Real-time daily fatigue, sleep, physical activity, and health-related fitness in adults with cerebral palsy.

AIM: To explore whether subgroups of adults with cerebral palsy (CP) with different fatigue diurnal profiles can be discerned, and to explore whether sleep, physical activity, or health-related fitness are associated with these profiles. METHOD: Thirty-two adults (median age 29 years 8 months; range 20-54 years; 11 males, 21 females) with spastic CP (Gross Motor Function Classification System levels I-III) with physical activity-related fatigue complaints participated. Real-time fatigue and physical activity were assessed for 7 consecutive days by short message service text four times during the day and by wearing an accelerometer respectively. Sleep was assessed by the Pittsburgh Sleep Quality Index, and fitness by assessing body composition and aerobic capacity. Latent class growth modelling was used to classify subgroups according to their diurnal profiles of real-time fatigue. Univariable multinomial logistic regression analysis explored whether participant characteristics, sleep, physical activity, or health-related fitness were associated with diurnal profiles. RESULTS: Three distinct fatigue diurnal profiles were identified: stable low (n = 10), increasing (n = 14), and stable high (n = 8). Only aerobic capacity was associated with fatigue profiles (odds ratio 1.15, 95% confidence interval 1.00-1.34; p = 0.05). INTERPRETATION: Fatigue in adults with CP may be low or high stable or may increase during the day. These findings indicate the relevance of assessing fatigue variability. WHAT THIS PAPER ADDS: We found three patterns of daily fatigue in adults with cerebral palsy (CP). Only aerobic capacity was associated with fatigue profiles in adults with CP. Moment-to-moment variations in fatigue can help with personalized fatigue management.

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

PURPOSE: To examine whether general fatigue and fatigue during or after walking are related to energy demands during walking and physical fitness in children and young adults with physical disabilities. METHODS: Sixty-eight individuals with physical disabilities participated. General fatigue (Checklist Individual Strength [CIS8R] questionnaire), walking-induced fatigue (OMNI [OMNIwalk] scale after walking for 6 min), gross and net energy costs (ECs) of walking, physical strain of walking, and aerobic and anaerobic fitness were measured. RESULTS: Regression analyses showed no relations with the CIS8R. For all participants, a higher net EC was weakly related to an increased OMNIwalk. For teenagers only, low anaerobic fitness and high physical strain of walking values were moderately related to high OMNIwalk scores. CONCLUSION: Low anaerobic fitness and high physical strain values partly explain fatigue after walking in teenagers with cerebral palsy, but not in younger children. General fatigue was not explained by low fitness levels or high energy demands of walking.

Focus on Risk Factors for Cardiometabolic Disease in Cerebral Palsy: Toward a Core Set of Outcome Measurement Instruments.

OBJECTIVE: To identify existing outcome measurement instruments (OMIs) assessing risk factors for cardiometabolic disease in adolescents and adults with cerebral palsy (CP) reported on in the literature or used in the field. DATA SOURCES: The COnsensus-based Standards for the selection of health Measurement Instruments database of systematic reviews and 4 electronic databases (Embase, MEDLINE/Ovid, MEDLINE/Pubmed, PsychINFO) were searched up to June 19, 2017, that yielded 2594 articles. Experts in the field were consulted to identify any additional OMIs. STUDY SELECTION: Two reviewers independently applied inclusion criteria to select eligible studies using or evaluating measurement properties of OMIs assessing 1 of 8 outcomes: cardiorespiratory endurance, body size, body composition, physical behavior, sleep, nutrition, blood pressure, and blood lipids and glucose. Studies with an experimental or observational design including ≥10 adolescents or adults with CP were included. DATA EXTRACTION: One reviewer extracted data that were summarized for study and sample characteristics, outcomes, OMIs used, and if applicable data on measurement properties. Two reviewers rated the methodological quality and the quality of the OMIs. Feasibility for clinical practice and research was rated by experts in the field. DATA SYNTHESIS: Ninety OMIs were identified from 56 included articles and by the experts. Seventy OMIs pertained to cardiorespiratory endurance, body size, body composition, and physical behavior, whereas only 5 were identified for sleep and nutrition. Overall synthesis revealed that there is moderate to poor evidence for good quality of OMIs in this population. Based on feasibility for clinical practice, experts agreed on a single OMI per outcome (and 2 for cardiorespiratory endurance) to be included in a core set. CONCLUSION: Despite the range of available OMIs to assess risk factors for cardiometabolic disease in adolescents and adults with CP, evidence of good quality is often lacking. Nonetheless, a preliminary core set of 9 OMIs was systematically developed.

