Health Promotion and Physical Wellness in Pediatric Physical Therapy.

PURPOSE: A health promotion and physical wellness (HPPW) life course approach for pediatric physical therapy (PT) is recommended to improve children's health outcomes across the lifespan. SUMMARY OF KEY POINTS: A life course approach describes how a child's individual responses to environmental factors influence health outcomes. Using HPPW strategies, pediatric physical therapists can identify health risks and promote positive outcomes. Outcome measures and intervention recommendations are outlined to assist therapists in integrating HPPW strategies to ensure a longitudinal plan of care and optimal health outcomes for children. CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE: A child's health trajectory begins in the prenatal period and is influenced by individual and environmental factors. Pediatric PT uses child- and family-centered approaches and environmental assessments to design plans of care that address child and family HPPW goals. Incorporating HPPW strategies into pediatric PT facilitates positive health and physical wellness across a child's lifespan.See the video abstract for insights from the authors. VIDEO ABSTRACT: Supplemental digital content available at https://www.dropbox.com/scl/fi/3g468hj1rpxrrivbeses0/HPPW-Video-Abstract_1080.mp4?rlkey=4p1i8z1gynroz064zpx3alijz&st=8u0gqemz&dl=0.

Promoting Cycling Skills and Participation with Two-Wheel Bike Riding for Children with Neurodevelopmental Disorders.

AIMS: Evaluate changes in two-wheel cycling skills and biking participation goals for children with neurodevelopmental disorders (ND) receiving a home visit and email following iCan Bike camp. METHODS: Participants: 11 children with ND, 9-16 years, and one of their parents. A cycling skills checklist, two-wheel riding Goal Attainment Scaling (GAS), and biking participation GAS were completed before camp (T1), at support visit after camp (T2), and three months following camp (T3). Parents completed biking practice logs. Participants received a support visit to provide instruction, coaching, and address questions, and an email to check progress. RESULTS: Significant changes were made in two-wheel riding GAS T1 to T2 (p = 0.01), biking participation GAS T2 to T3 (p = 0.02), and cycling skills T1 to T2 (p = 0.01) and T2 to T3 (p = 0.02). Practice frequency was related to cycling skills (0.72, p = 0.01) and biking participation (0.86, p < 0.001); cycling skills were related to biking participation (0.81, p = 0.003). CONCLUSION: Children improved cycling skills and biking participation following camp, support visit, and email check-in. Children who practiced more had greater cycling skills and biking participation. Encouraging weekly bicycling and providing support may promote cycling skills and participation following camp.

Accurate COP Trajectory Estimation in Healthy and Pathological Gait Using Multimodal Instrumented Insoles and Deep Learning Models.

Measuring center-of-pressure (COP) trajectories in out-of-the-lab environments may provide valuable information about changes in gait and balance function related to natural disease progression or treatment in neurological disorders. Traditional equipment to acquire COP trajectories includes stationary force plates, instrumented treadmills, electronic walkways, and insoles featuring high-density force sensing arrays, all of which are expensive and not widely accessible. This study introduces novel deep recurrent neural networks that can accurately estimate dynamic COP trajectories by fusing data from affordable and heterogeneous insole-embedded sensors (namely, an eight-cell array of force sensitive resistors (FSRs) and an inertial measurement unit (IMU)). The method was validated against gold-standard equipment during out-of-the-lab ambulatory tasks that simulated real-world walking. Root-mean-square errors (RMSE) in the mediolateral (ML) and anteroposterior (AP) directions obtained from healthy individuals (ML: 0.51 cm, AP: 1.44 cm) and individuals with neuromuscular conditions (ML: 0.59 cm, AP: 1.53 cm) indicated technical validity. In individuals with neuromuscular conditions, COP-derived metrics showed significant correlations with validated clinical measures of ambulatory function and lower-extremity muscle strength, providing proof-of-concept evidence of the convergent validity of the proposed method for clinical applications.

Categorization of a Universal Coding System to Distinguish Use of Durable Medical Equipment and Supplies in Pediatric Patients.

