we chose to combine those activities, because the AM-p does not change position when comparing sitting to standing. ...
Background
Pediatric healthcare professionals facilitate children to enhance and maintain a physically active lifestyle. Activity monitors (AM) can help pediatric healthcare professionals assess physical activity in everyday life. However, validation research of activity monitors has often been conducted in laboratories and insight into physical activity of children in their own everyday environment is lacking. Our goal was to study the criterion validity of a prototype AM (AM-p) model in a natural setting.
Methods
Cross-sectional community-based study with ambulatory children (2-19 years) with and without developmental disability. Children wore the AM-p on the ankle and were filmed (gold standard) while performing an activity protocol in a natural setting. We labelled all videos per 5-second epoch with individual activity labels. Raw AM-p data were synchronized with activity labels. Using machine learning techniques, activity labels were subdivided in three pre-defined categories. Accuracy, recall, precision, and F1 score were calculated per category.
Results
We analyzed data of 93 children, of which 28 had a developmental disability. Mean age was 11 years (SD 4.5) with 55% girls. The AM-p model differentiated between ‘stationary’, ‘cycling’ and ‘locomotion’ activities with an accuracy of 82%, recall of 78%, precision of 75%, and F1 score of 75%, respectively. Children older than 13 years with typical development can be assessed more accurately than younger children (2-12 years) with and without developmental disabilities.
Conclusion
The single ankle-worn AM-p model can differentiate between three activity categories in children with and without developmental disabilities with good accuracy (82%). Because the AM-p can be used for a heterogenous group of ambulatory children with and without developmental disabilities, it may support the clinical assessment for pediatric healthcare professionals in the future.
... This supports understanding that movement and weight-bearing activities are essential for healthy bone development. In children with CP, maintaining mobility, even at minimal levels, could be a crucial factor in preventing long-term complications such as osteoporosis or bone fractures, which are common in this population due to reduced physical activity (27). By contrast, non-ambulant children are more likely to experience secondary complications, such as contractures, pressure sores, and poor cardiopulmonary function due to prolonged immobility. ...
... It is important to recognize that PA levels of children with disabilities trend even lower as they demonstrate high levels of sedentary behavior and low levels of moderate to vigorous PA. Thus, identifying realistic PA opportunities for this often under-represented population is essential (4). Since 1973, United States' federal regulations have supported the inclusion and participation of children with disabilities in public school programming, including physical education (5). ...
Introduction
Pediatric therapists in school-based practice can incorporate exercise promotion through adaptive cycling for children with disabilities who experience high levels of sedentary behavior and low levels of moderate to vigorous activity.
Methods
The impacts of an adaptive cycling pilot program for children with disabilities were investigated through a community-based participatory study. During an eight-week intervention, students had a goal of riding adaptive cycles three times a week for twenty minutes. Using a pre-and post-test design, primary outcomes included individualized goal attainment scaling (GAS) linked to students' individualized education plans (IEP) and the 6-minute cycling test (6MCT) measuring cycling distance. Secondary outcomes included cycling duration over time, assistance levels for pedaling and steering, a “happiness scale”, and overall program satisfaction of parents and teachers. To prevent harm, pain behavior was examined using the Faces, Legs, Activity, Cry, Consolability (FLACC).
Results
Cycling had a positive impact on students with disabilities. No increased levels of pain behavior or adverse events were reported. Individual GAS T-score means significantly improved to 0.24 and program effectiveness achieved a T-score value of 50.53. The mean distance of 6MCT increased from 728.95 feet to 880.5 feet. Secondary measures also documented significant improvement. Parents and teachers reported high overall satisfaction.
Discussion
Adaptive cycling can incorporate needed physical activity into the school day and also support the achievement of IEP goals, physical activity capacity, and emotional happiness. Scaling adaptive cycling programs for children with disabilities should be considered an excellent opportunity for educational growth, health, and well-being.
... 5 Children living with disability are less likely to be physically active compared with those without a disability. [5][6][7] PA guidelines report that children from 5 to 17 years of age with and without disabilities should be active for an average of at least 60 minutes per day in moderate-to-vigorous activity (MVPA), as well as engaged in activities designed to strengthen muscle and bone at least 3 days a week and should limit sedentary time. 5,8 The WHO defines the age range of 2-19 years old as encompassing childhood and adolescence. ...
Objective
To evaluate psychometrics of wearable devices measuring physical activity (PA) in ambulant children with gait abnormalities due to neuromuscular conditions.
Data Sources
We searched PubMed, Embase, PsycINFO, CINAHL, and SPORTDiscus in March 2023.
Study Selection
We included studies if (1) participants were ambulatory children (2-19y) with gait abnormalities, (2) reliability and validity were analyzed, and (3) peer-reviewed studies in the English language and full-text were available. We excluded studies of children with primarily visual conditions, behavioral diagnoses, or primarily cognitive disability. We performed independent screening and inclusion, data extraction, assessment of the data, and grading of results with 2 researchers.
Data Extraction
Our report follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We assessed methodological quality with Consensus-based Standards for the selection of health measurement instruments. We extracted data on reported reliability, measurement error, and validity. We performed meta-analyses for reliability and validity coefficient values.
Data Synthesis
Of 6911 studies, we included 26 with 1064 participants for meta-analysis. Results showed that wearables measuring PA in children with abnormal gait have high to very high reliability (intraclass correlation coefficient [ICC]+, test-retest reliability=0.81; 95% confidence interval [CI], 0.74-0.89; I²=88.57%; ICC+, interdevice reliability=0.99; 95% CI, 0.98-0.99; I²=71.01%) and moderate to high validity in a standardized setting (r+, construct validity=0.63; 95% CI, 0.36-0.89; I²=99.97%; r+, criterion validity=0.68; 95% CI, 0.57-0.79; I²=98.70%; r+, criterion validity cutoffpoint based=0.69; 95% CI, 0.58-0.80; I²=87.02%). The methodological quality of all studies included in the meta-analysis was moderate.
Conclusions
There was high to very high reliability and moderate to high validity for wearables measuring PA in children with abnormal gait, primarily due to neurological conditions. Clinicians should be aware that several moderating factors can influence an assessment.
... CP is a group of permanent but not immutable disorders of movement and/or posture and motor function due to a non-progressive interference, injury, or abnormality of the developing/immature brain [12]. Some research shows that individuals with CP who exercise and play sports experience improved health benefits, such as cardiorespiratory endurance [13][14][15]. Studies also point to the benefits of some types of muscle-strengthening exercises in adolescents with CP, such as strength gain and improvement in motor activity and walking ability [16,17]. ...
Introduction: Systematic reviews and meta-analyses point to the benefits of physical exercise for adolescents with cerebral palsy, improving physical conditioning, muscle strength, balance, and walking speed. However, given the high number of reviews that include randomized and non-randomized studies, it is increasingly necessary to assess the methodological quality of these reviews. This scoping review investigated the methodological quality of systematic reviews and meta-analyses on the effects of physical exercise in adolescents with cerebral palsy to elucidate the methodological limitations of the research and the priorities to be observed in future research. Method: The electronic search used PubMed, Web of Science, and Cochrane. Studies published between 2016 and 2023 were selected. The terms used were “cerebral palsy” combined with “physical fitness”, “exercise”, and “physical activity”. Results: A total of 219 original reviews were selected. Of these, 19 reviews were included for data analysis. AMSTAR2 was used to assess the methodological quality of the reviews. Three reviews presented high methodological quality (15.78%) and three had moderate methodological quality (15.78%). The remaining reviews had low or critically low methodological quality, according to AMSTAR2. Interpretation: This study evidenced that systematic reviews have variable methodological quality and that new studies are still needed.
... [8][9][10][11][12] Participation in ADL is essential for health, personal autonomy, physical, emotional and psychosocial development, productivity, communication skills, well-being and quality of life of all children with or without disabilities. [13][14][15][16] However, children with CP face more participation limitations in different activities of daily life than their typically developing peers. 9,17,18 Reduced engagement in physical and leisure activities in children with CP due to their physical disability can also negatively affect their social relationships, interests and academic performance. ...
The aim of this correlational study was to compare the participation in out of school activities, activity preferences, and quality of life (QoL) of children between 8 and 12 years of age with cerebral palsy (CP) (n = 30) and typical development (n = 60) in Turkey. Outcome measures included the Children's Assessment of Participation and Enjoyment, Preferences for Activity of Children, and the Health-Related Quality of Life Questionnaire. Results suggest children with CP were at a disadvantage compared to their typically developing peers in participating in out-of-school activities, however they tended to report greater preference for these activities than their typically developing peers. Based on these findings, we recommended health professionals aim to increase the quality of life for clients with CP by including social participation as one component of rehabilitation.
... Research supports exercise for adults with CP and has been shown to have effective, positive effects on their general health, specifically relief of pain and fatigue. [70][71][72] Future research should include adults with CP in virtual exercise interventions. ...
Objective
To analyze existing literature on virtual exercise interventions delivered to people with disabilities to assess effectiveness, efficiency, usability, satisfaction, and feasibility, and describe current trends that aimed to improve health outcomes among people with disabilities.
Data Sources
CINAHL, MEDLINE, and PsycINFO were searched.
Study Selection
Articles were included if they were (1) incorporated a virtual exercise intervention including people with physical disabilities and mobility limitations aged 18 years and older and (2) published between the years of 2009-August 14, 2024 with free access to full-text, peer-reviewed papers; and (3) published in English. Exclusion criteria: (1) unrelated to disability; (2) non–peer-reviewed articles; (3) protocol or review papers; (4) study focused on virtual exercise through perspective other than that of the participant; (5) study's primary objectives were not related to physical functioning and/or rehabilitation; and (6) study used only qualitative methods.
Data Extraction
A single search was conducted from January 2023 and ceased on August 14, 2023. Duplicate records were pulled from the article search within each database; article abstracts were assessed; and finally, full-text articles were retained upon meeting inclusion criteria. The primary researcher conducted the initial search, while 2 independent reviewers, J.R. and J.W., assisted with and confirmed article extraction.
Data Synthesis
Thirty-seven articles were included. Trends were explained by recapitulating statistically significant results per study among each disability group and virtual exercise delivery mode, exercise type, and intervention synchronicity.
Conclusions
More facilitators, satisfaction, usability, and perceived benefits were reported when compared to reported barriers among people with physical disabilities and mobility limitations who participated in virtual exercise interventions.
... machine-based exercises), insufficient loading, and the unique impairments associated with CP. 10 Reviews indicate that training protocols incorporating functional tasks and closed-chain isotonic exercises are more likely to enhance motor learning and facilitate the transfer of the strength gains to daily activities, gait, and mobility. [10][11][12][13] A systematic review and meta-analysis by Shilesh et al. (2023) 14 demonstrated that functional training, involving open and closed-chain exercises using free weights or body weight applied approximately three times a week for 12 weeks, had a moderate-to-large positive effect on Gross Motor Function (GMFM D and E) 15 in children with spastic CP. Additionally, recent studies have highlighted the potential benefits of high-intensity training. ...
Purpose:
This pilot study assessed the safety and effects of progressive functional high-intensity training in a group setting for adolescents with unilateral cerebral palsy (CP) on daily function indicators.
Methods:
Nine adolescents (mean age 16.9 years, GMFCS levels I-II) participated in 12 weeks of training (2x/week). Evaluations included 3D gait analysis, the 6-min walking test (6MWT), clinical exams, and the Gross Motor Function Measure-66 (GMFM-66).
Results:
No adverse events occurred, and GMFM-66 scores significantly improved (p = .031, Δ = 2.19%). Although increases in 6MWT (p = .09, Δ = 29.8 m) performance and propulsion ratio (p = .067, Δ = 5.4%) for the affected leg were observed, they were not statistically significant.
Discussion:
The study suggests that this training is safe and may enhance gross motor function, endurance, and gait asymmetry in unilateral CP. Future research should include upper limb evaluations and out-of-clinic motion analysis with wearable inertial measurement units (IMUs) to provide a more comprehensive assessment of functional movements.
