The power of Para sport: the effect of performance-focused swimming training on motor function in adolescents with cerebral palsy and high support needs (GMFCS IV) - a single-case experimental design with 30-month follow-up.

OBJECTIVE: This study aims to evaluate the effect of a performance-focused swimming programme on motor function in previously untrained adolescents with cerebral palsy and high support needs (CPHSN) and to determine whether the motor decline typical of adolescents with CPHSN occurred in these swimmers. METHODS: A Multiple-Baseline, Single-Case Experimental Design (MB-SCED) study comprising five phases and a 30-month follow-up was conducted. Participants were two males and one female, all aged 15 years, untrained and with CPHSN. The intervention was a 46-month swimming training programme, focused exclusively on improving performance. Outcomes were swim performance (velocity); training load (rating of perceived exertion min/week; swim distance/week) and Gross Motor Function Measure-66-Item Set (GMFM-66). MB-SCED data were analysed using interrupted time-series simulation analysis. Motor function over 46 months was modelled (generalised additive model) using GMFM-66 scores and compared with a model of predicted motor decline. RESULTS: Improvements in GMFM-66 scores in response to training were significant (p<0.001), and two periods of training withdrawal each resulted in significant motor decline (p≤0.001). Participant motor function remained above baseline levels for the study duration, and, importantly, participants did not experience the motor decline typical of other adolescents with CPHSN. Weekly training volumes were also commensurate with WHO recommended physical activity levels. CONCLUSIONS: Results suggest that adolescents with CPHSN who meet physical activity guidelines through participation in competitive swimming may prevent motor decline. However, this population is clinically complex, and in order to permit safe, effective participation in competitive sport, priority should be placed on the development of programmes delivered by skilled multiprofessional teams. TRIAL REGISTRATION NUMBER: ACTRN12616000326493.

Physical Activity Preferences of People Living with Brain Injury: Formative Qualitative Research to Develop a Discrete Choice Experiment.

BACKGROUND AND OBJECTIVE: The World Health Organization physical activity guidelines for people living with disability do not consider the needs of people living with moderate-to-severe traumatic brain injury. This paper describes the qualitative co-development of a discrete choice experiment survey to inform the adaption of these guidelines by identifying the physical activity preferences of people living with moderate-to-severe traumatic brain injury in Australia. METHODS: The research team comprised researchers, people with lived experience of traumatic brain injury and health professionals with expertise in traumatic brain injury. We followed a four-stage process: (1) identification of key constructs and initial expression of attributes, (2) critique and refinement of attributes, (3) prioritisation of attributes and refinement of levels and (4) testing and refining language, format and comprehensibility. Data collection included deliberative dialogue, focus groups and think-aloud interviews with 22 purposively sampled people living with moderate-to-severe traumatic brain injury. Strategies were used to support inclusive participation. Analysis employed qualitative description and framework methods. RESULTS: This formative process resulted in discarding, merging, renaming and reconceptualising attributes and levels. Attributes were reduced from an initial list of 17 to six: (1) Type of activity, (2) Out-of-pocket cost, (3) Travel time, (4) Who with, (5) Facilitated by and (6) Accessibility of setting. Confusing terminology and cumbersome features of the survey instrument were also revised. Challenges included purposive recruitment, reducing diverse stakeholder views to a few attributes, finding the right language and navigating the complexity of discrete choice experiment scenarios. CONCLUSIONS: This formative co-development process significantly improved the relevance and comprehensibility of the discrete choice experiment survey tool. This process may be applicable in other discrete choice experiment studies.

Dietary Patterns of Competitive Swimmers with Moderate-to-Severe Cerebral Palsy: A 3-Year Longitudinal Evaluation.

AIM: To evaluate the longitudinal dietary patterns of three adolescents with moderate-to-severe cerebral palsy (CP) participating in a performance-focused swimming training intervention. METHOD: Participants were three previously inactive adolescents with CP (15-16 years, GMFCS IV) who had recently (<6 months) enrolled in a swimming training program. Diet quality from diet histories was calculated at 10-time points over 3.25 years using the Dietary Guidelines Index for Children and Adolescents (DGI-CA) and the Healthy Eating Index for Australian Adults (HEIFA-2013). A food group analysis was compared to the Australian Guide to Healthy Eating recommendations. Trends were considered in the context of dietary advice given and the training load. RESULTS: Longitudinal diet quality scores were consistent and ranged from 40 to 76 (DGI-CA) and 33 to 79 (HEIFA-2013). Food group intake remained stable; participants rarely met the recommendations for fruit, vegetables, dairy, grain, and meat but frequently achieved discretionary serves. CONCLUSIONS: Participants with moderate-to-severe CP who were enrolled in a performance-focused swimming training intervention and were monitored frequently maintained diet quality throughout a period where it conventionally declined. Scores were higher than the general population and were maintained irrespective of the training load. Participants frequently met food group recommendations for discretionary foods and were comparable to the general population for other food groups.