Importance: Although durable medical equipment and supplies (DMES) are commonly used to optimize the health and function in pediatric patients, little is known about the prevalence of use and spending on DMES. Objective: To categorize the Healthcare Common Procedure Coding System (HCPCS) for distinguishing DMES types, and to measure the prevalence and related spending of DMES in pediatric patients using Medicaid. Design, Setting, and Participants: This study is a cross-sectional analysis of the 2018 Merative Medicaid Database and included 4 569 473 pediatric patients aged 0 to 21 years enrolled in Medicaid in 12 US states from January 1 to December 31, 2018. Data were analyzed from February 2019 to April 2023. Exposure: DMES exposure was identified with the Centers for Medicare & Medicaid Services HCPCS codes. Three pediatricians categorized HCPCS DMES codes submitted by vendors for reimbursement of dispensed DMES into DMES types and end-organ systems; 15 expert reviewers refined the categorization (2576 DMES codes, 164 DMES types, 14 organ systems). Main Outcomes and Measures: The main outcome was DMES prevalence & Medicaid spending. The χ2 test was used to compare DMES prevalence and Wilcoxon rank sum tests were used to compare per-member-per-year (PMPY) spending by complex chronic conditions (CCC). Results: Of the 4 569 473 patients in the study cohort, 49.3% were female and 56.1% were aged 5 to 15 years. Patients used 133 of 164 (81.1%) DMES types. The DMES prevalence was 17.1% (95% CI, 17.0%-17.2%) ranging from 10.1% (95% CI, 10.0%-10.2%) in patients with no chronic condition to 60.9% (95% CI, 60.8%-61.0%) for patients with 2 or more CCCs. The PMPY DMES spending was $593, ranging from $349 for no chronic condition to $4253 for 2 or more CCCs. Lens (7.9%), vision frames (6.2%), and orthotics for orthopedic injury (0.8%) were the most common DME in patients with no chronic condition. Enteral tube / feeding supplies (19.8%), diapers (19.2%), lower extremity orthotics (12.3%), wheelchair (9.6%), oxygen (9.0%), and urinary catheter equipment (4.2%) were among the most common DMES in children with 2 or more CCCs. Conclusions and Relevance: In this cross-sectional study, HCPCS distinguished a variety of DME types and use across pediatric populations. Further investigation should assess the utility of the HCPCS DMES categorization with efforts to optimize the quality and safety of DMES use.

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

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

Hospitalized Infants With Medical Complexity Experience Slow Acquisition of Gross Motor Skills.

OBJECTIVES: The progression of infant gross motor development during an acute hospitalization is unknown. Understanding gross motor skill acquisition in hospitalized infants with complex medical conditions is necessary to develop and evaluate interventions that may lessen delays. Establishing a baseline of gross motor abilities and skill development for these infants will guide future research. The primary purposes of this observational study were to: (1) describe gross motor skills of infants with complex medical conditions (n = 143) during an acute hospitalization and (2) evaluate the rate of change in gross motor skill development in a heterogenous group of hospitalized infants with prolonged length of stay (n = 45). METHODS: Gross motor skills in hospitalized infants aged birth to 18 months receiving physical therapy were evaluated monthly using the Alberta Infant Motor Scale. Regression analysis was completed to assess rate of change in gross motor skills. RESULTS: Of the 143 participants, 91 (64%) demonstrated significant motor delay at initial evaluation. Infants with prolonged hospitalization (mean 26.9 ± 17.5 weeks) gained new gross motor skills at a significant rate of 1.4 points per month in Alberta Infant Motor Scale raw scores; however, most (76%) continued with gross motor delays. CONCLUSIONS: Infants with complex medical conditions admitted for prolonged hospitalization frequently have delayed gross motor development at baseline and have slower than typical acquisition of gross motor skills during hospitalization, gaining 1.4 new skills per month compared with peers acquiring 5 to 8 new skills monthly. Further research is needed to determine effectiveness of interventions designed to mitigate gross motor delay in hospitalized infants.

Baseline Range of Motion, Strength, Motor Function, and Participation in Youth with Hutchinson-Gilford Progeria Syndrome.