... Cho and Lee (2020) conducted a randomized control trial with 25 children with spastic CP performing functional progressive resistance exercise for 30 minutes, 3x/wk, for 6 weeks and found improved strength assessed with hand-held dynamometer, increased rectus femoris cross-sectional area and quadriceps thickness on ultrasound imaging, and improved functional ability on GMFM-88. Verschuren et al. (2016) reviewed dosing recommendations for exercise and physical activity for CP. A scoping review by Mooney and Rose (2019) found weakness and spasticity were improved with single-channel neuromuscular electrical stimulation (NMES) during gait for children with CP. ...
Identification of neuromuscular impairments in cerebral palsy (CP) is essential to providing effective treatment. However, clinical recognition of neuromuscular impairments in CP and their contribution to gait abnormalities is limited, resulting in suboptimal treatment outcomes. While CP is the most common childhood movement disorder, clinical evaluations often do not accurately identify and delineate the primary neuromuscular and secondary musculoskeletal impairments or their specific impact on mobility. Here we discuss the primary neuromuscular impairments of CP that arise from early brain injury and the progressive secondary musculoskeletal impairments, with a focus on spastic CP, the most common form of CP. Spastic CP is characterized by four primary interrelated neuromuscular impairments: 1. muscle weakness, 2. short muscle-tendon units due to slow muscle growth relative to skeletal growth, 3. muscle spasticity characterized by increased sensitivity to stretch, and 4. impaired selective motor control including flexor and extensor muscle synergies. Specific gait events are affected by the four primary neuromuscular impairments of spastic CP and their delineation can improve evaluation to guide targeted treatment, prevent deformities and improve mobility. Emerging information on neural correlates of neuromuscular impairments in CP provides the clinician with a more complete context with which to evaluate and develop effective treatment plans. Specifically, addressing the primary neuromuscular impairments and reducing secondary musculoskeletal impairments are important treatment goals. This perspective on neuromuscular mechanisms underlying gait abnormalities in spastic CP aims to inform clinical evaluation of CP, focus treatment more strategically, and guide research priorities to provide targeted treatments for CP.
... They also emphasize the need for more rigorous research methods, including randomized controlled trials (RCTs) and quasi-RCTs. 26 Another one study presents the first CPspecific physical activity and exercise recommendations. These recommendations are based on a comprehensive review of the literature, expert opinion, and extensive clinical experience. ...
Background: Cerebral palsy (CP) is a prevalent childhood disability caused by developmental issues in the brain, leading to movement and posture impairments. Caregivers of children with CP often experience heightened stress due to factors such as the caregiver's attributes, the extent of the child's disability, their shared history, and social elements. Despite the family-centered approach in research, a comprehensive perspective on the overall impact on parents and factors influencing their coping mechanisms is lacking. Our study aims to fill this gap by exploring caregivers' perceptions of the value of and compliance with prescribed exercise regimens for children with CP, contributing to the development of more effective, holistic, and family-centered interventions for managing CP. Aim of the study: Explore perceptions about the value of exercise regimens for children with cerebral palsy. Objective: To evaluate the importance of exercises in terms of physical, general health and psychological well-being in children with cerebral palsy (CP). Material and Method: A total of 100 participants, male and female from different areas and town of Surat city were selected for the study as per the eligibility criteria. Age range of the child was 1-15 years. An interview-based questionnaire was developed to assess the awareness and validated for its content validity by five experts. After validation, participants were asked to fill out the questionnaire and the data was transferred to Microsoft excel and IBM SPSS for further analysis. Result: Among the study participants, 85% of respondents emphasize importance of exercises. 57% reported significant improvements in mobility. While more significant improvements are noted in muscle strength (60%) and coordination and balance (62%). The impact of exercises on overall health is considered significant by 72% and on independency was 57%. Furthermore, 67% highlight the significant role of exercises in encouraging emotional wellbeing and confidence building. Conclusion: Individuals were found to have a good understanding of the importance of exercise to improve overall health, balance coordination, muscle strength, confidence, social interaction in Surat city. It is more significant with education of the parents and caregiver of child with cerebral palsy. This study showed that opinion about the value of and compliance with exercise regimen was equivalent to that of developed countries Keywords: Cerebral Palsy (CP), Parenting caregivers, Exercise regimen, Physiotherapy, Pediatric rehabilitation, Perspectives, Caregiver burden, Therapy adherence.
... Most young people with physical disability do insufficient physical activity [1][2][3][4] . This has significant implications for their future health 5 . ...
Objective The objective of this scoping review is to identify evidence of collaboration between healthcare and recreational sectors aimed at supporting community-based physical activity participation among young people with childhood-onset physical disability. Introduction Most young people with physical disabilities do insufficient physical activity, significantly impacting their future health. There have been long outstanding calls for collaboration between healthcare and recreational professionals to support physical activity participation for people with disabilities. Given the importance of physical activity and the roles of health and recreational professionals, there is a need to systematically identify evidence on collaborative strategies between sectors, describe the experiences of all individuals involved in delivering and receiving these collaborations and describe any outcomes measured as part of implementing these strategies. Inclusion criteria This review will include studies that involve healthcare professionals and recreational professionals working together to support community based physical activity. Specifically aimed young people aged 10 to 24 years with childhood-onset physical disabilities. Studies that report the experiences of individuals in delivering and receiving these collaborations will be included as well as studies that describe an evaluation of collaborative strategies. Methods This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology of scoping reviews. A comprehensive search strategy will be developed in consultation with an information specialist. The following databases will be searched: MEDLINE, CINAHL, Embase, Web of Science and Scopus. The review will consider studies of any design that address collaboration between health and recreation sectors including qualitative, quantitative and mixed-methods study designs. Two reviewers will independently screen each retrieved title and abstract and assess full-text articles against the inclusion criteria to determine eligibility. Data will be extracted and synthesized quantitively and qualitatively and mapped to a relevant framework.
... The progression of intervention has shifted the focus from primarily addressing the underlying symptoms and impairments to improve function, to instead focusing on training activities and real-life tasks that hold significance to the individual [12]. In addition, there is a requirement to promote increased engagement in exercise, in line with recommendations, to attain elevated levels of fitness, diminish risk factors for diseases, and minimize subsequent problems such as premature functional decline [21]. Exercise programs for cerebral palsy exhibit significant variation in terms of their types, such as gait training, body-weight-supported treadmill training, balance training, or multi-component approaches, and the efficacy of different exercises has not been established in improving the functional abilities of children with cerebral palsy [13,[22][23][24]. ...
Objective
To determine the effectiveness of exercise intervention on postural balance, gait parameters, and muscle strength in children with cerebral palsy by quantifying the information from randomized controlled trials (RCTs).
Methods
We conducted a systematical search for RCTs from the databases, including PubMed, ISI Web of Science, and Scopus using a between-group design involving children with cerebral palsy and assessing the effect of exercise intervention on postural balance, gait parameters, and muscle strength. The specified inclusion criteria were determined by the PICOS tool. The outcomes of included studies were evaluated by meta-analysis, and subgroup and sensitivity analyses were conducted to analyze the observed heterogeneities using Review Manager 5.4 and Stata version 18.0. The revised Cochrane risk of bias tool for randomized trials (RoB 2) was used to evaluate the risk of bias and quality of the included studies.
Results
Twenty-four studies were included in this meta-analysis, with 579 children with cerebral palsy. Exercise intervention showed a statistically significant favorable effect on gross motor function (SMD = 0.32; 95%CI [0.03 to 0.61]; I² = 16%), anteroposterior stability index (SMD = -0.93; 95%CI [-1.69 to -0.18]; I² = 80%), and mediolateral stability index (SMD = -0.60; 95%CI [-1.16 to -0.03]; I² = 73%) compared to control group among children with cerebral palsy. None of the above meta-analyses exhibited publication bias, as indicated by Egger’s test with p-values greater than 0.05 for all.
Conclusions
Exercise is effective in improving gross motor function and balance in children with cerebral palsy. Due to the lack of studies examining the efficacy of each exercise type, we are unable to provide definitive training recommendations.
... Dynamic balance was measured using the end-point maximal excursion test, the maximal limit of stability test, the maximal antero-posterior sway tests, and the maximal antero-direction test. Results showed a significant and moderate effect of the intervention compared with the control groups (i.e., all four receiving standard therapy): ES = 0. 85 ...
The aim of this systematic review was to assess the effects of plyometric-jump training (PJT) on the physical fitness of youth with cerebral palsy (CP) compared with controls (i.e., standard therapy). The PRISMA 2020 guidelines were followed. Eligibility was assessed using the PICOS approach. Literature searches were conducted using the PubMed, Web of Science, and SCOPUS databases. Methodological study quality was assessed using the PEDro scale. Data were meta-analyzed by applying a random-effects model to calculate Hedges' g effect sizes (ES), along with 95% confidence intervals (95% CI). The impact of heterogeneity was assessed (I2 statistic), and the certainty of evidence was determined using the GRADE approach. Eight randomized-controlled studies with low-to-moderate methodological quality were included, involving male (n = 225) and female (n = 138) youth aged 9.5 to 14.6 years. PJT interventions lasted between 8 and 12 weeks with 2–4 weekly sessions. Compared with controls, PJT improved the muscle strength (ES = 0.66 [moderate], 95% CI = 0.36–0.96, p < 0.001, I2 = 5.4%), static (ES = 0.69 [moderate], 95% CI= 0.33–1.04, p < 0.001, I2 = 0.0%) and dynamic balance (ES = 0.85 [moderate], 95% CI = 0.12–1.58, p = 0.023, I2 = 81.6%) of youth with CP. Therefore, PJT improves muscle strength and static and dynamic balance in youth with CP compared with controls. However, more high-quality randomized-controlled trials with larger sample sizes are needed to provide a more definitive recommendation regarding the use and safety of PJT to improve measures of physical fitness.
... Its goal is to help individuals maintain functionality, alleviate spasticity, prevent osteopenia, acquire new movement patterns, and reduce muscle pain. It's recommended that individuals engage in daily physical activity tailored to their physical abilities [33,34]. ...
Introduction and purpose: A collection of symptoms known as cerebral palsy first manifest in early childhood and result in profound physical impairment. Cerebral palsy is thought to affect 1 in 500 live births, or roughly 17 million people worldwide. The type of cerebral palsy determines the clinical symptoms. Movement coordination disorders, epilepsy, muscle weakness, and feeding difficulties are the most common symptoms. The purpose of this article is to familiarize readers with the options for nutritional therapy for cerebral palsy patients. Material and methods The following review was based on articles from the PubMed and Google Scholar databases. Key search terms included cerebral palsy; nutrition; treatment; gut microbiota.. State of knowledge Early identification of malnutrition symptoms and appropriate interventions, such as the implantation of a percutaneous endoscopic gastrostomy tube in patients who are unable to swallow food, are the cornerstones of nutritional therapy for cerebral palsy patients. Dysphagia is a major problem in the population of patients with cerebral palsy, and multidisciplinary therapy is necessary for them. Patients' serum vitamin D levels are also influenced by their diet; 50% of those with cerebral palsy have a deficiency in this nutrient. Conclusions For people with cerebral palsy, nutrition is very important. Premature death may arise from malnutrition brought on by the disease's advancement. As a result, individuals with cerebral palsy need to receive specialized care
... It seeks to enhance muscle tone, strength, and range of 1 1 motion, boosting functional capacities. Proprioceptive neuromuscular facilitation, stretching methods, and therapeutic exercises are utilized to improve motor control and reduce spasticity [12]. Physiotherapy for hip dislocations works to stabilize the joint and strengthen the surrounding muscles [13]. ...
Girdlestone arthroplasty is a traditional approach for complicated infections occurring with contralateral spastic hemiplegic cerebral palsy, which presents intricate challenges in rehabilitation. In this case report, an 18-year-old girl came to a multispecialty hospital with a history of falls. She was an identified case of femoral head dislocation with acute osteomyelitis and a history of spastic hemiplegic cerebral palsy. She underwent girdlestone arthroplasty with additional upper tibial and ankle pin traction. After that, she was referred to physiotherapy management. To further aid recovery, rehabilitation protocol included a combination of static exercises, ankle pumps on the affected side, and stretching, bimanual hand-arm training with lower limb training on the unaffected side to reduce spasticity. Once the stitches were removed and traction discontinued, the focus shifted to improving mobility through basic activities like rolling and transitioning to sitting, gradually progressing to standing with the assistance of a walker and bimanual hand-arm training with lower limb training for spasticity. Outcome measures like functional independence measure, numerical pain rating scale, range of motion, and manual ability classification system were used to record patient progress during rehabilitation. This case report serves the crucial role physiotherapy plays in the treatment of orthopedic and neurological conditions in younger patients, with the ultimate goal of regaining functional independence and enhancing overall quality of life.