Energy expenditure and muscle activity during lying, sitting, standing, and walking in people with motor-incomplete spinal cord injury.

STUDY DESIGN: Cross-sectional exploratory study. OBJECTIVES: To determine oxygen uptake (VO2), energy expenditure (EE), and muscle activity (MA) during lying (rest), sitting, standing, and walking among ambulatory individuals with spinal cord Injury (SCI) and to compare VO2, EE, and MA between individuals with different levels of ambulation. SETTING: Rehabilitation institution with a spinal cord injury unit. METHODS: A total of 22 adults with motor-incomplete SCI, ten in a low-ambulation group (non-functional or household walker) and 12 in a high-ambulation group (community or normal walker). VO2 was measured using indirect calorimetry. EE was expressed in metabolic equivalent of task (MET). MA was measured using a wireless surface electromyography device. RESULTS: Mean VO2 was 3.19 ml/kg/min. During lying and sitting, EE was below 1.5 METs for all participants. During standing, three participants of the low-ambulation group and none in the high-ambulation group showed MET values of >1.5. In the walking condition, all participants showed MET values above 1.5. MA during stance was higher compared to the sitting condition and significantly higher in the low-ambulation group compared to the high-ambulation group. CONCLUSION: Lying, supported- and unsupported sitting, without moving, appear to be sedentary behaviors for ambulatory individuals with a motor-incomplete SCI (MET values of <1.5 and a lack of MA). Walking, but not standing, is a moderate physical activity (>1.5 METs), which can be used by all individuals with motor-incomplete SCI to interrupt sedentary behavior.

Exercise and physical activity recommendations for people with cerebral palsy.

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.

Associations between fitness and mobility capacity in school-aged children with cerebral palsy: a longitudinal analysis.

AIM: The aim of this study was to determine the longitudinal associations among fitness components and between fitness and mobility capacity in children with cerebral palsy (CP). METHOD: Forty-six children (26 males, 20 females; mean age 9y 7mo [SD 1y 8mo]) with a bilateral (n=24) or a unilateral spastic CP (n=22) participated in aerobic and anaerobic fitness measurements on a cycle ergometer and isometric muscle strength tests (Gross Motor Function Classification System [GMFCS] level I [n=26], level II [n=12], level III [n=8]). Mobility capacity was assessed with the gross motor function measure (GMFM) and a walking capacity test. Associations over longitudinal measurements (three or four measurements over 1y) were determined since longitudinal data allow a more accurate estimation. The associations were determined using a mixed model with fixed effects (mobility capacity as dependent variables and fitness components as independent variables) and a random intercept. RESULTS: In children with bilateral CP, changes in aerobic fitness were associated with changes in anaerobic fitness (p<0.001), and changes in aerobic fitness showed an association with changes in muscle strength (p<0.05). Anaerobic fitness was not associated with muscle strength. No associations between fitness components were found in unilateral CP. Anaerobic fitness and muscle strength were significant determinants for GMFM and walking capacity in bilateral but not in unilateral CP. INTERPRETATION: The longitudinal associations between aerobic and anaerobic fitness and mobility indicate that increasing either aerobic or anaerobic fitness is associated with improvements in mobility in children with bilateral CP. While increasing anaerobic fitness might be beneficial for mobility capacity in children with bilateral CP, this is less likely for children with unilateral CP.

[Anterior shoulder dislocation: revised Dutch Clinical Guideline in practice]. / Primaire anterieure schouderluxatie.