AIMS: Limited information is available on impairments, activity limitations and participation restrictions in youth with Hutchinson-Gilford progeria syndrome (HGPS), a rare genetic premature aging disease. The purposes were to: (1) describe range of motion (ROM), grip, pinch and quadriceps strength, functional balance, walking endurance, and gross motor limitations and participation restrictions; (2) evaluate the association between ROM impairments and age; and (3) evaluate the association between the Gross Motor Function Measure-88 (GMFM) scores and lower extremity (LE) ROM, quadriceps strength, and age. METHODS: Upper and LE ROM, grip, pinch and quadriceps strength, Timed Up and Go (TUG), Six Minute Walk Test, GMFM-88, and Canadian Occupational Performance Measure data were recorded for 38 participants with HGPS. RESULTS: All youth exhibited ROM impairments and most displayed decreased grip and pinch strength, walking endurance, and gross motor skills when compared to same-aged peers. However, the majority had good functional balance with TUG scores in the normal range. Participation restrictions included difficulty keeping up with peers when walking and difficulty completing activities of daily living. Some ROM measurements were negatively associated with age indicating that older participants had more extensive ROM limitation than younger participants. CONCLUSIONS: Physical and occupational therapists can use this information when evaluating youth with HGPS, designing a plan of care, and providing treatment interventions.

Effect of upper extremity constraints on functional and dynamic postural control in children with hemiplegic cerebral palsy.

PURPOSE: To compare the effects of upper extremity constraints on functional and dynamic postural control in children with hemiplegic cerebral palsy. MATERIALS AND METHODS: Twelve children with hemiplegic cerebral palsy and 12 typically developing children ages 5 to 12 years (GMFCS I-II) were evaluated with the Timed Up and Go (TUG) and Biodex Balance System during three upper extremity (UE) conditions: 1) Free UEs (no constraints), 2) Simple UE constraint (unaffected/dominant UE constrained with a sling), and 3) Difficult UE constraint (Simple constraint plus the other UE holding cup of water). RESULTS: The UE condition had significant effects on Overall Stability Index (OSI) (F(2,44) = 24.899, p < .001), Medial-Lateral Stability Index (MLSI) (F(2,44) = 4.380, p = .018), Anterior-Posterior Stability Index (F(2,44) = 6.187, p = .004), and TUG scores (F(2,44) = 113.372, p < .001). Group was significant for OSI (F(1,22) = 7.906, p = .010), MLSI (F(1,22) = 13.113, p = .002), and TUG (F(1,22) = 36.282, p < .001). CONCLUSIONS: The upper extremity appears to have a role in maintaining functional balance and postural stability in children with hemiplegic cerebral palsy and should be considered during intervention programs.

Psychometric properties of the PEDI-CAT for children and youth with spinal muscular atrophy.

PURPOSE: The purpose of this study was to examine the psychometric properties of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) in children and youth with Spinal Muscular Atrophy (SMA). METHODS: In this prospective cross-sectional study, caregivers of children and youth with SMA completed the PEDI-CAT Daily Activities and Mobility domains. A subset of caregivers completed a questionnaire about the measure. RESULTS: Mean ranks of scaled scores for Daily Activities (n = 96) and Mobility (n = 95) domains were significantly different across the three SMA types and across the three motor classifications. Normative scores indicated that 85 participants (89.5%) had limitations in Mobility and 51 in Daily Activities (53.1%). Floor effects were observed in≤10.4% of the sample for Daily Activities and Mobility. On average, caregivers completed the Mobility domain in 5.4 minutes and the Daily Activities domain in 3.3 minutes. Most caregivers reported that they provided meaningful information (92.1%), were willing to use the PEDI-CAT format again (79%), and suggested adding content including power wheelchair mobility items. CONCLUSION: Convergent validity was demonstrated for the Daily Activities and Mobility domains. Normative scores detected limitations in Mobility and Daily Activity performance for most participants with SMA. The PEDI-CATwas feasible to administer and caregivers expressed willingness to complete the PEDI-CAT in the future.

A Pediatric Hospital Physical Therapy and Occupational Therapy Department's Response to COVID-19: An Administrative Case Report.

