Children with cerebral palsy do not achieve healthy physical activity levels

Effects of exercise intervention on balance function in children with cerebral palsy: a systematic review and meta-analysis of randomized controlled trials

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.

Lifelong Fitness in Ambulatory Children and Adolescents with Cerebral Palsy I: Key Ingredients for Bone and Muscle Health

Physical activity of a sufficient amount and intensity is essential to health and the prevention of a sedentary lifestyle in all children as they transition into adolescence and adulthood. While fostering a fit lifestyle in all children can be challenging, it may be even more so for those with cerebral palsy (CP). Evidence suggests that bone and muscle health can improve with targeted exercise programs for children with CP. Yet, it is not clear how musculoskeletal improvements are sustained into adulthood. In this perspective, we introduce key ingredients and guidelines to promote bone and muscle health in ambulatory children with CP (GMFCS I-III), which could lay the foundation for sustained fitness and musculoskeletal health as they transition from childhood to adolescence and adulthood. First, one must consider crucial characteristics of the skeletal and muscular systems as well as key factors to augment bone and muscle integrity. Second, to build a better foundation, we must consider critical time periods and essential ingredients for programming. Finally, to foster the sustainability of a fit lifestyle, we must encourage commitment and self-initiated action while ensuring the attainment of skill acquisition and function. Thus, the overall objective of this perspective paper is to guide exercise programming and community implementation to truly alter lifelong fitness in persons with CP.

Lifelong Fitness in Ambulatory Children and Adolescents with Cerebral Palsy II: Influencing the Trajectory

Physical activity of at least moderate intensity in all children contributes to higher levels of physical and psychological health. While essential, children with cerebral palsy (CP) often lack the physical capacity, resources, and knowledge to engage in physical activity at a sufficient intensity to optimize health and well-being. Low levels of physical activity place them at risk for declining fitness and health, contributing to a sedentary lifestyle. From this perspective, we describe a framework to foster a lifelong trajectory of fitness in ambulatory children with CP (GMFCS I-III) as they progress into adolescence and adulthood, implemented in conjunction with a training program to augment bone and muscle health. First, we recommend that altering the fitness trajectory of children with CP will require the use of methods to drive behavioral change prior to adolescence. Second, to promote behavior change, we suggest embedding lifestyle intervention into fitness programming while including meaningful activities and peer socialization to foster self-directed habit formation. If the inclusion of lifestyle intervention to drive behavior change is embedded into fitness programs and found to be effective, it may guide the delivery of targeted programming and community implementation. Participation in comprehensive programming could alter the long-term trajectory of musculoskeletal health while fostering strong self-efficacy in persons with CP.

Physical activity and quality of life in children with idiopathic toe walking: a cross sectional study

Objectives

To determine if children with idiopathic toe walking (ITW) reach Australian 24-hour movement guidelines. Additional objectives were to identify any factors associated with moderate to vigorous physical activity time of children with ITW.

Design

Cross sectional.

Setting

Private practice, public health outpatient, community clinics.

Participants

Children between 4 and 14 years, who toe walked and had no medical conditions known to cause ITW.

Outcome measures

Physical activity intensity, sedentary behaviour and sleep data were collected via an ActiGraph. Physical activity level intensity data were triangulated with the Child Leisure Activities Study Survey (CLASS) to highlight the subjective nature of parent-reported measures. Health related quality of life information was collected using the Parent-Proxy and Child-Self Report Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scale. Regression analyses were used to explore individual factors associated with moderate to vigorous physical activity.

Results

Twenty-seven participants, 17(63%) male, age mean = 6.62 (SD = 2.29) years, provided information on physical activity (CLASS n = 18, ActiGraph n = 22), physical functioning and psychosocial functioning domains on the PedsQL (Parent-Proxy n = 25, Child n = 22). All participants exceeded Australian recommendations for physical activity, 44% (8/18) met recommended screen time amounts, and two (9%) met recommended sleep times. The Child-Self Report PedsQL scale score of social functioning was the only factor associated with an increase in physical activity (Coef = 0.48, 95%CI = 0.09 to 0.87, p = 0.019).