Shoulder dislocations remain the most frequent of joint dislocations, with anterior displacement of the humeral head being the direction of dislocation seen most often (97%). Recently, the Dutch clinical guideline on shoulder dislocations has been revised on the basis of predetermined bottlenecks in clinical practice. In this paper, the guideline is translated to clinical practice by means of two fictional cases, in which the novel recommendations are incorporated. The following topics were systematically assessed based on the best available scientific evidence: primary diagnostics, reduction techniques, painmedication/ sedation surrounding reduction and the need for physiotherapy, stabilization surgery and immobilization. Also, a best practice care pathway is advocated. Since scientific evidence is often inconclusive to provide undebatable therapeutic rules, the committee graded the available evidence and additionally used expert opinion to carefully draft recommendations. The paper concludes with an overview of all the recommendations stated in the updated multidisciplinary guideline.

Ambulatory activity of children with cerebral palsy: which characteristics are important?

AIM: To assess ambulatory activity of children with cerebral palsy (CP), aged 7 to 13 years, and identify associated characteristics. METHOD: Sixty-two children with spastic CP (39 males, 23 females; mean age 10y 1mo, SD 1y 8mo; age range 7-13y), classified as Gross Motor Function Classification System (GMFCS) levels I to III, participated. Ambulatory activity was measured during 1 week with a StepWatch activity monitor as steps per day, and time spent at medium and high step rates. Multiple linear regression analyses were performed following a backward selection procedure until only independent variables with p<0.05 remained in the model. Ambulatory activity outcome parameters served as dependent variables, and disease, personal, and environmental characteristics as independent variables. Ambulatory activity was corrected for body height. RESULTS: Children took more steps during school days (5169 steps, SD 1641) than during weekend days (4158 steps, SD 2048; p<0.001). Higher GMFCS level, bilateral CP, and higher age were associated with lower ambulatory activity on school days (R(2) ranged from 43-53%), whereas bilateral CP, higher age, and no sport club participation were associated with lower ambulatory activity in the weekend (R(2) ranged from 21-42%). Correcting for body height decreased the association with age. INTERPRETATION: Interventions should focus at increasing physical activity at the weekend for children with bilateral spastic CP.

A Comparison of the Physiology of Sedentary Behavior and Light Physical Activity in Adults With and Without a Physical Disability.

BACKGROUND: It is questionable whether postures that are regarded as sedentary behavior in able-bodied persons evoke comparable physiological responses in adults with stroke or cerebral palsy (CP). This study aimed to compare metabolic demand and muscle activity in healthy controls, adults with stroke, and adults with CP during sedentary behavior and light physical activities. METHODS: Seventy-one adults (45.6 [18.9] y, range 18-86) participated in this study, of which there were 18 controls, 31 with stroke, and 22 with CP. The metabolic equivalent of task (MET) and level of muscle activation were assessed for different sedentary positions (sitting supported and unsupported) and light physical activities (standing and walking). RESULTS: During sitting supported and unsupported, people with mild to moderate stroke and CP show comparable MET and electromyographic values as controls. While sitting unsupported, people with severe stroke show higher METs and electromyographic values (P < .001), and people with severe CP only show higher METs compared with controls (P < .05) but all below 1.5 METs. Standing increased electromyographic values in people with severe stroke or CP (P < .001) and reached values above 1.5 METs. CONCLUSIONS: Physiologic responses during sedentary behavior are comparable for controls and adults with mild to moderate stroke and CP, whereas higher metabolic demands and muscle activity (stroke only) were observed in severely affected individuals.

Multimorbidity risk assessment in adolescents and adults with cerebral palsy: a protocol for establishing a core outcome set for clinical research and practice.