OBJECTIVE: The purpose of this case report is to describe the challenges that COVID-19 presented for therapists in a pediatric hospital and the response to these challenges. METHODS: The case report setting is a physical therapy and occupational therapy department (department) of an academic pediatric medical center that provides a range of health care services for children and youth. Challenges that COVID-19 presented to the department included (1) managing safety concerns for patients, their families, and staff; (2) continuing to provide high-quality therapy services within state-mandated restrictions; (3) triaging patients; and (4) keeping clinicians employed and working productively. RESULTS: The department therapists responded to these challenges by (1) increasing communication huddles; (2) developing procedures for staffing and triaging of patients; (3) developing procedures for telehealth therapy services; and (4) designing a remote work program for all department employees. The number of patients and staff on site were reduced by initiating telehealth services, triaging patients, and developing a remote work plan. Communication huddles, department meetings, and supervision meetings were converted to virtual meetings. Staffing rates, patient-care productivity, and department project work were maintained. CONCLUSION: In response to COVID-19, the department developed new protocols and provided information about the protocols, which might be helpful for other pediatric hospitals or outpatient settings when planning for future pandemics or other issues that challenge the ability to provide usual care. Increasing the frequency of verbal and written communication on operational topics is recommended. Primary sources of information from national organizations (eg, the American Physical Therapy Association and the American Occupational Therapy Association) can assist with determining the scope of practice and code of conduct during a pandemic. IMPACT: COVID-19 posed challenges to operations and delivery of patient care. Although this case report is specific to COVID-19, principles applied and lessons learned from this experience can be applied to other emergency situations.

Scoping Review of Judgment-Based Measures of Ambulation with Assistive Devices for Children and Youth.

AIM: To identify available judgment-based measures of ambulation with assistive devices for the purpose of examining item content and responses to aid in the expansion of the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) Mobility Domain. METHODS: PubMed and CINAHL databases were used to identify measures meeting the following criteria: 1) applicable for children/youth; 2) self-report, proxy-report, or interview administration; and 3) assistive device (walker, cane, crutches, gait trainer) use specified or considered with responses. Population, administration, respondent(s), items, and responses were compiled. Item content was categorized and response scales grouped by type. RESULTS: Fifteen measures met inclusion criteria. Measures included child and proxy-report. Item categories included Surfaces, Steps/Stairs, Dual Tasks, Negotiation of Environment, Distance, and Time. Only two measures distinguished between device type within items. One measure specified gait trainers. "Difficulty" and "Assistance" were the most frequently used response scales. CONCLUSIONS: Available measures have content examining device use; however, none of the measures are comprehensive, devices are not consistently specified, and responses are imprecise. Items with well-defined responses for measuring a child's ambulation with an assistive device are needed for clinical practice, research, and program evaluation.

Examination of the short-term impact of a disability awareness training on attitudes toward people with disabilities: A community-based participatory evaluation approach.

Background: Worldwide over a billion people live with a disability including 400,000 people in Ecuador. People with disabilities (PWD) face barriers to full participation in society. Barriers are generated by negative attitudes created through socio-cultural experiences. Awareness about disability can be facilitated through disability awareness training (DAT). Studies examining outcomes on DAT exist in high-resourced countries but are nonexistent in Ecuador. Study purposes:1) create a DAT using community input and conduct the training; 2) examine the impact of the DAT on attitudes toward and awareness of PWD; and 3) explore community perceptions regarding the impact of the DAT on action. Methods: Community-based participatory evaluation was employed to design and assess the impact of a DAT with 60 community members from Latacunga, Ecuador. The DAT incorporated a multi-modal approach (interactive discussion, problem-solving, hands-on activities) and was informed by the theory of planned behavior. Data sources were the Multidimensional Attitudes Scale (MAS) (Spanish version) administered pre- and post-DAT and interviews conducted with nine DAT participants. Results: Mann Whitney U revealed significant changes in two of four MAS constructs: emotion p = .005 and cognition p = .003. Five themes emerged from the interviews: 1) view of disability; 2) contact; 3) attitude; 4) training impact; and 5) action. Conclusion: In the short-term DAT may increase awareness of and decrease negative attitudes associated with disability. Effective strategies highlighted for raising awareness and improving attitudes were contact with PWD and education. Education leads to more positive perceptions of the barriers PWD face and their ability to participate in society.

A content validity evaluation of the PEDI-CAT Speedy Mobility domain.