The effect of physical activity on health outcomes in people with moderate-to-severe traumatic brain injury: a rapid systematic review with meta-analysis.

BACKGROUND: In 2020, the World Health Organization (WHO) released the first global physical activity and sedentary behaviour guidelines for children and adults living with disability. The evidence informing the guidelines though is not specific to people living with traumatic brain injury (TBI), but rather comes from other disabling conditions such as Parkinson's disease, and stroke. There remains a clear lack of direct evidence of the effects of physical activity for people living with TBI. The objective of this rapid review was to identify direct evidence of the effect of physical activity on health outcomes in people with moderate-to-severe TBI to inform adaptation of the WHO physical activity guidelines into clinical practice guidelines. METHODS: We conducted a rapid systematic review with meta-analysis of randomised controlled trials, including people of any age with moderate-to-severe TBI, investigating physical activity interventions compared to either usual care, a physical activity intervention with different parameters, or a non-physical activity intervention. Four databases (CENTRAL, SPORTDiscus, PEDro, Ovid MEDLINE) were searched from inception to October 8, 2021. The primary outcomes were physical function, cognition, and quality of life. RESULTS: Twenty-three studies were included incorporating 812 participants (36% females, majority working-age adults, time post-TBI in studies ranged from 56 days (median) to 16.6 years (mean)). A range of physical activity interventions were evaluated in rehabilitation (n = 12 studies), community (n = 8) and home (n = 3) settings. We pooled data from the end of the intervention for eight outcomes. Participation in a virtual reality physical activity intervention improved mobility, assessed by the Community Balance and Mobility Scale (range 0 to 96; higher score indicates better mobility) more than standard balance training (two studies, 80 participants, Mean Difference = 2.78, 95% CI 1.40 to 4.16; low certainty evidence). There was uncertainty of effect for the remaining outcomes, limited by small sample sizes, diverse comparators and a wide range of outcome measures. CONCLUSION: This review consolidates the current evidence base for the prescription of physical activity for people with moderate-to-severe TBI. There remains a pressing need for further rigorous research in order to develop practice guidelines to support clinical decision-making when prescribing physical activity in this population.

Time cost associated with sports participation for athletes with high support needs: a time-motion analysis of tasks required for para swimming.

Objectives: People with cerebral palsy and high support needs (CP&HSN) are profoundly inactive but also under-represented in studies evaluating physical activity interventions. Reasons for their exclusion have not been evaluated. We hypothesised that CP&HSN would be associated with high time costs of preparatory activities (eg, getting dressed/undressed), possibly contributing to low participation and under-representation. Accordingly, this pilot study aimed to: (1) evaluate whether the time required for preparatory activities was extremely different (≥3 SD) between swimmers with and without CP&HSN; and (2) provide a qualitative indication of the preparatory tasks undertaken by swimmers with CP&HSN. Methods: Each of three experienced (5 years) para swimmers with CP&HSN and 20 non-disabled swimmers were timed entering and then exiting the pool on three occasions. Mean entry and exit time for each para swimmer was compared with the group mean for non-disabled swimmers, and differences of greater than 3.0 SD were considered extreme. A qualitative description of the tasks completed by the para swimmers was recorded. Results: The differences in time costs between para and non-disabled swimmers met the criterion of extreme. Pool entry times for para swimmers were 8-13 times greater (Effect size = 4.1-8.7). Pool exit times were 6-10 times greater (ES=7.0-9.5). 90% of tasks completed by para swimmers required personal assistance or wheeled mobility. Conclusions: This pilot study suggests that, compared with non-disabled swimmers, time costs for preparation to commence or depart training are extremely high for swimmers with CP&HSN. Further research is required to evaluate the veracity of these findings.

Effects of a therapeutic exercise program in children with non-cystic fibrosis bronchiectasis: A pilot randomized controlled trial.