Purpose
Dance is a leisure time physical activity (LTPA) known to improve motor, cognitive, and psychosocial functions in youth with cerebral palsy (CP). Online exercise or tele-programs are promising in overcoming the environmental barriers of accessibility to LTPA. To ensure successful implementation, it is necessary to identify limitations specific to dance in a pediatric population. The aim was to explore the perspectives of the main stakeholders, i.e., dance instructors and youth, to implement such a program.
Methods
In a mixed-method design, feasibility indicators were assessed by participation and retention rates, the Physical Activity Enjoyment Scale (PACES), and the Children's Effort Rating Table (CERT). Semi-structured interviews were conducted before and after the intervention with youth with CP [n = 15] and dance instructors [n = 3]. Interviews were analyzed with an inductive approach.
Results
Participation and retention rates were 86.7% ± 10.7 and 100%, and the PACES and CERT average scores were 91% ± 11 and 3.7 ± 1.3, respectively. Four themes emerged from the interviews: 1) Technology; 2) Pedagogical Approach; 3) Participant's Environment; and 4) Social Relations.
Conclusion
The teledance program is feasible and enjoyable, requiring minimal equipment and travel. However, there is a need to consider and provoke social interaction, to enhance the social and relational dimension of dance.
Objective The objective of this scoping review is to identify evidence of collaboration between healthcare and recreational sectors aimed at supporting community-based physical activity participation among young people with childhood-onset physical disability. Introduction Most young people with physical disabilities do insufficient physical activity, significantly impacting their future health. There have been long outstanding calls for collaboration between healthcare and recreational professionals to support physical activity participation for people with disabilities. Given the importance of physical activity and the roles of health and recreational professionals, there is a need to systematically identify evidence on collaborative strategies between sectors, describe the experiences of all individuals involved in delivering and receiving these collaborations and describe any outcomes measured as part of implementing these strategies. Inclusion criteria This review will include studies that involve healthcare professionals and recreational professionals working together to support community based physical activity. Specifically aimed young people aged 10 to 24 years with childhood-onset physical disabilities. Studies that report the experiences of individuals in delivering and receiving these collaborations will be included as well as studies that describe an evaluation of collaborative strategies. Methods This scoping review will be conducted in accordance with the Joanna Briggs Institute methodology of scoping reviews. A comprehensive search strategy will be developed in consultation with an information specialist. The following databases will be searched: MEDLINE, CINAHL, Embase, Web of Science and Scopus. The review will consider studies of any design that address collaboration between health and recreation sectors including qualitative, quantitative and mixed-methods study designs. Two reviewers will independently screen each retrieved title and abstract and assess full-text articles against the inclusion criteria to determine eligibility. Data will be extracted and synthesized quantitively and qualitatively and mapped to a relevant framework.
Background/Objectives: Cerebral palsy (CP) is a neurological disorder that affects movement and posture. Physical activity (PA) is safe and crucial for healthy development; however, this population faces barriers that hinder its implementation. Virtual reality (VR) is an emerging and promising technology that promotes PA in young people with CP. This work aims to compile and analyze the current scientific literature on physical exercise (PE) programs using VR in children and adolescents with CP through a PRISMA systematic review. Methods: A systematic review was conducted and reported based on the PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses) statement. The search was conducted through the Web of Science, PubMed, and Scopus databases on 1st September 2024. Studies based on PA interventions using VR in children and adolescents with CP were selected. Results: A total of 24 experimental research articles were selected for this review. The studies included comprise a total sample of 616 participants between 4 and 18 years old. The studies involved a diverse range of interventions, from brief sessions to intensive training. The results consistently demonstrated improvements in motor control, muscle strength, aerobic capacity, and overall participation in daily activities. Conclusions: The results highlight that the use of VR for PE programs has numerous benefits such as increased enjoyment, facilitation of motor learning, and acquisition of functional skills. PE through VR in children and adolescents with CP represents a promising tool; more scientific and practical evidence is needed to confirm its long-term effectiveness.
Aim
This study aimed to compare gross motor function between aquatic‐ and land‐based exercises in children and adolescents with cerebral palsy (CP).
Methods
The authors conducted an electronic search of nine databases from their inception to 21 November 2024 (PROSPERO registration: CRD42020194121). Inclusion criteria were randomized controlled trials involving aquatic‐based exercises for children and adolescents with CP, assessing gross motor function using standardized scales or tests. Three authors independently extracted data using a predetermined Excel form. The risk of bias was assessed with the PEDro scale. The body of evidence was synthesized using the GRADE approach. Meta‐analysis was conducted using the Revman 5.3 program.
Results
A total of 369 children aged 2–18 years from 15 studies were included. Most participants were ambulatory and classified as having spastic hemiparetic or diparetic CP. The majority of studies had a high risk of bias and small sample sizes. Aquatic‐based exercises were categorized as aquatic physical therapy, Halliwick, swimming exercises, gait training and exercises. Low‐quality evidence indicated that aquatic physical therapy resulted in higher gross motor function than land‐based exercises (SMD = 0.47, n = 93, 4 trials, I ² = 5%, p = 0.03), with a small effect size. No significant differences were found for Halliwick or swimming exercises.
Interpretation
There is low‐quality evidence, because of high risk of bias, imprecision and inconsistency, suggesting that aquatic‐based exercises are comparable with land‐based exercises. Future research should focus on well‐designed interventions with adequate sample sizes to compare the combination of aquatic‐ and land‐based therapies with land‐based therapy alone.
Dance is an activity that engages the physical, cognitive, and socialdimensions of movement and health. Research in dance and disability is oftenfocused on reducing symptoms and behaviours, rather than individual experiences.Using a constructionist lens, we explored the meaning of dance as shared throughpersonal narratives from adult dancers who live with neurodevelopmental disabilityand aimed to deepen our understanding of their experiences and perspectives oninstruction. Interviews were conducted with 14 dancers from across Canada and theUnited States. Through an iterative thematic analysis, we identified three mainthemes and contextualized them using the combined constraints model of motordevelopment and embodied knowledge theory: i) dance is who I am, ii) danceprovides skills for life, iii) inclusive instruction and culture that supports me as adancer. Collectively the dancers gained a sense of direction and belonging thatfueled their motivation to interact socially. We also found that through strengths-based and person-centered approaches the dancers experienced greater purpose,direction, and gained skills applicable to dance and daily life.
Background and purpose:
Adults living with Cerebral Palsy (CP) who are non-ambulatory are at increased risk for falls, contractures, reduced bone density, and pain. There is limited evidence for core strength training, anterior chain activation exercises, or high intensity gait training (HIGT) to improve gait function in adults with CP. The purpose of this case report is to describe the use of anterior chain muscle activation and HIGT to improve walking in a non-ambulatory adult male with quadriplegic CP.
Case description:
The participant was a 26 y.o. male living with spastic quadriplegic CP with a goal to cross the finish line of an adaptive triathlon while ambulating. The outpatient physiotherapy protocol emphasized anterior chain activation exercises and HIGT to improve strength, gait, and mobility at a frequency of 1-2 times a week for 8 months.
Outcomes:
The minimal detectable change of 19 points was achieved on the Function in Sitting Test (FIST). The original ambulation goal was exceeded to a maximum of 76 meters overground. The participant was able to walk across the finish line using a gait trainer while supervised at an adaptive triathlon.
Conclusions:
Focusing on anterior chain exercises and HIGT was effective to minimize extensor spasticity by strengthening body flexors allowing improved mobility and gait.
Background: Cerebral palsy (CP) is a prevalent childhood physical disability requiring long-term therapeutic interventions. Conventional rehabilitation methods face challenges maintaining engagement and providing personalized, measurable outcomes. Methods: This study assessed current CP therapy approaches through a literature review and primary data analysis. We propose an innovative digital therapeutic platform integrating gamification, virtual reality, and AI-based motion tracking. Results: Our analysis revealed limitations in traditional therapies, including lack of engagement, limited personalization, and insufficient progress tracking. The proposed technology-driven solution shows potential for enhancing motivation, customization, and measurable progress in CP rehabilitation. Conclusions: Our proposed digital platform offers promising avenues for improving rehabilitation outcomes and patient experiences by addressing key limitations in current CP therapy.
Robotic exoskeletons are increasingly being used for gait rehabilitation in individuals with neuromuscular disorders, such as cerebral palsy (CP). A primary rehabilitation goal for those with CP is to improve ankle push-off power, which is crucial for enhancing gait function. Previous research suggests that interleaving assistance and resistance within the same training session may improve certain aspects of gait, such as joint trajectories and torque profiles. This feasibility study sought to investigate the efficacy of priming the plantar flexor muscles with ankle exoskeleton plantar flexor assistance to facilitate increased ankle push-off power during subsequent resisted gait training bouts in individuals with CP. Specifically, we hypothesized that providing plantar-flexor assistance immediately prior to walking with resistance would increase peak biological ankle power and muscle activity compared to walking with resistance alone. We found that peak biological ankle power increased by 25% (p = 0.021) during assistance-primed resisted walking compared to the baseline resisted walking trail. While ankle angular velocity also increased alongside power, there was no significant difference in plantar flexor muscle activity, suggesting more efficient recruitment. These results contribute to our overarching goal of optimizing robotic exoskeleton interventions, potentially leading to the future design of more effective gait rehabilitation strategies
This study aims to measure the relationship between sedentary behaviour and metabolic rate among adult professionals. An intervention (e-mobile) approach was used to gather the information from the participants. A total of 40 participants (men = 30, and women = 10) with an average age of (36.53 years ± 8.85) were randomly assigned to an intervention group (n= 20) and a control group (n= 20). All the participants completed the Sedentary Behavior Questionnaire and The International Physical Activity Questionnaire at baseline and the end of eight weeks. The Participants in the intervention group were given physical activity guidelines targeted at increasing physical activity levels during daily activities. On the other side, the control group was advised to continue with their routine daily physical activity. Statistical analyses, including descriptive statistics and inferential analysis like mean, SD, T-tests, and ANOVA were used to analyze the data and determine relationships between variables. After analyzing the data, the results showed that significant differences in pre and post-metabolic rate scores (1488.31 ± 179.13 to 1468.44 ± 128.19) (f = 10.83, p < 0.000) were noted in the experimental group after eight weeks. The experimental group increased their walking (863.78 METs per week to 1625.55 METs per week), moderate activity (295 METs per week to 743 METs per week) and vigorous activity (362 METs per week to 1366 METs per week) physical activity (all p<0.001). No significant differences were found in the control group, highlighting that physical activity improves metabolic rate and reduces sedentary behaviour.
Introduction
Adults with cerebral palsy (CP) may have reduced motivation or interest in exercising, whereas exercise or even an active lifestyle could provide them the greatest possible degree of independence and functionality. It is proposed that patient-centered intervention can increase adherence to exercise and as a result change the patient's lifestyle. Cognitive and Behavioral Therapy (CBT) is a task-oriented approach that deals with cognitive beliefs and behaviors, and it is considered to be effective in lifestyle changes. This case report examined the effect of a functional physiotherapy intervention with cognitive and behavioral principles treatment, on an adult with CP.
Case description
The patient was a 52-year-old male with bilateral (diplegia) spastic cerebral palsy (level 3 according to Gross Motor Function Classification System - GMFCS) and prolonged inactivity. The patient engaged in a combination of a functional exercise program with cognitive and behavioral approach treatment. A tailored program of progressive exercises for 20 weeks was used to address patient's functional limitations. A combination of functional tests was used in order to monitor the progress.
Outcomes
The patient presented a gradual improvement in values of balance and strength at 6 and 20 weeks as well as of fear of fall at 20 weeks.