BACKGROUND: Estimates of multimorbidity, defined as the presence of at least two chronic conditions, some of which attributable to modifiable behaviours, are high in adults with cerebral palsy (CP). An assessment protocol evaluating multimorbidity risk is needed in order to develop and evaluate effective interventions to optimize lifelong health in individuals with CP. The aim of this protocol paper is to describe the development of a core outcome set (COS) for assessing multimorbidity risk in adolescents and adults with CP, to be used in clinic and research. METHODS: The expert consortium will first define the target population and outcomes to be measured. Through a process of literature review and an international Delphi survey with expert clinicians and researchers, we will then determine which outcome measurement instruments (OMIs) can best measure those outcomes. The resulting OMIs will be used in a feasibility study with adolescents and adults with CP from an international clinical research network. Finally, a face-to-face stakeholder meeting with adolescents and adults with CP, their families/caregivers and researchers and clinicians who are experts in CP, will be organized to reach final agreement on the COS. DISCUSSION: This COS will guide clinicians and researchers in assessing multimorbidity risk in adolescents and adults with CP. The inclusion of experts and individuals with CP from international locations for establishing the COS lends strong support to its generalizability. Evidence of its feasibility and approval from all stakeholders will enable implementation in clinical practice, and guide future research using the COS in individuals with CP.

Beneficial Effect of BH4 Treatment in a 15-Year-Old Boy with Biallelic Mutations in DNAJC12.

BACKGROUND: Biallelic mutations in DNAJC12 were recently identified as a BH4-responsive cause of hyperphenylalaninemia (HPA). Outcome was only favorable when treatment was initiated early in life. We report on a 15-year-old boy with HPA due to a homozygous deletion in DNAJC12 in whom - despite his advanced age - treatment was initiated. CASE: A boy with developmental delay, an extrapyramidal movement disorder, and persistently elevated plasma phenylalanine levels was diagnosed with DNAJC12 deficiency at the age of 15 years. Diagnosis was made upon exome reanalysis revealing a homozygous 6.9 kb deletion in DNAJC12 which had not been detected by the standard exome analysis pipeline. Treatment with the BH4 analog sapropterin dihydrochloride (10 mg/kg/day) was initiated and evoked a 50% reduction of the plasma phenylalanine levels. More strikingly, a marked improvement in daily functioning and improved exercise tolerance was noted. Additionally, gait analysis before and after treatment initiation revealed a partial normalization of his movement disorder. CONCLUSION: Patients with hyperphenylalaninemia due to DNAJC12 deficiency may benefit from treatment with a BH4 analog - even when introduced at a later age.

Energy cost during walking in association with age and body height in children and young adults with cerebral palsy.

AIM: This cross-sectional study into children and young adults with cerebral palsy (CP) aimed to assess the association of gross energy cost (EC), net EC and net nondimensional (NN) EC during walking with age and body height, compared to typically developing (TD) peers. METHOD: Data was collected in 128 participants with CP (mean age 11y9mo; GMFCS I,n=48; II,n=56; III, n=24) and in 63 TD peers (mean age 12y5mo). Energy cost was assessed by measuring the oxygen consumption during over-ground walking at comfortable speed. Outcome measures derived from the assessment included the gross and net EC, and NN EC. Differences between the groups in the association between gross, net and NN EC with age and body height, were investigated with regression analyses and interaction effects (p<0.05). RESULTS: Interaction effects for age and body height by group were not significant, indicating similar associations for gross, net and NN EC with age or body height among groups. The models showed a significant decline for gross, net and NN EC with increasing age per year (respectively -0.201Jkg-1m-1; -0.073Jkg-1m-1; -0.007) and body height per cm (respectively -0.057Jkg-1m-1; -0.021Jkg-1m-1; -0.002). INTERPRETATION: Despite higher gross and net EC values for CP compared to TD participants , similar declines in EC outcomes can be expected with growth for participants aged 4-22 years with CP. All energy cost outcomes showed a decline with growth, indicating that correcting for this decline is required when evaluating changes in gross EC, and, to a lesser extent, in net and NN EC in response to treatment or from natural course over time.

Longitudinal Relationship Among Physical Fitness, Walking-Related Physical Activity, and Fatigue in Children With Cerebral Palsy.