Conclusion

Participants achieved high levels of daily moderate to vigorous physical activity, and this was associated with social functioning. Given current uncertainty regarding benefits and effectiveness of treatment choices for children who have ITW, these findings should encourage clinicians to consider how their treatment recommendations interact with the PA level and sleep of children with ITW. Any treatment choice should also be implemented with consideration of how it may impact social functioning. This study had a small sample size therefore results should be cautiously interpreted and not generalised to all children with ITW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03583-w.

Unequal physical activity among children with cerebral palsy in Sweden-A national registry study

AIM

To examine the extent to which sex, country of birth, and functional aspects influence participation in physical education and physical leisure activity among children with cerebral palsy (CP) in Sweden.

METHODS

This national cross-sectional registry study included children with CP aged 6 to 18 years who participated in the Swedish national quality registry, the Cerebral Palsy Follow-up Program, CPUP, in 2015. Comparisons and associations between sex, country of birth, and functional aspects and physical leisure/physical education were examined using chi-squared and multivariable logistic regression analysis.

RESULTS

The study included 1935 children. Of them, 1625 (87%) reported participating in physical education and 989 (53%) reported participating in physical leisure activity. Children born in Sweden had higher odds of participating in physical education (OR: 1.99; 95% CI: 1.20-3.28) and physical leisure activity (OR: 2.51; 95% CI: 1.70-3.72) compared with children born outside Europe. Greater impairment of gross motor function was associated with lower participation levels. Boys participated slightly more frequently in leisure activities than girls.

CONCLUSION

Enhancing social inclusion with regard to disability, birth country, and sex are important and achievable goals for policymakers and practitioners for promoting participation in physical activity for children and adolescents with CP.

Physical Activity in 6.5-Year-Old Children Born Extremely Preterm

Physical activity (PA) can prevent cardiovascular diseases. Because of increased risks of impairments affecting motor activity, PA in children born preterm may differ from that in children born at term. In this prospective cohort study, we compared objectively measured PA in 71 children born extremely preterm (<27 weeks gestational age), to their 87 peers born at term, at 6.5 years of age. PA measured with accelerometer on the non-dominant wrist for 7 consecutive days was compared between index and control children and analyzed for associations to prenatal growth, major neonatal brain injury, bronchopulmonary dysplasia and neonatal septicemia, using ANOVA. Boys born extremely preterm spent on average 22 min less time per day in moderate to vigorous physical activity (MVPA) than control boys (95% CI: -8, -37). There was no difference in girls. Amongst children born extremely preterm, major neonatal brain injury was associated with 56 min less time in MVPA per day (95%CI: -88, -26). Subgroups of children born extremely preterm exhibit lower levels of physical activity which may be a contributory factor in the development of cardiovascular diseases as adults.

Sedentary Behavior in Children With Cerebral Palsy Between 1.5 and 12 Years: A Longitudinal Study

PURPOSE

To determine longitudinal change in sedentary behavior in children with cerebral palsy (CP) from 1.5 to 12 years.

METHODS

Ninety-one children, Gross Motor Function Classification System (GMFCS) levels I to III, who participated in a large longitudinal cohort study were participants. Longitudinal change was analyzed in objectively measured sedentary behavior and associations with sex, body mass index Z score, and socioeconomic status. Moderate-vigorous intensity physical activity (MVPA) was estimated at 8 to 12 years.

RESULTS

Average sedentary minutes/day peaked at 4 years in children at GMFCS I and 5 years in children at GMFCS II to III, then plateaued. Male sex was associated with increased sedentary behavior. At 8 to 12 years, children at GMFCS I, II, and III accumulated on average 54, 47, and 14 minutes/day, respectively, of MVPA.

CONCLUSIONS

When measured to 12 years, sedentary behavior peaks by 5 years for children with CP who are walking with differences in trajectory according to GMFCS.

A cross-sectional examination of the 24-hour movement behaviours in Canadian youth with physical and sensory disabilities

BACKGROUND

Canada's 24-Hour Movement Guidelines for Children and Youth provide daily recommendations for physical activity (PA), screen time, and sleep for optimal health. The appropriateness of such guidelines for youth with disabilities remains unknown.

OBJECTIVE

To cross-sectionally examine the 24-h movement behaviours and guideline adherence in youth (ages 12-21 years) with physical and sensory disabilities.