Discussion
The positive outcomes from this new combination therapy for this patient are encouraging the opinion that a patient-centered intervention with enjoyable sessions and meaningful program based on CBT principles can increase adherence to exercise program, and as a result change the lifestyle.
Background:
Children with cerebral palsy (CP) present unique challenges to physical activity due to various factors. Despite the benefits of inclusive approaches and adapted physical education, low- and middle-income countries face specific barriers including environmental, equipment, personal, policy, social and professional barriers. Traditional Indian games, with their cultural significance and potential therapeutic benefits, offer a promising avenue for inclusive adaptations. At present we couldn't find any studies that explore's the method of adaptation of traditional Indian games for children with cerebral palsy of varying functional levels.
Purpose:
The aim of the study was to explore the adaptation of traditional Indian games for children with CP of varying functional levels.
Methods:
Traditional Indian games were identified through ethnographic qualitative research, and adapted using the Delphi process involving experts from various fields. A total of 10 traditional games were selected based on their health benefits using an operationalised conceptual model. The CHANGE IT model of adapted physical activity was used to systematically adapt each game. Validation of the model was then performed on children with CP [a smaller sample size, n = 10] with different levels of functioning.
Results:
The games varied in playing positions, surfaces and phases. Modifications included changes in game rules, play environment, equipment and time duration. The study validation through informal interview among the parents of CP children revealed that adapted traditional game protocol shown improvements in their children's activity levels and participation.
Conclusions:
While this is a preliminary exploration, no firm conclusion can be drawn. The model presented in this study lays the foundation for future randomised controlled trials to validate the effects of adapted traditional Indian games on children with cerebral palsy of different functional levels.
Aim
To establish consensus among adolescents with a physical disability regarding their priorities for enhancing participation in physical activity and help inform the design of future interventions for participation in physical activity.
Method
We conducted a national multi‐round Delphi study involving adolescents with a physical disability aged 13 to 17 years. Round 1 of the initial survey consisted of open‐ended questions. Free‐text responses were then analysed thematically, creating items categorized according to the family of participation‐related constructs (fPRC). In round 2, participants rated the perceived importance of these items using a 5‐point Likert scale. The top 10 priorities were constructed from the highest‐ranked items.
Results
One hundred and sixteen participants (mean age = 14 years 7 months, range = 13–17 years; 66 males; 58 with cerebral palsy; 43 wheelchair users) completed round 1; 108 items were included in round 2. Fifty‐eight items were rated as either ‘important’ or ‘really important’ by 70% of participants. The top 10 priorities were rated as important or really important by 82% to 94% of participants with a mean Likert score of 4.40 (range = 4.25–4.63). Seven of the top 10 priorities were related to the environmental context of the fPRC. The other three were related to involvement and the related concept of preference.
Interpretation
The priorities identified will help inform future physical activity interventions for adolescents with a physical disability.
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.
Full text available open access at https://www.sciencedirect.com/science/article/pii/S1413355524004921?via%3Dihub
Purpose:
The primary aim was to establish feasibility of a home-based motorised cycling intervention in non-ambulant adults with cerebral palsy (CP). The secondary aim was to investigate perceived outcomes on pain, sleep, fatigue, and muscle stiffness.
Materials and method:
Non-ambulant adults with CP were recruited from a specialist clinic. Feasibility encompassing recruitment, retention, adherence, acceptability, practicality, and safety, was the primary outcome., Cycling frequency and duration data were downloaded from the device and augmented by a usage diary and participant survey. Participant satisfaction was rated using a 5-point Likert scale where 1 = very satisfied. Quantitative data and open-ended survey responses were analysed using descriptive statistics and content analysis, respectively.
Results:
Ten non-ambulant adults with CP (5 female), 18 to 32 years, participated. The median (IQR) days cycled per week was 4 (3,5) with no serious adverse events recorded. The median (IQR) time cycled per session was 13.9 min, (10.2,19.8), per day. Participant satisfaction was high, median (IQR) 2 (1,2.5). Perceived benefits in pain, sleep, fatigue, stiffness, leg function, mood, behaviour, and social interactions were reported alongside occasional problems with spasms and foot placement.
Conclusion:
This study provides preliminary data to support the feasibility of motorised cycling for non-ambulant adults with CP.
Zusammenfassung
Ein innovativer Ansatz für funktionelles Training bei Jugendlichen mit Zerebralparese: wie wissenschaftliche Erkenntnisse umgesetzt in praktische Anwendungen erstaunliche Fortschritte ermöglichen.
This study uses US Medical Expenditure Panel Survey data between 2002 and 2010 to estimate the risk of 8 chronic conditions in adults with cerebral palsy.Adults with cerebral palsy (CP) represent an increasing population whose health status and health care needs are poorly understood.1 Mortality records reveal that death due to ischemic heart disease and cancer is higher among adults with CP2; however, there have been no national surveillance efforts to track disease risk in this population. We examined estimates of chronic conditions in a population-representative sample of adults with CP.
The purposes of this study were to examine differences in adipose tissue distribution, lumbar vertebral bone mineral density (BMD), and muscle attenuation in adults with and without cerebral palsy (CP), and to determine the associations between morphological characteristics.
Cross-sectional, retrospective analyses of archived computed tomography (CT) scans.
Clinical treatment and rehabilitation center for persons with CP.
Adults with CP with a mean ± SD age of 38.8 ± 14.4 years; body mass: 61.3 ± 17.1 kg; Gross Motor Function Classification level of I-V, and a matched cohort of neuro-typical adults. Of the 41 adults with CP included in the study, 10 were not matchable due to low body masses.
Not applicable MAIN OUTCOME MEASURE(S): Computed tomography scans were assessed for visceral and subcutaneous adipose tissue (VAT and SAT areas), psoas major area and attenuation in Hounsfield units (HU), and cortical and trabecular BMDs.
Adults with CP had lower cortical (β=-63.41 HU, p<0.001) and trabecular (β=-42.24 HU, p<0.001) BMDs, as well as psoas major areas (β=-374.51 mm(2), p<0.001) and attenuation (β=-9.21 HU, p<0.001), after controlling for age, sex, and body mass. Adults with CP had greater VAT (β=3914.81 mm(2), p<0.001) and SAT (β=4615.68 mm(2), p<0.001). Muscle attenuation was significantly correlated with trabecular (r=0.51, p=0.002) and cortical (r=0.46, p<0.01) BMD; whereas VAT was negatively associated with cortical BMD (β=-0.037 HU/cm(2); r(2)=0.13; p=0.03).
Adults with CP had lower BMDs, smaller psoas major area, greater intermuscular adipose tissue, and greater trunk adiposity than neuro-typical adults. VAT and cortical BMD were inversely associated.
Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Adults with cerebral palsy (CP) are known to participate in reduced levels of total physical activity. There is no information available however, regarding levels of moderate-to-vigorous physical activity (MVPA) in this population. Reduced participation in MVPA is associated with several cardiometabolic risk factors. The purpose of this study was firstly to compare levels of sedentary, light, MVPA and total activity in adults with CP to adults without CP. Secondly, the objective was to investigate the association between physical activity components, sedentary behavior and cardiometabolic risk factors in adults with CP. Adults with CP (n = 41) age 18–62 yr (mean ± SD = 36.5 ± 12.5 yr), classified in Gross Motor Function Classification System level I (n = 13), II (n = 18) and III (n = 10) participated in this study. Physical activity was measured by accelerometry in adults with CP and in age- and sex-matched adults without CP over 7 days. Anthropometric indicators of obesity, blood pressure and several biomarkers of cardiometabolic disease were also measured in adults with CP. Adults with CP spent less time in light, moderate, vigorous and total activity, and more time in sedentary activity than adults without CP (p < 0.01 for all). Moderate physical activity was associated with waist-height ratio when adjusted for age and sex (β = −0.314, p < 0.05). When further adjustment was made for total activity, moderate activity was associated with waist-height ratio (β = −0.538, p < 0.05), waist circumference (β = −0.518, p < 0.05), systolic blood pressure (β = −0.592, p < 0.05) and diastolic blood pressure (β = −0.636, p < 0.05). Sedentary activity was not associated with any risk factor. The findings provide evidence that relatively young adults with CP participate in reduced levels of MVPA and spend increased time in sedentary behavior, potentially increasing their risk of developing cardiometabolic disease.
Question: In children with cerebral palsy, does a 6-month physical activity stimulation program improve physical activity, mobility capacity, fitness, fatigue and attitude towards sports more than usual paediatric physiotherapy? Design: Multicentre randomised controlled trial with concealed allocation, blinded assessments and intention-to-treat analysis. Participants: Forty-nine walking children (28 males) aged 7–13 years with spastic cerebral palsy and severity of the disability classified as Gross Motor Function Classification System level I–III. Intervention: The intervention group followed a 6-month physical activity stimulation program involving counselling through motivational interviewing, home-based physiotherapy, and 4 months of fitness training. The control group continued their usual paediatric physiotherapy. Outcome measures: Primary outcomes were walking activity (assessed objectively with an activity monitor) and parent-reported physical activity (Activity Questionnaire for Adults and Adolescents). Secondary outcomes were: mobility capacity, consisting of Gross Motor Function Measure-66 (GMFM-66), walking capacity and functional strength, fitness (aerobic and anaerobic capacity, muscle strength), self-reported fatigue, and attitude towards sport (child and parent). Assessments were performed at baseline, 4 months, 6 months and 12 months. Results: There were no significant intervention effects for physical activity or secondary outcomes at any assessment time. Positive trends were found for parent-reported time at moderate-to-vigorous intensity (between-group change ratio = 2.2, 95% CI 1.1 to 4.4) and GMFM-66 (mean between-group difference = 2.8 points, 95% CI 0.2 to 5.4) at 6 months, but not at 12 months. There was a trend for a small, but clinically irrelevant, improvement in the children's attitudes towards the disadvantages of sports at 6 months, and towards the advantages of sports at 12 months. Conclusions: This physical activity stimulation program, that combined fitness training, counselling and home-based therapy, was not effective in children with cerebral palsy. Further research should examine the potential of each component of the intervention for improving physical activity in this population. Trial registration: NTR2099. [Van Wely L, Balemans ACJ, Becher JG, Dallmeijer AJ (2014) Physical activity stimulation program for children with cerebral palsy did not improve physical activity: a randomised trial.Journal of Physiotherapy60: XX–XX]
To report the prevalence of cardiometabolic risk factors in a cohort of adults with cerebral palsy (CP) and to investigate the ability of anthropometric measures to predict these factors.
Cross-sectional study SETTING: Testing took place in a laboratory setting PARTICIPANTS: Fifty-five adults with CP (mean±SD age 37.5±13.3 yr; Gross Motor Function Classification System levels I-V) participated in this study.
Not applicable MAIN OUTCOME MEASURES: Total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides, glucose, insulin and C-reactive protein were measured from a fasting venous blood sample. Insulin resistance was calculated using the Homeostasis Model Assessment Index (HOMA-IR). The metabolic syndrome was defined according to the 2009 Joint Interim Statement. Blood pressure, body mass index (BMI), waist circumference (WC), waist-hip ratio and waist-height ratio were also measured.
The prevalence of the metabolic syndrome was 20.5% in ambulatory adults and 28.6% in non-ambulatory adults. BMI was associated with HOMA-IR only (β=0.451, p<0.01). WC was associated with HOMA-IR (β=0.480, p<0.01), triglycerides (β=0.450, p<0.01) and systolic blood pressure (β=0.352, p<0.05). Receiver operating characteristic curve analysis revealed that WC provided the best indication of hypertensive blood pressure, dyslipidaemia, HOMA-IR, and the presence of multiple risk factors (area under the curve values of 0.713-0.763).
A high prevalence of the metabolic syndrome was observed in this relatively young sample of adults. WC was a better indicator of a number of risk factors compared to BMI and presents as a clinically useful method of screening for cardiometabolic risk among adults with CP.
Objective:
To describe in detail the health-related physical fitness of adolescents and young adults with cerebral palsy, compared with able-bodied references, and to assess differences related to Gross Motor Functioning Classification System (GMFCS) level and distribution of cerebral palsy.
Design:
Cross-sectional.
Subjects:
Fifty ambulatory persons with spastic cerebral palsy, GMFCS level I or II, aged 16-24 years.