BACKGROUND: A vicious circle of decreased physical fitness, early fatigue, and low physical activity levels (PAL) is thought to affect children with cerebral palsy (CP). However, the relationship of changes in physical fitness to changes in PAL and fatigue is unclear. OBJECTIVE: The objective of this study was to investigate the associations among changes in physical fitness, walking-related PAL, and fatigue in children with CP. DESIGN: This study was a secondary analysis of a randomized controlled trial with measurements at baseline, 6 months (after the intervention period), and 12 months. METHODS: Twenty-four children with bilateral spastic CP and 22 with unilateral spastic CP, aged 7 to 13 years, all walking, participated in this study. Physical fitness was measured by aerobic capacity, anaerobic threshold, anaerobic capacity, and isometric and functional muscle strength. Walking-related PAL was measured using an ankle-worn activity monitor for 1 week. Fatigue was determined with the Pediatric Quality of Life (PedsQL) Multidimensional Fatigue Scale. Longitudinal associations were analyzed by random coefficient regression analysis. RESULTS: In children with bilateral CP, all fitness parameters showed a positive, significant association with walking-related PAL, whereas no associations between physical fitness and walking-related PAL were seen in children with unilateral CP. No clinically relevant association between physical fitness and fatigue was found. LIMITATIONS: Although random coefficient regression analysis can be used to investigate longitudinal associations between parameters, a causal relationship cannot be determined. The actual direction of the association between physical fitness and walking-related PAL, therefore, remains inconclusive. CONCLUSIONS: Children with bilateral spastic CP might benefit from improved physical fitness to increase their PAL or vice versa, although this is not the case in children with unilateral CP. There appears to be no relationship between physical fitness and self-reported fatigue in children with CP. Interventions aimed at improving PAL may be differently targeted in children with either bilateral or unilateral CP.

Objectively measured sedentary time in youth with cerebral palsy compared with age-, sex-, and season-matched youth who are developing typically: an explorative study.

BACKGROUND: Children with cerebral palsy (CP) demonstrate reduced physical activity levels compared with children with typical development. 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. OBJECTIVE: The aim of this study was 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 take fewer breaks to interrupt sedentary time. DESIGN: This was a cross-sectional, prospective study. METHODS: A convenience sample of 17 ambulatory children with CP (15 boys and 2 girls) (mean age=13.0 years, SD=2.2) and 17 age-, sex-, and season-matched youth who were developing typically (TD group) (mean age=12.9 years, SD=2.5) wore an accelerometer over a 7-day period. Sedentary time (in minutes) and number of breaks from sedentary time, corrected for monitoring and sedentary time, respectively, were examined. Differences between groups were determined with an independent-samples t test. RESULTS: Children with CP engaged in significantly more sedentary time (X̅=47.5 min/h, SD=4.9) compared with the TD group (X̅=43.6 min/h, SD=4.2), with significantly fewer breaks from sedentary time (CP group: X̅=179, SD=70; TD group: X̅=232 breaks/h sedentary, SD=61). LIMITATIONS: The sample included only ambulatory youth with CP, classified as Gross Motor Function Classification System levels I to III. CONCLUSIONS: Sedentary time was higher in the CP group and was characterized by less frequent breaks compared with the TD group. Future research should examine the extent to which sedentary time is associated with cardiovascular and metabolic risk in youth with CP.

Reliability of a progressive maximal cycle ergometer test to assess peak oxygen uptake in children with mild to moderate cerebral palsy.