METHODS

54 youth with physical and sensory disabilities completed two, 24-h recalls to assess PA, sedentary behaviour, and sleep. Descriptive statistics were used to analyze behavioural patterns and guideline adherence. Gender and age differences were tested using analyses of variance and logistic regressions.

RESULTS

55.5%, 13.0%, and 53.7% of the sample met the individual guidelines for PA, sedentary behaviour, and sleep, respectively. 3.7% of the sample met all three movement guidelines. No significant gender or age differences in guideline achievement were found. Over a 24-h period, youth spent 77 (59) minutes engaging in moderate to vigorous PA, 252 (120) minutes engaging in sedentary activity, and 546 (90) minutes sleeping. Boys reported significantly more time (adjusted M_difference = 11 min) playing passive video games than girls.

CONCLUSION

Overall, our sample of youth with physical and sensory disabilities falls far short of meeting the Canadian 24-Hour Movement Guidelines for Children and Youth. The low proportion of youths' time spent engaging in sport and active play is concerning, highlighting the importance of creating access to these types of PA experiences for this population. Future population-based research is needed among children and youth with all types of disabilities to build an evidence-base of their movement behaviours.

Wearable electromyography recordings during daily life activities in children with cerebral palsy

AIM

To test whether wearable textile electromyography (EMG) recording systems may detect differences in muscle activity levels during daily activities between children with cerebral palsy (CP) and age-matched typically developing children.

METHOD

Wearable textile EMG recording systems were used to obtain leg muscle activity in 10 children with spastic CP (four females, six males; mean age 9y 6mo, standard deviation [SD] 2y 4mo, range: 6-13y; Gross Motor Function Classification System [GMFCS] level I and II) and 11 typically developing children (four females, seven males; mean age 9y 9mo, SD 1y 11mo, 7-12y) at rest and while performing seven daily activities.

RESULTS

Children with CP showed significantly lower absolute EMG levels during maximal voluntary contractions (MVCs) of muscles on the most affected side as compared to the least affected side and to typically developing children. None of the typically developing children or children with CP showed detectable EMG activity in resting situations. EMG activity relative to MVC was greater in children with CP during walking, jumping, and kicking on the most affected side as compared to the least affected side and to typically developing children.

INTERPRETATION

Wearable textile EMG recording systems may be used to determine differences in muscle activity during daily activities in children with CP. Children with CP showed reduced muscle activity during daily activities compared to their peers, but used a significantly larger part of their maximal voluntary muscle strength to perform these activities.

WHAT THIS PAPER ADDS

Wearable textile electromyography (EMG) systems are feasible for measurement of daily muscle activity in children with cerebral palsy (CP). Children with CP showed reduced EMG levels during maximal voluntary contractions. Neither typically developing children or children with CP showed EMG activity in resting situations. Children with CP used a larger part of their voluntary muscle strength during daily activities.

The Relationship between Parent-reported PEDI-CAT Mobility and Gross Motor Function in Children with Cerebral Palsy: Brief Report

Purpose: The PEDI-CAT mobility domain (PEDI-mob) is a parent-reported measure of mobility for children up to 21 years of age. The purpose of this research is to investigate the relationship between the PEDI-mob and Gross Motor Function Measure (GMFM)-66 and Gross Motor Function Classification Scale (GMFCS) levels.Methods: Fifty-seven children (N = 57), ages 2-8.8 years participated. PEDI-mob and GMFM were administered and GMFCS was confirmed during the same session. A Pearson correlation coefficient was calculated for PEDI-mob and GMFM-66 scores to evaluate the association between these two measures. An ANOVA was used to analyze PEDI-mob across GMFCS levels.Results: Large, statistically significant correlation was found between PEDI-mob and GMFM-66 scores (r = 0.894, p-value<0.001). Differences in PEDI-mob scores were found across GMFCS levels (p-value <0.001), where patients with higher GMFCS levels had lower PEDI-mob scores.Conclusion: These results support a strong relationship between parent-reported and clinically measured motor function.