Methods:
Physical fitness measures were: (i) cardiopulmonary fitness by maximal cycle ergometry, (ii) muscle strength, (iii) body mass index and waist circumference, (iv) skin-folds, and (v) lipid profile.
Results:
Regression analyses, corrected for age and gender, showed that persons with bilateral cerebral palsy had lower cardiopulmonary fitness and lower hip abduction muscle strength than those with unilateral cerebral palsy. Comparisons between persons with GMFCS levels I and II showed a difference only in peak power during cycle ergometry. Cardiopulmonary fitness, hip flexion and knee extension strength were considerably lower (< 75%) in persons with cerebral palsy than reference values.
Conclusion:
The distribution of cerebral palsy affects fitness more than GMFCS level does. Furthermore, adolescents and young adults with cerebral palsy have reduced health-related physical fitness compared with able-bodied persons. This stage of life has a strong influence on adult lifestyle, thus it is an important period for intervention.
To assess physical behaviour, including physical activity and sedentary behaviour, of ambulatory adolescents and young adults with cerebral palsy (CP). We compared participant physical behaviour to that of able-bodied persons and assessed differences related to Gross Motor Functioning Classification System (GMFCS) level and CP distribution (unilateral/bilateral).
In 48 ambulatory persons aged 16 to 24 years with spastic CP and in 32 able-bodied controls, physical behaviour was objectively determined with an accelerometer-based activity monitor. Total duration, intensity and type of physical activity were assessed and sedentary time was determined (lying and sitting). Furthermore, distribution of walking bouts and sitting bouts was specified.
Adolescents and young adults with CP spent 8.6% of 24 hours physically active and 79.5% sedentary, corresponding with respectively 123 minutes and 1147 minutes per 24 hours. Compared to able-bodied controls, persons with CP participated 48 minutes less in physical activities (p < 0.01) and spent 80 minutes more sedentary per 24 hours (p < 0.01). Physical behaviour was not different between persons with GMFCS level I and II and only number of short sitting bouts were significantly more prevalent in persons with bilateral CP compared to unilateral CP (p < 0.05).
Ambulatory adolescents and young adults with CP are less physically active and spend more time sedentary compared to able-bodied persons, suggesting that this group may be at increased risk for health problems related to less favourable physical behaviour.Trial registration: Nederlands trial register: NTR1785.
The purpose of this study was to determine the gender-specific independent association between muscular strength and cardiometabolic risk clustering in a large cohort (n = 1421) of children.
Principal component analysis was used to determine the pattern of risk clustering and to derive a continuous aggregate score (MetScore) from various cardiometabolic risk components: percent body fat (%BF), fasting glucose, blood pressure, plasma triglycerides levels, and HDL-cholesterol. Gender-stratified risk and MetScore were assessed by using general linear models and logistic regression for differences between strength tertiles, as well as independent associations with age, BMI, estimated cardiorespiratory fitness (CRF), physical activity, and muscular strength (normalized for body mass).
In both boys (n = 670) and girls (n = 751), there were significant differences in cardiometabolic profiles across strength tertiles, such that stronger adolescents had lower overall risk. Age, BMI, cardiorespiratory fitness, physical activity participation, and strength were all individually correlated with multiple risk components, as well as the overall MetScore. However, in the adjusted model, only BMI (β = 0.30), physical inactivity (β = 0.30), and normalized strength capacity (β = -1.5) emerged as significant (P < .05) predictors of MetScore. %BF was the strongest loading coefficient within the principal component analysis-derived MetScore outcome.
Normalized strength is independently associated with lower cardiometabolic risk in boys and girls. Moreover, %BF was associated with all cardiometabolic risk factors and carried the strongest loading coefficient. These findings bolster the importance of early strength acquisition and healthy body composition in childhood.
Children with cerebral palsy (CP) demonstrate reduced physical activity levels when compared with their typically developing peers. Sedentary behavior, including the duration and frequency of sedentary bouts, has not yet been objectively examined in this population but may have clinical implications for the development of secondary health complications.
To identify time spent sedentary and frequency of breaks interrupting sedentary time in youth with CP compared with youth without CP. It was hypothesized that individuals with CP would spend more hours sedentary than their peers and show fewer breaks to interrupt sedentary time.
Cross-sectional, prospective study.
A convenience sample of 17 ambulatory children with CP (15 males), mean (SD) age of 13.0 (2.2) years, and 17 age-, sex-, and season-matched typically developing youth (TD, age: 12.9 (2.5) years) wore an accelerometer over a 7-day period. Sedentary time (min) and breaks (#) from sedentary time, corrected for monitoring and sedentary time, respectively, were examined. Differences between groups were determined with an independent samples t-test (p<0.05).
Children with CP engaged in significantly more sedentary time (47.5 (4.9) vs TD 43.6 (4.2) min/h, p=0.017), with significantly fewer breaks from sedentary time (179 (70) vs TD 232 (61) breaks/h sedentary, p=0.025).
The sample only includes ambulatory youth with CP, classified as GMFCS levels I-III.
Sedentary time is higher in children with CP and is characterized by less frequent breaks when compared with their typically developing peers. Future research should examine the extent to which sedentary time is associated with cardiovascular and metabolic risk in youth with CP.
The aim of the study was to investigate the tracking of physical activity (PA) from preschool age to adulthood in six age cohorts of males and females.
A random sample of 3596 boys and girls aged 3-18 years participated in the Cardiovascular Risks in Young Finns Study in 1980. The follow-up measurements were repeated in 1986, 1992, 2001 and 2007. The PA was measured by mother's report in 3- and 6-year-olds and self-report in 9-year-olds and older. Tracking of PA was analyzed using Spearman's rank order correlation and a simplex-model.
Mother-reported PA at age 3 and 6 significantly predicted self-reported PA in youth and in young adulthood, and there was significant indirect effect of mother report on adult PA 2007 in males. Simplex models that fitted the data very well produced higher stability coefficients than the Spearman's rank order correlations showing moderate or high tracking. The tracking was higher in males than in females.
This study has shown that physically active lifestyle starts to develop very early in childhood and that the stability of physical activity is moderate or high along the life-course from youth to adulthood.
Objective: To explore: (i) cardiovascular disease risk factors and the 10-year clustered risk of a fatal cardiovascular event in adults with spastic bilateral cerebral palsy; and (ii) relationships between the 10-year risk and body fat, aerobic fitness and physical activity. Design: Cross-sectional study. Subjects: Forty-three adults with spastic bilateral cerebral palsy without severe cognitive impairment (mean age 36.6 years (standard deviation 6); 27 men). Methods: Biological and lifestyle-related risk factors and the 10-year risk according to the Systematic Coronary Risk Evaluation (SCORE) were assessed. Relationships were studied using multivariable linear regression analysis. Results: The following single risk factors were present: hypertension (n = 12), elevated total cholesterol (n = 3), low high-density lipoprotein cholesterol (n = 5; all men), high-risk waist circumference (n = 11), obesity (body mass index; n = 5; all men), reduced aerobic fitness (on average 80% of reference values), reduced level of everyday physical activity (on average 78% of reference values) and smoking (n=9). All participants had a 10-year risk <1%. Corrected for gender, participants with higher waist circumference (β = 0.28; p = 0.06) or body mass index (β=0.25; p = 0.08) tended to have a higher 10-year risk. Conclusion: In this relatively young adult sample of people with spastic bilateral cerebral palsy several single cardiovascular disease risk factors were present. The 10-year fatal cardiovascular disease risk was low, and higher body fat tended to be related to higher 10-year risk.
Rehabilitation is a major goal for children with cerebral palsy, although the potential to enhance cardio-respiratory fitness in such individuals remains unclear. This study thus compared current cardio-respiratory status between children with cerebral palsy and able-bodied children, and examined the ability to enhance the cardio-respiratory fitness of children with cerebral palsy by cycle ergometer training. 10 children with cerebral palsy (Gross Motor Function Classification System levels I and II) participated in thrice-weekly 30 min cycle ergometer training sessions for 8 weeks (mean age: 14.2±1.9 yrs). 10 additional subjects with cerebral palsy (mean age: 14.2±1.8 yrs) and 10 able-bodied subjects (mean age: 14.1±2.1 yrs) served as controls, undertaking no training. All subjects undertook a progressive cycle ergometer test of cardio-respiratory fitness at the beginning and end of the 8-week period. Cardio-respiratory parameters [oxygen intake V ˙ O2), ventilation V ˙ E) and heart rate (HR)] during testing were measured by Cosmed K4 b gas analyzer. The children with cerebral palsy who engaged in aerobic training improved their peak oxygen consumption, heart rate and ventilation significantly (p<0.05) and they also showed a non-significant trend to increased peak power output. In conclusion, children with cerebral palsy can benefit significantly from cardio-respiratory training, and such training should be included in rehabilitation programs.
Sedentary behavior is a risk factor for cardiometabolic disease. Regularly interrupting sedentary behavior with activity breaks may lower this risk.
We compared the effects of prolonged sitting, continuous physical activity combined with prolonged sitting, and regular activity breaks on postprandial metabolism.
Seventy adults participated in a randomized crossover study. The prolonged sitting intervention involved sitting for 9 h, the physical activity intervention involved walking for 30 min and then sitting, and the regular-activity-break intervention involved walking for 1 min 40 s every 30 min. Participants consumed a meal-replacement beverage at 60, 240, and 420 min.
The plasma incremental area under the curve (iAUC) for insulin differed between interventions (overall P < 0.001). Regular activity breaks lowered values by 866.7 IU · L(-1) · 9 h(-1) (95% CI: 506.0, 1227.5 IU · L(-1) · 9 h(-1); P < 0.001) when compared with prolonged sitting and by 542.0 IU · L(-1) · 9 h(-1) (95% CI: 179.9, 904.2 IU · L(-1) · 9 h(-1); P = 0.003) when compared with physical activity. Plasma glucose iAUC also differed between interventions (overall P < 0.001). Regular activity breaks lowered values by 18.9 mmol · L(-1) · 9 h(-1) (95% CI: 10.0, 28.0 mmol · L(-1) · 9 h(-1); P < 0.001) when compared with prolonged sitting and by 17.4 mmol · L(-1) · 9 h(-1) (95% CI: 8.4, 26.3 mmol · L(-1) · 9 h(-1); P < 0.001) when compared with physical activity. Plasma triglyceride iAUC differed between interventions (overall P = 0.023). Physical activity lowered values by 6.3 mmol · L(-1) · 9 h(-1) (95% CI: 1.8, 10.7 mmol · L(-1) · 9 h(-1); P = 0.006) when compared with regular activity breaks.
Regular activity breaks were more effective than continuous physical activity at decreasing postprandial glycemia and insulinemia in healthy, normal-weight adults. This trial was registered with the Australian New Zealand Clinical Trials registry as ACTRN12610000953033.
Muscular weakness has long been recognized as a problem in individuals with cerebral palsy (CP), but has been ignored therapeutically until recently. The purpose of this study was to examine the effects of a progressive resistance exercise (PRE) programme of seated leg press (SLP) on gait function in adults with spastic diplegic CP, Gross Motor Function Classification System (GMFCS) level II and III, who experience reduced walking ability, using a single-blind randomized controlled trial. Twelve individuals were included, 6 in the training and 6 in the control group. The training group completed a PRE programme consisting of a 10-min warm-up, followed by SLP 12–15 repetitions maximum (RM) in 4 sets, 3 days a week, for the first 2 weeks, progressing to 6RM in 4 sets, 3 days a week, for the following 6 weeks. Six-RM tests in the SLP machine were performed to determine the training load. The control group continued individual treatment or training as usual. The primary outcome measure was the 6-Minute Walk Test (6MWT). Secondary outcome measures were the Ten-meter Walk Test (10 m), stair climbing, the Timed Stands Test (TST) and isokinetic muscle strength of the quadriceps. There was no significant change, or difference in change between the groups, in any of the outcome measures from baseline to 8 weeks. Adults with CP, participating in an 8-week PRE, did not improve their walking, functional lower limb strength or isokinetic strength. The training group did improve their performance in SLP.