Background: In the absence of randomized controlled trials (RCTs) on the benefits of therapeutic exercise programs involving children with bronchiectasis, we undertook a pilot RCT to evaluate the effects of a play-based therapeutic exercise program on fundamental movement skill (FMS) proficiency. The effects of the program on cardiorespiratory fitness, perceived competence, and health-related quality of life (HR-QoL) were examined as secondary outcomes. Methods: Children [median (IQR) age: 6.8 (5.3-8.8) years] with bronchiectasis unrelated to cystic fibrosis were randomized to a 7-week therapeutic exercise program (n = 11) or wait-list control (n = 10). The exercise program comprised 7 × 60-min weekly sessions and was supplemented by a home-based program 2-days/week. Participants were assessed on: FMS (locomotor and object control skills) using the Test of Gross Motor Development 2nd Edition (TGMD-2); cardiovascular fitness by calculating the percent change in heart rate (%ΔHR) from rest to completion of the first stage of a submaximal treadmill test; perceived competence using Harter's athletic competence subscale; and QoL with the PedsQL. Results: Significant group by time interactions were observed for locomotor and object control skills. Children completing the therapeutic exercise program exhibited significant improvements in both locomotor (pre 29.0 ± 2.0, post 35.2 ± 2.2, p = 0.01) and object control (pre 27.0 ± 2.0, post 35.5 ± 2.2, p = 0.01) skills, with no significant change in controls (pre 31.6 ± 2.1, post 31.8 ± 2.3 and pre 31.0 ± 2.1, post 32.3 ± 2.3, respectively). Among children completing the program, %ΔHR declined by 6% points, while %ΔHR declined only marginally among controls (0.9% points), but the group by time interaction was not statistically significant. The program had a small positive impact on competence perceptions (Cohen's d = 0.2) and HR-QoL (Cohen's d = 0.3). Conclusion: This pilot RCT provides preliminary evidence for the efficacy of a play-based therapeutic exercise program to improve proficiency in FMS and fitness in children with bronchiectasis. The results are sufficiently positive to warrant conducting a larger RCT testing the efficacy of the exercise program in children with bronchiectasis and/or other chronic respiratory conditions.

Evaluation of a physical activity promotion intervention for adults with whiplash associated disorders: a single-case experimental design study.

PURPOSE: There is considerable variation in the physical and psychological presentations of people with whiplash-associated disorder (WAD). Optimal treatment continues to be a challenge. This research evaluated the efficacy of a community-located, theory-based intervention designed to promote physically active behaviour in people with persistent WAD, and thereby improve perceptions of pain interference and confidence completing activities in the presence of neck pain. MATERIALS AND METHODS: A multiple-baseline, single-case experimental design was used to evaluate the 16-week intervention across six participants. RESULTS: Weighted Tau-U showed significantly increased accelerometer-measured physical activity in three participants with large effect sizes (>0.5), with increased confidence in one participant (ES > 0.5), and reduced pain interference in another participant (ES > 0.7). Changes in other behaviours included clinically important improvements in quality of life for five participants and, in those participants with baseline symptom levels outside threshold levels, improvements in pain catastrophizing and pain self-efficacy. CONCLUSIONS: Participation in a theory-based intervention resulted in significant improvements in physical and psychological health for five of six participants. Providing this type of community-located physical activity promotion strategy, to individuals with persistent WAD, may help address physical impairments and psychological distress commonly experienced in WAD. Trial registration: The trial was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN: ACTRN12617001261303p) and ClinicalTrials.gov (Protocol Number: 2018000349/2017/743).Implications for rehabilitationRehabilitation professionals should consider recommending theory-based physical activity promotion strategies to reduce physical impairments and psychological distress in individuals with persistent WAD.Individually tailored physical activity promotion strategies may help individuals with persistent WAD become more physically active thereby reducing their risk of diseases associated with inactivity which may compound the effects of WADImprovements in physical and psychological health may occur independently of increasing habitual physical activity.Rehabilitation professionals may find that other community-located strategies which aim to promote physically active behaviour confer similar benefits for individuals with persistent WAD.

Bicycling and Tricycling Road Race Performance in International Para-Cycling Events Between 2011 and 2019.

ABSTRACT: This study described bicycling (C classes) and tricycling (T classes) performance in the International Cycling Federation road race events between 2011 and 2019. A total of 3243 race results from 33 events were analyzed. Race velocity was calculated for each result. Bicycling and tricycling data were separately modeled using a linear mixed-effects model. Bicycling velocity was statistically different between all adjacent men's classes (Cohen d = 0.14-0.73) and between the women's C1 and C2 (d = 1.15) and C3 and C4 (d = 0.48) classes. The absence of statistical differences between some women's bicycling classes may be due to a limited number of observations in these classifications. As expected, velocity was statistically different between men's (d = 1.64) and women's (d = 1.38) T1 and T2 classes. Road race performance was hierarchical within the disciplines of bicycling and tricycling, although not all adjacent women's bicycling classes were statistically different. The existence of a performance hierarchy does not necessarily validate the classification system. The integration of information regarding athlete impairment type and severity, with performance data, would provide greater insight into the validity of the classification system and should be prioritized as an area of future research.