Objective: To evaluate the content validity of the PEDI-CAT Speedy Mobility domain through analysis of item and content area exposure, score range and scoring precision.Methods: Retrospective analysis of 3,364 items from assessments (n = 301) completed from 2013 to 2017. Content validity was appraised through analysis of item and content area exposure (item, content area, response frequency), score range (floor and ceiling effect) and scoring precision (person fit, score reliability, item information function).Results: Sixty-five of the 75 general mobility items from the PEDI-CAT Mobility domain item bank were exposed. "Stands up from the middle of the floor" (68%) was the most frequently exposed non-mandatory item. Almost half (49%) of all items were from the Basic Mobility and Transfers content area. Scaled scores ranged from 26.77 to 69.40 with a floor (scores ≤27; n = 51, 17%) but no ceiling effect. Person fit statistics were acceptable for 238 (79%), suggesting limited outliers. Score reliability was sufficient with 68% of scores above threshold (>0.9). Item information function plot indicated less discriminating items at the lower end of the score range.Conclusion: Content is adequately and reliably measuring the intended construct, but additional items at the lower end of the scale could improve score precision.

Efficacy of Lower Extremity Cycling Interventions for Youth with Intellectual Disabilities: A Systematic Review.

PURPOSE: To systematically examine the efficacy of lower extremity cycling interventions for youth with intellectual disability (ID). METHODS: Seven databases were searched from March 2000 to October 2019 for English-language articles on cycling interventions for youth with ID. The American Academy of Cerebral Palsy and Developmental Medicine guidelines were used for assigning levels of evidence and grading study quality. RESULTS: Eight articles met inclusion criteria. Children and young adults, 7-26 years (n = 229), with diagnoses of Down syndrome, autism spectrum disorder, or unspecified ID participated in the studies. Moderate evidence (one level II single subject design study) suggests that a specific cycling intervention can improve two-wheeled cycling skills in youth with ID. Weak evidence (level II group studies) supports stationary cycling for short-term improvements in cognitive skills and two-wheeled riding intervention for increasing physical activity one-year after intervention. CONCLUSIONS: Moderate to weak evidence exists to support two-wheeled cycling instructional programs or stationary cycling interventions for children and young adults with intellectual disabilities. Therapists can use this information when discussing cycling interventions for individuals with ID. Further research is needed to inform therapists in clinical decision-making related to dosing cycling interventions.

Development and Validation of Equations to Link Pediatric Evaluation of Disability Inventory (PEDI) Functional Skills Scores to PEDI-Computer Adaptive Test Scores for Youth with Cerebral Palsy.

Aim: The Pediatric Evaluation of Disability Inventory (PEDI) was revised to the PEDI-Computer Adaptive Test (PEDI-CAT). The PEDI has been used for over two decades to track function in youth, so it is important that follow-up data are not lost with this transition. The purpose of this study was to develop and validate equations for linking PEDI scores to PEDI-CAT scores.Methods: Caregivers of 101 youth 6.1 to 19.8 years of age with cerebral palsy (CP) and classified at Gross Motor Classification System (GMFCS) Levels I-V completed the PEDI and PEDI-CAT. Scaled score data from this sample were used to develop and validate linking equations using least squares regression and bootstrap cross-validation techniques. Next, equations were tested in an independent sample of 35 children with developmental disabilities.Results: The equations to predict PEDI-CAT scores exhibited excellent model fit. PEDI Self-care, Mobility, and Social Function explained 92%, 84%, and 85% of the variation in PEDI-CAT Daily Activities, Mobility, and Social/Cognitive domains, respectively. No differences were detected between actual and predicted PEDI-CAT scores across all domains and by GMFCS level for the equation development sample and for an equation validation independent sample.Conclusions: The model fit was excellent; however, equations should be used cautiously when evaluating changes in function for individual children with ceiling level PEDI scores. Valid score prediction equations for youth with CP will assist with transitioning from the PEDI to the PEDI-CAT.

Measuring the Reliability and Construct Validity of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) in Children With Cerebral Palsy.