The cardiopulmonary exercise test (CPET) is an important physiological investigation that can aid clinicians in their evaluation of exercise intolerance and dyspnea. Maximal oxygen consumption ([Formula: see text]) is the gold-standard measure of aerobic fitness and is determined by the variables that define oxygen delivery in the Fick equation ([Formula: see text] = cardiac output × arterial-venous O(2) content difference). In healthy subjects, of the variables involved in oxygen delivery, it is the limitations of the cardiovascular system that are most responsible for limiting exercise, as ventilation and gas exchange are sufficient to maintain arterial O(2) content up to peak exercise. Patients with lung disease can develop a pulmonary limitation to exercise which can contribute to exercise intolerance and dyspnea. In these patients, ventilation may be insufficient for metabolic demand, as demonstrated by an inadequate breathing reserve, expiratory flow limitation, dynamic hyperinflation, and/or retention of arterial CO(2). Lung disease patients can also develop gas exchange impairments with exercise as demonstrated by an increased alveolar-to-arterial O(2) pressure difference. CPET testing data, when combined with other clinical/investigation studies, can provide the clinician with an objective method to evaluate cardiopulmonary physiology and determination of exercise intolerance.
To explore the extent to which muscular strength in adolescence is associated with all cause and cause specific premature mortality (<55 years).
Prospective cohort study.
Sweden.
1 142 599 Swedish male adolescents aged 16-19 years were followed over a period of 24 years.
Baseline examinations included knee extension, handgrip, and elbow flexion strength tests, as well as measures of diastolic and systolic blood pressure and body mass index. Cox regression was used to estimate hazard ratios for mortality according to muscular strength categories (tenths).
During a median follow-up period of 24 years, 26 145 participants died. Suicide was a more frequent cause of death in young adulthood (22.3%) than was cardiovascular diseases (7.8%) or cancer (14.9%). High muscular strength in adolescence, as assessed by knee extension and handgrip tests, was associated with a 20-35% lower risk of premature mortality due to any cause or cardiovascular disease, independently of body mass index or blood pressure; no association was observed with mortality due to cancer. Stronger adolescents had a 20-30% lower risk of death from suicide and were 15-65% less likely to have any psychiatric diagnosis (such as schizophrenia and mood disorders). Adolescents in the lowest tenth of muscular strength showed by far the highest risk of mortality for different causes. All cause mortality rates (per 100 000 person years) ranged between 122.3 and 86.9 for the weakest and strongest adolescents; corresponding figures were 9.5 and 5.6 for mortality due to cardiovascular diseases and 24.6 and 16.9 for mortality due to suicide.
Low muscular strength in adolescents is an emerging risk factor for major causes of death in young adulthood, such as suicide and cardiovascular diseases. The effect size observed for all cause mortality was equivalent to that for well established risk factors such as elevated body mass index or blood pressure.
Background:
Clustering of cardiovascular disease (CVD) risk factors has been found in children as young as 9 y of age. However, the stability of this clustering over the course of childhood has yet to be determined. The purpose of this study was to determine the tracking of clustered CVD risk from young school age through adolescence and to examine differences in tracking between levels of overweight/obesity and cardiorespiratory fitness (VO(2peak)).
Methods:
Beginning at 6 y, children (n = 434) were measured three times in 7 y. Anthropometrics, blood pressure, and VO(2peak) were measured. Fasting blood samples were analyzed for CVD risk factors. A clustered risk score (z-score) was constructed by adding sex-specific z-scores for blood pressure, homeostatic model assessment (HOMA-IR), triglyceride (TG), skinfolds, and negative values of high-density lipoprotein cholesterol (HDLc) and VO(2peak).
Results:
Significant tracking coefficients were found between clustered z-score at all time intervals (r = 0.514, 0.559, and 0.381 between ages 6-9, 9-13, and 6-13 y, respectively, all P < 0.0001). Tracking was higher for low-fit children, whereas no clear pattern was found for different levels of body fat.
Conclusion:
We found that clustered z-score is a fairly stable characteristic through childhood. Implementation of preventive strategies could therefore start at early school age.
Purpose:
To systematically review and compare the daily habitual physical activity levels and sedentary times of young people with cerebral palsy to their typically developing peers and to physical activity guidelines.
Method:
After searching electronic databases, two reviewers independently applied criteria. Studies were required to include young people with cerebral palsy (up to 18 years) and to quantitatively measure habitual physical activity, defined as activity across at least one day. Data extraction was independently verified, and quality analysis completed by two reviewers.
Results:
Of 895 identified studies, six moderate to high quality studies were included. There were four measures of habitual physical activity. Participants were aged 5 to 18 years and typically had moderate to high gross motor function. Across all ages and levels of motor function, young people with cerebral palsy participated in 13% to 53% less habitual physical activity than their peers. Levels of activity were approximately 30% lower than guidelines. Sedentary times were twice the maximum recommended amount.
Conclusions:
Young people with cerebral palsy participate in significantly lower levels of habitual physical activity than their peers, and less than recommended guidelines. Long-term negative health consequences of inactivity such as metabolic dysfunction, cardiovascular disease and poor bone density are therefore more likely.
To examine the independent association between various anthropometric indicators and standard clinical markers of cardiometabolic health risk among adults with cerebral palsy (CP).
Cross-sectional study.
Clinical center for CP treatment and rehabilitation.
Adults with CP (N=43) with a mean age ± SD of 37.3±13.2 years, and Gross Motor Function Classification System (GMFCS) levels of I-V.
Not applicable.
Adults with CP were assessed for body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), waist-to-height ratio (WtHR), and serum lipid profiles. Data were analyzed with multiple regression analysis and general linear models, and are reported as means ± SDs.
Mean BMI was 29.1±7.8kg/m(2). BMI was not associated with any measures of cardiometabolic risk. Using GMFCS categories (2 groups: GMFCS levels I-III and IV-V), BMI was significantly lower among GMFCS levels IV-V (24.2±6.2kg/m(2)) versus GMFCS levels I-III (30.1±7.6kg/m(2)). WC and WtHR were not correlated with any cardiometabolic outcomes. Conversely, measures of WHR were independently associated with various indices of risk, including total cholesterol to high-density lipoprotein (HDL) cholesterol ratio (r=.45; P<.05), HDL cholesterol (r=-.51; P<.01), and triglycerides (r=.40; P<.05), suggesting that greater WHR was indicative of elevated risk.
It is likely that WHR represents a stronger predictor of risk, because this measure was robustly and independently associated with 3 primary clinical markers of cardiometabolic health in adults with CP.
To describe family distress as reported by parents of children with cerebral palsy (CP) and to identify factors associated with distress.
In this descriptive, historical cohort study, parents of school-age children (9.2 ± 2.1 years) with CP completed the Parenting Stress Index, the Impact on Family Scale and family-related items on the Child Health Questionnaire. Predictor variables considered were sociodemographic factors, motor, cognitive and behavioral difficulties and functional limitations. These were assessed using the Gross Motor Function Measure, Leiter IQ, Strengths and Difficulties Questionnaire and Vineland Adaptive Behavior Scale.
Parents of 95 children were recruited, of whom 45% were highly stressed and 11% defensive. Half indicated that their child's health impacted on their time, emotional status and family activities. Family distress measures were modestly associated with motor (r = 0.30-0.48) and cognitive abilities (r = 0.29-0.37) but more strongly correlated with particular behavioral difficulties (r = -0.42 to 0.55). Activity limitations across domains were highly associated with measures of distress.
Parents of school-aged children with CP are likely to experience high stress, increased time constraints and financial and psychological burden. Findings illustrate the need to monitor family functioning intermittently as the child develops and direct appropriate resources to optimize child and family well-being.
Physical activity guidelines from around the world are typically expressed in terms of frequency, duration, and intensity parameters. Objective monitoring using pedometers and accelerometers offers a new opportunity to measure and communicate physical activity in terms of steps/day. Various step-based versions or translations of physical activity guidelines are emerging, reflecting public interest in such guidance. However, there appears to be a wide discrepancy in the exact values that are being communicated. It makes sense that step-based recommendations should be harmonious with existing evidence-based public health guidelines that recognize that "some physical activity is better than none" while maintaining a focus on time spent in moderate-to-vigorous physical activity (MVPA). Thus, the purpose of this review was to update our existing knowledge of "How many steps/day are enough?", and to inform step-based recommendations consistent with current physical activity guidelines. Normative data indicate that healthy adults typically take between 4,000 and 18,000 steps/day, and that 10,000 steps/day is reasonable for this population, although there are notable "low active populations." Interventions demonstrate incremental increases on the order of 2,000-2,500 steps/day. The results of seven different controlled studies demonstrate that there is a strong relationship between cadence and intensity. Further, despite some inter-individual variation, 100 steps/minute represents a reasonable floor value indicative of moderate intensity walking. Multiplying this cadence by 30 minutes (i.e., typical of a daily recommendation) produces a minimum of 3,000 steps that is best used as a heuristic (i.e., guiding) value, but these steps must be taken over and above habitual activity levels to be a true expression of free-living steps/day that also includes recommendations for minimal amounts of time in MVPA. Computed steps/day translations of time in MVPA that also include estimates of habitual activity levels equate to 7,100 to 11,000 steps/day. A direct estimate of minimal amounts of MVPA accumulated in the course of objectively monitored free-living behaviour is 7,000-8,000 steps/day. A scale that spans a wide range of incremental increases in steps/day and is congruent with public health recognition that "some physical activity is better than none," yet still incorporates step-based translations of recommended amounts of time in MVPA may be useful in research and practice. The full range of users (researchers to practitioners to the general public) of objective monitoring instruments that provide step-based outputs require good reference data and evidence-based recommendations to be able to design effective health messages congruent with public health physical activity guidelines, guide behaviour change, and ultimately measure, track, and interpret steps/day.
Worldwide, public health physical activity guidelines include special emphasis on populations of children (typically 6-11 years) and adolescents (typically 12-19 years). Existing guidelines are commonly expressed in terms of frequency, time, and intensity of behaviour. However, the simple step output from both accelerometers and pedometers is gaining increased credibility in research and practice as a reasonable approximation of daily ambulatory physical activity volume. Therefore, the purpose of this article is to review existing child and adolescent objectively monitored step-defined physical activity literature to provide researchers, practitioners, and lay people who use accelerometers and pedometers with evidence-based translations of these public health guidelines in terms of steps/day. In terms of normative data (i.e., expected values), the updated international literature indicates that we can expect 1) among children, boys to average 12,000 to 16,000 steps/day and girls to average 10,000 to 13,000 steps/day; and, 2) adolescents to steadily decrease steps/day until approximately 8,000-9,000 steps/day are observed in 18-year olds. Controlled studies of cadence show that continuous MVPA walking produces 3,300-3,500 steps in 30 minutes or 6,600-7,000 steps in 60 minutes in 10-15 year olds. Limited evidence suggests that a total daily physical activity volume of 10,000-14,000 steps/day is associated with 60-100 minutes of MVPA in preschool children (approximately 4-6 years of age). Across studies, 60 minutes of MVPA in primary/elementary school children appears to be achieved, on average, within a total volume of 13,000 to 15,000 steps/day in boys and 11,000 to 12,000 steps/day in girls. For adolescents (both boys and girls), 10,000 to 11,700 may be associated with 60 minutes of MVPA. Translations of time- and intensity-based guidelines may be higher than existing normative data (e.g., in adolescents) and therefore will be more difficult to achieve (but not impossible nor contraindicated). Recommendations are preliminary and further research is needed to confirm and extend values for measured cadences, associated speeds, and MET values in young people; continue to accumulate normative data (expected values) for both steps/day and MVPA across ages and populations; and, conduct longitudinal and intervention studies in children and adolescents required to inform the shape of step-defined physical activity dose-response curves associated with various health parameters.