BACKGROUND: Rehabilitation research in children with cerebral palsy (CP) is increasingly addressing cardiorespiratory fitness testing. However, evidence on the reliability of peak oxygen uptake (Vo2peak) measurements, considered the best indicator of aerobic fitness, is not available in this population. OBJECTIVE: The objective of this study was to establish the reliability of a progressive maximal cycle ergometer test when assessing Vo2peak in children with mild to moderate CP. DESIGN: Repeated measures were used to assess test-retest reliability. METHODS: Eligible participants were ambulant, 6 to 14 years of age, and classified as level I, II, or III according to the Gross Motor Function Classification System (GMFCS). Two progressive maximal cycle ergometer tests were conducted (separated by 3 weeks), with the workload increasing every minute in steps of 3 to 11 W, dependent on height and GMFCS level. Reliability was determined by means of the intraclass correlation coefficient (ICC [2,1]) and smallest detectable change (SDC). RESULTS: Twenty-one children participated (GMFCS I: n=4; GMFCS II: n=12; and GMFCS III: n=5). Sixteen of them (9 boys, 7 girls; GMFCS I: n=3; GMFCS II: n=11; and GMFCS III: n=2) performed 2 successful tests, separated by 9.5 days on average. Reliability for Vo2peak was excellent (ICC=.94, 95% confidence interval=.83-.98). The SDC was 5.72 mL/kg/min, reflecting 14.6% of the mean. LIMITATIONS: The small sample size did not allow separate analysis of reliability per GMFCS level. CONCLUSIONS: In children with CP of GMFCS levels I and II, a progressive maximal cycle ergometer test to assess Vo2peak is reliable and has the potential to detect change in cardiorespiratory fitness over time. Further study is needed to establish the reliability of Vo2peak in children of GMFCS level III.

Daily stride rate activity and heart rate response in children with cerebral palsy.

OBJECTIVE: To compare daily stride rate activity, daily exercise intensity, and heart rate intensity of stride rate in children with cerebral palsy with that of typically developing children. METHODS: Forty-three children with cerebral palsy, walking without (Gross Motor Function Classification System (GMFCS) I and II) or with (GMFCS III) an aid and 27 typically developing children (age range 7-14 years) wore a StepWatch™ activity monitor and a heart rate monitor. Time spent and mean heart rate reserve at each stride rate activity level and time spent in each mean heart rate reserve zone was compared. RESULTS: Daily stride rate activity was lower in children with cerebral palsy (39%, 49% and 79% in GMFCS I, II and III, respectively) compared with typically developing children (p < 0.05), while there were no differences in time spent at different mean heart rate reserve zones. Mean heart rate reserve at all stride rate activity levels was not different between typically developing children, GMFCS I and II, while mean heart rate reserve was higher for GFMCS III at stride rates < 30 strides/min (p < 0.05). CONCLUSION: Stride rate activity levels reflect the effort of walking, in children with cerebral palsy who are walking without aids, similar to that of typically developing, whereas children with cerebral palsy using walking aids show higher effort of walking. Despite a lower stride rate activity in cerebral palsy, daily exercise intensity seems comparable, indicating that the StepWatch™ monitor and the heart rate monitor measure different aspects of physical activity.

Walking activity of children with cerebral palsy and children developing typically: a comparison between the Netherlands and the United States.

PURPOSE: To compare walking activity of children with and without cerebral palsy (CP) between the Netherlands and the United States. METHODS: A cross-sectional analysis on walking activity data from an international retrospective comparison study including a convenience sample of 134 walking children aged 7-12 years with spastic CP, classified as Gross Motor Function Classification System (GMFCS) level I (N = 64), II (N = 49) or III (N = 21), and 223 typically developing children (TDC) from the Netherlands and the United States. Walking activity was assessed during a one-week period using a StepWatch™ activity monitor. Outcomes were the daily number of strides, daily time being inactive and spent at low (0-15 strides/min), moderate (16-30 strides/min) and high stride rate (31-60 strides/min). Walking activity was compared between countries using multiple linear regression analyses. RESULTS: Walking activity of TDC was not significantly different between countries. Compared to their American counterparts, Dutch children in GMFCS level I and II showed less walking activity (p < 0.05), whereas Dutch children in GMFCS level III showed more walking activity (p < 0.05). CONCLUSION: The absence of differences in walking activity between Dutch and American TDC, and the presence of differences in walking activity between Dutch and American children with CP suggest that between-country differences affect walking activity differently in children with CP. IMPLICATIONS FOR REHABILITATION: Physical activity of children with CP should be promoted in both the United States and the Netherlands. The between-country differences in walking activity illustrate that apart from the severity of the CP walking activity seems to be influenced by environmental aspects. In the promotion of physical activity, practitioners should pay attention to environmental barriers that families may experience for increasing physical activity.

Maximal aerobic and anaerobic exercise responses in children with cerebral palsy.

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.