Physical activity patterns in children with cerebral palsy and typically developing peers

Objective: To compare physical activity level between children with cerebral palsy and typically developing peers using accelerometer and activity diary.Method: Twenty children with spastic cerebral palsy Level I and II according to Gross Motor Function Classification System, and 20 healthy age- and sex-matched typically developing peers were included. An activity diary was logged, and each child wore an accelerometer for 4 days, 2 weekdays and 2 weekend days.Results: Total and physical activity energy expenditure assessed using either accelerometer or activity diary was markedly lower in children with spastic cerebral palsy compared to typically developing peers. Moderate and vigorous physical activities and daily total energy expenditure assessed using activity diary were significantly lower in children with cerebral palsy than those of typically developing peers (p < .05). There was a significant relationship between accelerometer and activity diary in total energy expenditure for children with cerebral palsy (r = 0.752, p < .001) and typically developing peers (r = 0.732, p < .001) and a moderate significant relationship in physical activity energy expenditure for children with cerebral palsy (r = 0.463, p = .040).Conclusion: In this study, children with cerebral palsy had lower physical activity levels than their typically developing peers. The activity diary provided detailed information about physical activities and was correlated with accelerometer data. The activity diary could be a valid measure of physical activity levels in children with cerebral palsy.

Natural variability of daily physical activity measured by accelerometry in children with a mitochondrial disease

In this exploratory study we aimed to select the most valid and feasible accelerometer to measure daily physical activity at home in 10 children with mitochondrial disease. Using the experimentally-selected GENEActiv, good to excellent short- and long-term test-retest reliability of daily physical activity was found. Especially in children with more severe limitations daily physical activity seemed more stable and less susceptible to weather conditions. Moreover, small standard errors of measurement were found, indicating high precision of this measuring method. We conclude that measuring daily physical activity using accelerometry is a promising outcome measure for future studies in this unique population.

Microvascularization is not a limiting factor for exercise in adults with cerebral palsy

Muscle contractures are a common complication in patients with central nervous system (CNS) lesions which limit range of movement and cause joint deformities. Furthermore, it has previously been shown that muscles with contractures have a reduced number of capillaries, indicating decreased tissue vascularization. The aim of the present study was to investigate the microvascular volume (MV) at rest and after acute exercise in the muscle tissue of individuals with cerebral palsy (CP) and healthy control individuals. Contrast-enhanced ultrasound (CEUS) was used before and after 30 min of walking or running on a treadmill in 10 healthy control participants and 10 individuals with CP to detect MV of their skeletal muscle tissue. A significant increase in the MV was observed after exercise both in the adult CP group (21–53 yr) and in the control group (21–52 yr) (1.8 ± 0.8 ΔdB to 3.1 ± 0.9 ΔdB or 42.9% and 1.5 ± 0.6 ΔdB to 2.5 ± 0.9 ΔdB or 39.0%, respectively). Furthermore, a difference in the resting MV was observed between the most severe cases of CP [gross motor function classification scale (GMFCS) 3 and 4] (2.3 ± 0.5 ΔdB) and the less severe cases (GMFCS 1 and 2) (1.5 ± 0.2 ΔdB). When the CP group was walking (3.4 km/h), the lactate levels, Borg score, and heart rate matched the level of controls when they were running (9.8 km/h). In conclusion, individuals with CP become exhausted at much lower exercise intensities than healthy individuals. This is not explained by impaired microvascularization, since the MV of the individuals with CP respond normally to increased O2 demand during acute exercise.

NEW & NOTEWORTHY Cerebral palsy (CP) patients were less physically active compared with typically developed individuals. This may affect the microvascularization. We observed that the CP group became exhausted at much lower exercise intensities compared with healthy individuals. However, impaired microvascularization was not the reason for the decreased physical activity as the CP group responded normally to increased O2 demand during acute exercise. These results indicate that walking may be recommended as an intervention to train and maintain skeletal muscle tissue in individuals with CP.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

WHAT THIS PAPER ADDS

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

Physiotherapeutic interventions and physical activity for children in Northern Sweden with cerebral palsy: a register study from equity and gender perspectives

Background: Young people with disabilities, especially physical disabilities, report worse health than others. This may be because of the disability, lower levels of physical activity, and discrimination. For children with cerebral palsy, access to physiotherapy and physical activity is a crucial prerequisite for good health and function. To date, there is limited knowledge regarding potential gender bias and inequity in habilitation services.