The purpose of this Position Stand is to provide guidance to professionals who counsel and prescribe individualized exercise to apparently healthy adults of all ages. These recommendations also may apply to adults with certain chronic diseases or disabilities, when appropriately evaluated and advised by a health professional. This document supersedes the 1998 American College of Sports Medicine (ACSM) Position Stand, "The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Healthy Adults." The scientific evidence demonstrating the beneficial effects of exercise is indisputable, and the benefits of exercise far outweigh the risks in most adults. A program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health is essential for most adults. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500-1000 MET·min·wk. On 2-3 d·wk, adults should also perform resistance exercises for each of the major muscle groups, and neuromotor exercise involving balance, agility, and coordination. Crucial to maintaining joint range of movement, completing a series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk is recommended. The exercise program should be modified according to an individual's habitual physical activity, physical function, health status, exercise responses, and stated goals. Adults who are unable or unwilling to meet the exercise targets outlined here still can benefit from engaging in amounts of exercise less than recommended. In addition to exercising regularly, there are health benefits in concurrently reducing total time engaged in sedentary pursuits and also by interspersing frequent, short bouts of standing and physical activity between periods of sedentary activity, even in physically active adults. Behaviorally based exercise interventions, the use of behavior change strategies, supervision by an experienced fitness instructor, and exercise that is pleasant and enjoyable can improve adoption and adherence to prescribed exercise programs. Educating adults about and screening for signs and symptoms of CHD and gradual progression of exercise intensity and volume may reduce the risks of exercise. Consultations with a medical professional and diagnostic exercise testing for CHD are useful when clinically indicated but are not recommended for universal screening to enhance the safety of exercise.
Although weakness has been identified in cerebral palsy (CP) in isolated muscle groups, the magnitude of weakness in multiple muscles and the patterns of weakness across joints have not been documented. The maximum voluntary contraction of eight muscle groups in the lower extremities of 15 children with spastic diplegia, 15 with spastic hemiplegia, and 16 age-matched peers was determined using a hand-held dynamometer. Children with spastic diplegia were shown to be weaker than age-matched peers in all muscles tested, as were the children with hemiplegia on the involved side, with strength differences also noted on the uninvolved side. Weakness was more pronounced distally in the groups with CP, and the hip flexors and ankle plantarflexors in spastic CP tended to be relatively stronger than their antagonists as compared with the strength ratios of the comparison group. In conclusion, children with spastic CP demonstrate quantifiable lower-extremity weakness and muscle imbalance across joints.
This section features a recent systematic review that is indexed on PEDro, the Physiotherapy Evidence Database (http://www.pedro.org.au). PEDro is a free, web-based database of evidence relevant to physiotherapy.
▸ Park EY, Kim WH. Meta-analysis of the effect of strengthening interventions in individuals with cerebral palsy. Res Dev Disabil 2014;35:239–49.
Muscle weakness is a common motor impairment that affects the performance of activities of daily living in children1 and adults2 with cerebral palsy. Strengthening interventions in people with cerebral palsy produce patient-perceived improvements in strength, walking ability and activity participation.3 Inspite of this, previous systematic reviews demonstrate that the effects of strengthening interventions on strength and physical performance are still uncertain.4 ,5
This systematic review aimed to determine the effectiveness of strengthening interventions on strength and physical performance in people with cerebral palsy.
Six databases (PubMed, Web of Science, PsychINFO, PEDro, CINAHL and Sports Discuss) were searched for studies published from 2001 to 2012. Studies …
WHO developed the Global Recommendations on Physical Activity for Health with the overall aim of providing national and regional level policy makers with guidance on the dose-response relationship between the frequency, duration, intensity, type and total amount of physical activity needed for the prevention of NCDs. The recommendations set out in this document address three age groups: 5-17 years old; 18-64 years old; and 65 years old and above. The section below includes the recommendations for each age group. For further information click below and download the complete document or click on the individual age groups for specific recommendations.
This brief report updates the core set of exercise tests for use with youth with cerebral palsy to reflect additions since 2010. Copyright © 2015 Wolters Kluwer Health, Inc. and the Section on Pediatrics of the American Physical Therapy Association.
Objective and subjective quantification of habitual physical activity (HPA) and sedentary time in ambulatory and nonambulatory adults with cerebral palsy (CP).
We recruited a clinical sample of adults with CP (N=42; 21 female; mean age: 33.5 yr, SD 12.3 yr; Gross Motor Function Classification System (GMFCS) distribution: Level I (n=5), Level II (n=9), Level III (n=10), Level IV (n=11), and Level V (n=7). Objective measures of HPA and sedentary time were obtained by using ActiGraph GT3X accelerometers, at both hip and wrist sites. Three previously established cut-point values distinguishing light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) were evaluated across GMFCS levels. The concurrent validity of the self-report Physical Activity Recall Assessment for People with Spinal Cord Injury (PARA-SCI) was assessed for LPA and MVPA intensities in GMFCS levels II-V.
Participants showed little reluctance to wearing accelerometers; one participant reported discomfort. Nonambulatory adults (GMFCS level IV-V) differed from ambulatory adults (GMFCS level I-III) for recorded activity counts (hip and wrist sites), minutes of MVPA with each cut-point value, and breaks from sedentary time (all p<0.05). For the same measures, adults in GMFCS level III also differed from GMFCS level I (all p<0.05). The PARA-SCI correlated significantly with accelerometer-derived minutes of MVPA per day (r=0.396, p=0.014) and per hour of monitoring time (r=0.356, p=0.027).
Our findings support the use of accelerometers to objectively measure HPA and sedentary behavior in adults with CP across the severity spectrum, regardless of cut-point implementation. The PARA-SCI is a valid tool to capture subjectively reported patterns of MVPA in adults with CP who are GMFCS level II-V.
Objective:
To examine the association between sedentary behavior and cardiometabolic risk, while taking into account cardiorespiratory fitness (fitness) and physical activity.
Participants and methods:
We examined the association of sedentary behavior, physical activity, and fitness (exposure variables) to cardiometabolic biomarkers and metabolic syndrome (outcome measures) among a historic cohort (January 2, 1981, through October 16, 2012) of men. First, we estimated the association (cross-sectionally and longitudinally) of sedentary behavior along with physical activity and fitness to lipids and lipoproteins, glucose, blood pressure, and markers of adiposity, including body mass index, waist circumference, and body fat percentage. We then prospectively examined the effects of baseline sedentary time on the incidence of metabolic syndrome, while adjusting for physical activity, fitness, and other covariates in multivariate models.
Results:
Multivariate analysis of baseline data revealed that in comparison with the reference group (≤9 h/wk of sedentary time), more sedentary behavior was significantly associated with a higher triglyceride level, a higher triglycerides-high-density lipoprotein cholesterol ratio, and a higher body mass index, waist circumference, and body fat percentage (P<.05 for trend), after adjusting for physical activity and covariates. When adjusting for fitness and covariates, prolonged sedentary time was only associated with a higher triglyceride-high-density lipoprotein cholesterol ratio (P=.02 for trend). Sedentary time was not associated with the incidence of metabolic syndrome in multivariate models. Longitudinal analyses revealed that a 1-metabolic equivalent increase in fitness was significantly (P<.05) associated with almost all biomarkers when adjusting for sedentary behavior, with little moderation observed.
Conclusion:
The association between prolonged sedentary time and cardiometabolic biomarkers is markedly less pronounced when taking fitness into account. Further exploration of the effects of sedentary behavior on cardiometabolic risk is warranted in cohorts with available fitness data. Furthermore, our findings underscore the need to encourage achieving higher fitness levels through meeting physical activity guidelines to decrease disease risk factors.
AimOptimal physical behaviour is important, as physical inactivity contributes to functional deterioration and reduced social participation. Nevertheless, research showed that persons with cerebral palsy (CP) have low physical activity levels. The objective of this study is to evaluate the effectiveness of a lifestyle intervention programme on physical behaviour.Method
Fifty-seven persons (36 completed the total study) with spastic CP (age range 16 to 25y; 27 males, 30 females), classified as Gross Motor Function Classification System levels I-IV were included in this randomized controlled trial. Twenty-nine participants had a unilateral CP and 27 had a bilateral CP. A 6-month lifestyle intervention consisting of fitness training and counselling on physical behaviour and sports participation was evaluated. Physical behaviour was objectively measured using ambulatory activity monitors. Self-reported physical activity was determined using the Physical Activity Scale for Individuals with Physical Disabilities.ResultsThe intervention did not affect the objectively measured physical activity during the intervention (beta=0.34, CI=−1.70 to 2.37) or at follow-up (beta=0.30, CI=−1.99 to 2.59). Self-reported physical activity was positively affected during the intervention period (beta=7.61, CI=0.17-15.05); however, this effect was not present at follow-up (beta=3.65, CI=−3.05 to 10.36).InterpretationThe lifestyle intervention was ineffective in eliciting a behavioural change towards more favourable physical behaviour in adolescents and young adults with spastic CP.
Adolescents and young adults with cerebral palsy (CP) show reduced motor function and gait efficiency, and lower levels of habitual physical activity (HPA), than adolescents with typical development and children with CP. This study examined activity duration and patterns in this population in the Middle East through long-term monitoring of a large sample using accelerometers.
Adolescents and young adults with bilateral CP at Gross Motor Function Classification System (GMFCS) levels II, III, and IV, were monitored in their habitual environment for four consecutive days with ActivPAL3 monitors. Time spent in sedentary, standing, and walking activities, and frequency of walking steps and transitions, were analysed for each GMFCS level.
Measurements were made on 222 participants (132 males, 90 females; mean age 16y 9mo SD 2y, range 13y 4mo-22y). The Mann-Whitney U test demonstrated significant differences (p<0.05) between GMFCS levels, showing reduced walking and standing activity and increased sedentary duration at higher GMFCS levels (p<0.001), except for increased standing time between GMFCS levels II and III (p=0.07). Participants in educational facilities exhibited less sedentary behaviour than those who were homebound (p<0.05).
These descriptions of duration and frequency of active and sedentary behaviours may serve as a basis for recommendations to minimize inactivity in this population. Adolescents and young adults with CP in the Middle East demonstrate similar patterns of HPA to their peers in other regions.
The aim of this study was to investigate whether individualized resistance training improves the physical mobility of young people with cerebral palsy (CP).
Forty-eight participants with spastic diplegic CP (26 males, 22 females; mean age 18y 1mo, SD 1y 11mo) classified as level II or III on the Gross Motor Function Classification System were allocated randomly to progressive resistance training or usual-care control. Resistance training was completed twice weekly for 12 weeks at a community gymnasium under the supervision of a physiotherapist. Exercises were based on instrumented gait analysis and targeted muscles contributing to walking difficulties. Outcomes at 12 weeks and 24 weeks included objective measures of mobility (6-min walk test, instrumented gait analysis, and Gross Motor Function Measure dimensions D and E), participant-rated measures of mobility (Functional Mobility Scale and Functional Assessment Questionnaire), and muscle performance.
The strength of targeted muscles increased by 27% (95% CI 8-46%) compared with control group. There were no between-group differences in any objective measure of mobility at 12 weeks (6-min walk test: mean difference 0.1m; 95% CI -21 to 21m) or at 24 weeks. Participant-rated mobility improved (Functional Mobility Scale at 5m: mean 0.6 units; 95% CI 0.1-1.1 units; Functional Assessment Questionnaire: 0.8 units; 95% CI 0.1-1.6 units) compared with control group at 12 weeks.
Individualized progressive resistance training increased strength in adolescents and young adults with spastic diplegic CP. Despite participant-rated benefits, the increased strength did not result in objective improvements in mobility.