OBJECTIVE: The purpose of this study was to (1) investigate the construct validity and (2) test-retest reliability of the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT) in children with cerebral palsy (CP). DESIGN: A prospective convenience cross-sectional sample. SETTING: Multidisciplinary CP clinic in a tertiary level pediatric children's hospital. PARTICIPANTS: English- and Spanish-speaking school-aged children (N=101) with a diagnosis of CP, stratified by Gross Motor Function Classification System level, who presented to our multidisciplinary clinic. Participants were excluded if they underwent recent surgery (<6mo) or botulinum neurotoxin A injection (<3mo). A subset of 17 families participated in retest reliability. MAIN OUTCOME MEASURES: Convergent and divergent validity were evaluated using Spearman correlation coefficient analysis; test-retest reliability was assessed using intraclass correlation coefficients (ICCs). RESULTS: Mean age was 12±3.7 years. Convergent validity was established between Mobility (PEDI-CAT) and Functional Mobility Scale (FMS) (5 m, r=0.85; 50 m, r=0.84; 500 m, r=0.76; P<.001). In ambulant children, convergent validity was established between Daily Activities (PEDI-CAT vs Pediatric Quality of Life CP [PedsQL-CP] [r=0.85, P<.001]) and between Social/Cognitive (PEDI-CAT) and Speech and Communication (PedsQL-CP) (r=0.42, P<.001). In nonambulant children, convergent validity was established between Daily Activities (PEDI-CAT) and Personal Care (Caregiver Priorities and Child Health Index of Life with Disabilities [CPCHILD]) (r=0.44, P<.001) and between social/cognitive (PEDI-CAT) and Communication (CPCHILD) (r=0.64, P<.001). A lack of correlation between Daily Activities, Social/Cognitive, and Responsibility (PEDI-CAT) and FMS and between the Mobility (PEDI-CAT) and Communication (PedsQL) domains confirmed divergent validity. Test-retest reliability was excellent for all domains of the PEDI-CAT (ICC=0.96-0.99). CONCLUSIONS: The PEDI-CAT is an outcome measure that demonstrates strong construct validity and reliability in children with CP.

Machine learning algorithms for activity recognition in ambulant children and adolescents with cerebral palsy.

BACKGROUND: Cerebral palsy (CP) is the most common physical disability among children (2.5 to 3.6 cases per 1000 live births). Inadequate physical activity (PA) is a major problem effecting the health and well-being of children with CP. Practical, yet accurate measures of PA are needed to evaluate the effectiveness of surgical and therapy-based interventions to increase PA. Accelerometer-based motion sensors have become the standard for objectively measuring PA in children and adolescents; however, current methods for estimating physical activity intensity in children with CP are associated with significant error and may dramatically underestimate HPA in children with more severe mobility limitations. Machine learning (ML) models that first classify the PA type and then predict PA intensity or energy expenditure using activity specific regression equations may be more accurate than standalone regression models. However, the feasibility and validity of ML methods has not been explored in youth with CP. Therefore, the purpose of this study was to develop and test ML models for the automatic identification of PA type in ambulant children with CP. METHODS: Twenty two children and adolescents (mean age: 12.8 ± 2.9 y) with CP classified at GMFCS Levels I to III completed 7 activity trials while wearing an ActiGraph GT3X+ accelerometer on the hip and wrist. Trials were categorised as sedentary (SED), standing utilitarian movements (SUM), comfortable walking (CW), and brisk walking (BW). Random forest (RF), support vector machine (SVM), and binary decision tree (BDT) classifiers were trained with features extracted from the vector magnitude (VM) of the raw acceleration signal using 10 s non-overlapping windows. Performance was evaluated using leave-one-subject out cross validation. RESULTS: SVM (82.0-89.0%) and RF (82.6-88.8%) provided significantly better classification accuracy than BDT (76.1-86.2%). Hip (82.7-85.5%) and wrist (76.1-82.6%) classifiers exhibited comparable prediction accuracy, while the combined hip and wrist (86.2-89.0%) classifiers achieved the best overall performance. For all classifiers, recognition accuracy was excellent for SED (94.1-97.9%), good to excellent for SUM (74.0-96.6%) and brisk walking (71.5-86.0%), and modest for comfortable walking (47.6-70.4%). When comfortable and brisk walking were combined into a single walking class, recognition accuracy ranged from 90.3 to 96.5%. CONCLUSIONS: ML methods provided acceptable classification accuracy for detection of a range of activities commonly performed by ambulatory children with CP. The resultant models can help clinicians more effectively monitor bouts of brisk walking in the community. The results indicate that 2-step models that first classify PA type and then predict energy expenditure using activity specific regression equations are worthy of exploration in this patient group.