Objectives: To map how physiotherapeutic interventions (PTI), physical leisure activity, and physical education are allocated for children with cerebral palsy regarding sex, age, level of gross motor function, and county council affiliation. This was done from a gender and equity perspective.

Methods: A register study using data from the Cerebral Palsy follow-Up Program (CPUP). Data included 313 children ≤18 years with cerebral palsy from the five northern counties in Sweden during 2013. Motor impairment of the children was classified according to the expanded and revised Gross Motor Function Classification System (GMFCS).

Results: In three county councils, boys received more physiotherapy interventions and received them more frequently than girls did. Differences between county councils were seen for frequency and reasons for physiotherapy interventions (p < 0.001). The physiotherapist was involved more often with children who had lower motor function and with children who had low physical leisure activity. Children with lower motor function level participated in physical leisure activity less often than children with less motor impairment (p < 0.001). Boys participated more frequently in physical education than did girls (p = 0.028).

Conclusion: Gender and county council affiliation affect the distribution of physiotherapy interventions for children with cerebral palsy, and there are associations between gender and physical activity. Thus, the intervention is not always determined by the needs of the child or the degree of impairment. A gender-bias is indicated. Further studies are needed to ensure fair interventions.

The efficacy of interventions to increase physical activity participation of children with cerebral palsy: a systematic review and meta-analysis

AIM

To determine efficacy of therapy and behaviour change interventions to increase the level of participation in leisure-time physical activities (LTPAs) and habitual physical activity in children and young people with cerebral palsy.

METHOD

Five databases were systematically searched. Included studies were randomized or comparison designs. Methodological quality was assessed with a modified Downs and Black Scale. Quantitative analysis was performed using RevMan 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). Intervention components and behaviour change constructs were mapped against (1) the International Classification of Functioning, Disability and Health (ICF) and (2) the Theoretical Domains Framework.

RESULTS

Searches yielded 2487 unique articles. Eight studies (nine articles) were included. Interventions included physical training, activity level training, combined physical training and behaviour change therapy, online behaviour change modules, and context-focused therapy. Study quality varied from moderate to high. There was a small, significant effect of physical activity intervention compared with passive usual care on level of habitual physical activity, of approximately 1000 additional steps per day (standardized mean difference 0.34, 95% confidence interval 0.03-0.66, p=0.030). There was no significant effect on LTPA participation (standardized mean difference 0.40, 95% confidence interval -0.40 to 1.19, p=0.330).

INTERPRETATION

Therapy and behaviour change interventions have the potential to increase LTPA participation of children and young people with cerebral palsy, although there is a need to depart from impairment-focused approaches. Inappropriate selection of outcomes and inadequate reporting of complex interventions are barriers to progress in this field.

ParticiPAte CP: a protocol of a randomised waitlist controlled trial of a motivational and behaviour change therapy intervention to increase physical activity through meaningful participation in children with cerebral palsy

INTRODUCTION

Children with cerebral palsy (CP) participate in leisure-time physical activities (PA) less often, with less intensity and reduced diversity than their typically developing peers. Participation in leisure-time physical activities may be an important source of habitual physical activity (HPA) for children with CP, who as a group have lower levels of HPA and increased sedentary time compared with their typically developing peers. The proposed study aims to compare the efficacy of a participation focused therapy (ParticiPAte CP) to usual care in a pragmatic, randomised waitlist controlled trial.

METHODS AND ANALYSIS

Thirty-six children with CP (18 in each group), classified as Gross Motor Function Classification System levels I to III, aged between 8 and 12 years will be recruited across South East Queensland, Australia. Children will be randomised to receive either ParticiPAte CP or waitlist usual care using concealed allocation. ParticiPAte CP is an individually tailored, goal-directed intervention model of pragmatic participation-focused therapy using a toolbox of evidence-based strategies in the treatment of children with CP. This will include goal-setting; identification of barriers and facilitators to participation goals, strategy formation and planning and communication guided by principles of Self-Determination Theory using strategies of Motivational Interviewing. The intervention comprises 8 weekly sessions of 1 hour duration conducted by a physiotherapist in the child's home or community.

TRIAL REGISTRATION NUMBER

ACTRN12615001064594.

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

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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