SUMMARY In order to stimulate further adaptation toward specific training goals, progressive resistance training (RT) protocols are necessary. The optimal characteristics of strength-specific programs include the use of concentric (CON), eccentric (ECC), and isometric muscle actions and the performance of bilateral and unilateral single- and multiple-joint exercises. In addition, it is recommended that strength programs sequence exercises to optimize the preservation of exercise intensity (large before small muscle group exercises, multiple-joint exercises before single-joint exercises, and higher-intensity before lower-intensity exercises). For novice (untrained individuals with no RT experience or who have not trained for several years) training, it is recommended that loads correspond to a repetition range of an 8-12 repetition maximum (RM). For intermediate (individuals with approximately 6 months of consistent RT experience) to advanced (individuals with years of RT experience) training, it is recommended that individuals use a wider loading range from 1 to 12 RM in a periodized fashion with eventual emphasis on heavy loading (1-6 RM) using 3- to 5-min rest periods between sets performed at a moderate contraction velocity (1-2 s CON; 1-2 s ECC). When training at a specific RM load, it is recommended that 2-10% increase in load be applied when the individual can perform the current workload for one to two repetitions over the desired number. The recommendation for training frequency is 2-3 dIwkj1 for novice training, 3-4 dIwkj1 for intermediate training, and 4-5 dIwkj1 for advanced training. Similar program designs are recom- mended for hypertrophy training with respect to exercise selection and frequency. For loading, it is recommended that loads corresponding to 1-12 RM be used in periodized fashion with emphasis on the 6-12 RM zone using 1- to 2-min rest periods between sets at a moderate velocity. Higher volume, multiple-set programs are recommended for maximizing hypertrophy. Progression in power training entails two general loading strategies: 1) strength training and 2) use of light loads (0-60% of 1 RM for lower body exercises; 30-60% of 1 RM for upper body exercises) performed at a fast contraction velocity with 3-5 min of rest between sets for multiple sets per exercise (three to five sets). It is also recommended that emphasis be placed on multiple-joint exercises especially those involving the total body. For local muscular endurance training, it is recommended that light to moderate loads (40-60% of 1 RM) be performed for high repetitions (915) using short rest periods (G90 s). In the interpretation of this position stand as with prior ones, recommendations should be applied in context and should be contingent upon an individual's target goals, physical capacity, and training
Purpose:
The objective of this study is to compare the maximal aerobic and anaerobic exercise responses of children with cerebral palsy (CP) by level of motor impairment and in comparison with those of typically developing children (TD).
Methods:
Seventy children with CP, with varying levels of motor impairment (Gross Motor Function Classification System (GMFCS) I-III), and 31 TD performed an incremental continuous maximal aerobic exercise test and a 20-s anaerobic Wingate test on a cycle ergometer. Peak oxygen uptake (V˙O2peak), anaerobic threshold (AT), peak ventilation (V˙Epeak), peak oxygen pulse (peak O2 pulse), peak ventilatory equivalent of oxygen (peak V˙E/V˙O2) and carbon dioxide (peak V˙E/V˙CO2), peak aerobic power output (POpeak), and mean anaerobic power (P20mean) were measured. Isometric leg muscle strength was determined as a secondary outcome.
Results:
Analysis revealed a lower V˙O2peak for CP (I: 35.5 ± 1.2 (SE); II: 33.9 ± 1.6; III: 29.3 ± 2.5 mL·kg-1·min-1) compared with TD (41.0 ± 1.3, P < 0.001) and a similar effect for AT (I: 19.4 ± 0.9; II: 19.2 ± 1.2; III: 15.5 ± 1.9; TD: 24.1 ± 1.0 mL·kg-1·min-1, P < 0.001). V˙Epeak and peak O2 pulse were also lower, whereas peak V˙E/V˙CO2 was higher in CP compared with TD (P < 0.05) and peak V˙E/V˙O2 similar between groups. All these variables showed no differences for different motor impairment levels. POpeak was lower for CP (I: 2.4 ± 0.1; II: 1.8 ± 0.1; III: 1.4 ± 0.2 W·kg-1) versus TD (3.0 ± 0.1, P < 0.001), together with a lower P20mean in CP (I: 4.6 ± 0.2; II: 3.3 ± 0.2; III: 2.5 ± 0.4 W·kg-1) versus TD (6.4 ± 0.2, P < 0.001), and both decreased significantly with increasing motor impairment.
Conclusion:
Children with CP have decreased aerobic and anaerobic exercise responses, but decreases in respiratory and aerobic exercise responses were not as severe as predicted by motor impairment. Future research should reveal the role of inactivity on the exercise responses of children with CP and possibilities for improvement through training interventions.
OBJECTIVE: To systematically evaluate the level of evidence of the clinimetric properties of measures of aerobic and anaerobic capacity used for children with cerebral palsy (CP). DATA SOURCES: A systematic search of databases PubMed, Embase, SPORTDiscus and PsycINFO through April 2011 was performed. STUDY SELECTION: Two independent raters identified and examined studies that reported laboratory or field-based measures of maximal aerobic or anaerobic capacity in children with CP aged 5-14 years. DATA EXTRACTION: The COSMIN checklist was used by two independent raters to evaluate the methodological quality of the included clinimetric studies and identify measures used in these studies. DATA SYNTHESIS: Twenty-four studies that used a maximal aerobic or anaerobic capacity measure were identified. Five studies reported clinimetric properties for five measures (2 aerobic and 3 anaerobic measures). Methodological quality was excellent in 3 studies showing good validity and reliability of field-based aerobic (Shuttle Run Test) and anaerobic (Muscle Power Sprint Test) measures. The studies on laboratory-based measures were rated fair, mainly due to inadequate statistics. The level of evidence was strong for good validity and reliability of the field-based tests. The level of evidence was unknown for validity and low to moderate for good reliability of laboratory-based tests. CONCLUSIONS: There is a paucity of research on the clinimetric properties of measurement instruments to assess aerobic and anaerobic capacity for children with cerebral palsy. Further clinimetric studies of laboratory-based measures in children with CP at all GMFCS levels and clinimetric studies of field-based measures in children who are classified at GMFCS levels III to V are required.
Although weakness has been identified in cerebral palsy (CP) in isolated muscle groups, the magnitude of weakness in multiple muscles and the patterns of weakness across joints have not been documented. The maximum voluntary contraction of eight muscle groups in the lower extremities of 15 children with spastic diplegia, 15 with spastic hemiplegia, and 16 age-matched peers was determined using a hand-held dynamometer. Children with spastic diplegia were shown to be weaker than age-matched peers in all muscles tested, as were the children with hemiplegia on the involved side, with strength differences also noted on the uninvolved side. Weakness was more pronounced distally in the groups with CP, and the hip flexors and ankle plantarflexors in spastic CP tended to be relatively stronger than their antagonists as compared with the strength ratios of the comparison group. In conclusion, children with spastic CP demonstrate quantifiable lower-extremity weakness and muscle imbalance across joints.
Fourteen ambulatory children with spastic diplegia participated in a bilateral quadriceps. strengthening program in an attempt to decrease the amount of knee crouch during gait. Each chid exercised three times a week for six weeks using free ankle weights at a load of 65 per cent of maximum. A normal comparison group of 25 children was also tested under identical conditions. Children with cerebral palsy were significantly weaker in the quadriceps and hamstrings muscle groups than controls. Quadriceps strength increased signficantly at all three angles of knee flexion as a result of the weight‐training program and did not differ statistically from normal at the end of the program. Quadriceps weakness was shown to be a factor in crouch gait; restoring strength through resistance exercise may be a useful adjunct in the treatment of cerebral palsy.
RÉSUMÉ
Réponse muscukiire aux exercices á haute résistance chez les enfants présentant tine IMC spastique
Un programme de renforcement bilatéral des quadriceps a été entrepris cheq 14 jeiines diplégiques spastiques dans une tentative de réduire le niveau de flexion du genou lors de la marche. Un exercice fut appliqué chez chaque enfant, trois fois par semaine durant six semaines utilisant des poids laissant la cheville libre, avec une charge équivalente à 65 pour cent du maximum. Un groupe de comparaison de 25 enfants normaux fut testé dans des conditions identiques. Les enfants IMC avaient une force significativement plus faible que celle des contrôles pout les quadriceps et les ischio‐jambiers. La force du quadriceps s'accrut significativement pour les trois angles de flexion du genou à la suite du programme d'exercice et ne différait plus statistiquement des contrôles à la fin du programme. Ainsi le rôle de la faiblesse du quadriceps dans la flexion du genou durant la démarche sc trouve démontrée; une récupération de force au Iravers d'exercices contre résistance peut étre un apport utile dans le traitement de L'IMC.
ZUSAMMENFASSUNG
Muskclantwort atif Krafttruhiing bei Kindern mit spastisclwr Cerebralparese
Vierzehn ambulante Kinder mit spastischer Diplegie nahmen an einem Trainingsprogramm zur bilateralen Kräftigung des Quadriceps teil, das in dem Versuch gestartet wurde, die Kniebeugestellung beim Gehen zu reduzieren. Jedes Kind trainierte dreimal/Woche insgesamt sechs Wochen lang mit freien Knöchelgewichten mit 65 Prozent der Maximalbelasiung. Eine Vergleichsgruppe von 25 gesunden Kindern urde unter identischen Bedingungen getestet. Die Kinder mit Cerebralparese waren in den Quadriceps‐ und Hamstring‐Muskelgruppen signifikant sehwächer als die Kontrollen. Nach dem Training war die Quadricepskraft in alien drei Winkelstellungen des Kniegelenks so gestärkt, daß sic sich am Ende des Programms statistisch nicht vom Normalen unterschied. Es zeigte Einknicken im Kniegelenk beim Gehen ist; Krafterhaltung durch Training kann ein sinnvolles Hilfsmittel bei der Behandlung der Cerebralparese sein.
RESUMEN
Respuesta muscular al ejercicio contra restistenciapesada en niños con parálisis cerebral espástica
Calorce niños ambuhilorios con diplejia espástica parliciparon en un prograinma de tortalecimicnto bilateral del cuadriceps don la idea de disminuir el grado de flexión de rodilla en la marcha. Cada niño hacia ejercicio tres veces por semana durante seis semanas, utilizando a nivel de la rodilla libre pesos de un 65 por ciento del máximo. Un grupo comparativo normal formado por 24 niños realizaron también las pruebas en idénticas condiciones. l.os niños con parálisis cerebral eran significativamcnte más débiles a nivel de cuadriceps y de gemelos que los controles. La potencia del cuádriceps aumcntaba significativamcnte en todos los tres ángulos de flexión de la rodilla como resultado del cntrencmicnto con pesos y no difería del normal cstadisticamente al final del programa. La debilidacl del cuadriceps se vió que era un factor en la marcha agachada. La restauración de la fuerza con ejercicios de resistcncia puede ser una ayuda útil en el tratamiento de la parálisis cerebral.
Obesity in childhood carries a wide range of physical, psychological and social disbenefits and also increases the risk of adult obesity with its well-recognised, enhanced risk of several common complex diseases as well as adverse socioeconomic and psychosocial sequelae. Understanding the tracking of the two key modifiable behaviours, food consumption and physical activity, between childhood and adulthood may illuminate the childhood determinants of adult obesity and contribute to the development of effective interventions.
Prolonged television (TV) viewing is the most prevalent and pervasive sedentary behavior in industrialized countries and has been associated with morbidity and mortality. However, a systematic and quantitative assessment of published studies is not available.
To perform a meta-analysis of all prospective cohort studies to determine the association between TV viewing and risk of type 2 diabetes, fatal or nonfatal cardiovascular disease, and all-cause mortality.
Relevant studies were identified by searches of the MEDLINE database from 1970 to March 2011 and the EMBASE database from 1974 to March 2011 without restrictions and by reviewing reference lists from retrieved articles. Cohort studies that reported relative risk estimates with 95% confidence intervals (CIs) for the associations of interest were included.
Data were extracted independently by each author and summary estimates of association were obtained using a random-effects model.
Of the 8 studies included, 4 reported results on type 2 diabetes (175,938 individuals; 6428 incident cases during 1.1 million person-years of follow-up), 4 reported on fatal or nonfatal cardiovascular disease (34,253 individuals; 1052 incident cases), and 3 reported on all-cause mortality (26,509 individuals; 1879 deaths during 202,353 person-years of follow-up). The pooled relative risks per 2 hours of TV viewing per day were 1.20 (95% CI, 1.14-1.27) for type 2 diabetes, 1.15 (95% CI, 1.06-1.23) for fatal or nonfatal cardiovascular disease, and 1.13 (95% CI, 1.07-1.18) for all-cause mortality. While the associations between time spent viewing TV and risk of type 2 diabetes and cardiovascular disease were linear, the risk of all-cause mortality appeared to increase with TV viewing duration of greater than 3 hours per day. The estimated absolute risk differences per every 2 hours of TV viewing per day were 176 cases of type 2 diabetes per 100,000 individuals per year, 38 cases of fatal cardiovascular disease per 100,000 individuals per year, and 104 deaths for all-cause mortality per 100,000 individuals per year.
Prolonged TV viewing was associated with increased risk of type 2 diabetes, cardiovascular disease, and all-cause mortality.