Fundamental movement skill proficiency and objectively measured physical activity in children with bronchiectasis: a cross-sectional study.

BACKGROUND: Bronchiectasis is a major contributor to respiratory morbidity and healthcare utilization in children. Children with bronchiectasis exhibit low levels of physical activity (PA) and poor fundamental movement skills (FMS) may be a contributing factor. However, there are no data on FMS's in this population. The current study assessed FMS proficiency in children with bronchiectasis and examined associations with objectively measured PA. METHODS: Forty-six children with bronchiectasis (mean age 7.5 ± 2.6 year, 63% Male) were recruited from the Queensland Children's Hospital, Brisbane. PA was measured using the ActiGraph GT3X + accelerometer. Raw accelerometer data were processed into daily time spent in sedentary activities, light-intensity activities and games, walking, running, and moderate-to-vigorous activities and games using a random forest (RF) PA classification algorithm specifically developed for children. Daily MVPA was calculated by summing time spent in walking, running, and moderate-to-vigorous activities and games. FMS were assessed using the Test of Gross Motor Development 2nd Edition (TGMD-2). RESULTS: Fewer than 5% of children demonstrated mastery in the run, gallop, hop, and leap; while fewer than 10% demonstrated mastery for the two-handed strike, overarm throw, and underarm throw. Only eight of the 46 children (17.4%) achieved their age equivalency for locomotor skills, while just four (8.7%) achieved their age equivalency for object control skills. One-way ANCOVA revealed that children achieving their age equivalency for FMS had significantly higher levels of MVPA than children not achieving their age equivalency (51.7 vs 36.7 min/day). When examined by the five activity classes predicted by the RF algorithm, children achieving their age equivalency exhibited significantly greater participation moderate-to-vigorous intensity activities and games (22.1 vs 10.7 min/day). No significant differences were observed for sedentary activities, light-intensity activities and games, walking, and running. CONCLUSION: Children with bronchiectasis exhibit significant delays in their FMS development. However, those who meet their age equivalency for FMS proficiency participate in significantly more daily MVPA than children who do not meet their age-equivalency. Therapeutic exercise programs designed to improve FMS proficiency are thus likely to be beneficial in this population.

Validity of Two Wheelchair-Mounted Devices for Estimating Wheelchair Speed and Distance Traveled.

This study evaluated the validity of two wheelchair-mounted devices-the Cateye® and Wheeler-for monitoring wheelchair speed and distance traveled. Speed estimates were validated against a calibrated treadmill at speeds from 1.5 to 10 km/hr. Twenty-five wheelchair users completed a course of known distance comprising a sequence of everyday wheelchair activities. Speed estimate validity was very good (mean absolute percentage error ≤ 5%) for the Wheeleri at all speeds and for the Cateye at speeds >3 km/hr but not speeds <3 km/hr (mean absolute percentage error > 20%). Wheeleri distance estimates were good (mean absolute percentage error < 10%) for linear pushing activities and general maneuvering but poor for confined-space maneuvering. Cateye estimates were good for continuous linear propulsion but poor for discontinuous pushing and maneuvering (both general and confined space). Both devices provided valid estimates of speed and distance for typical wheelchair-based exercise activities. However, the Wheeleri provided more accurate estimates of speed and distance during typical everyday wheelchair activities.

Does sports-specific training improve measures of impairment developed for para sport classification? A multiple-baseline, single-case experiment.

Conceptually, sports-specific training should not influence measures of impairment used to classify Para athletes. This study evaluated the extent to which measures of strength, range of movement and coordination developed for Para swimming classification changed in response to a performance-focused swimming programme. A five-phase multiple-baseline, single-case experimental research design was utilized. Three participants with cerebral palsy and high support needs completed the 64-week study, which included two 16-week performance-focused swimming training blocks. Swimming speed, isometric shoulder extension strength, shoulder flexion range of movement and upper limb coordination were monitored throughout.Interrupted Time-Series Simulation Method analysis demonstrated large, significant changes in swimming speed (m/s) during the first (d = 2.17; 95% CI 0.45-3.88; p = 0.01) and second (d = 2.59; 95% CI 1.66-3.52; p = 0.00) training blocks. In contrast, changes in strength, range of movement and coordination were predominantly trivial and non-significant. This was the first study to investigate training responsiveness of measures developed for Para sport classification. Results indicate that despite significantly improved swimming performance, impairment measures remained relatively stable, and therefore these measures of impairment may be valid for the purposes of Para swimming classification. Further research is required in elite athletes, different sports and different impairment types.

Challenges and opportunities in wheelchair basketball classification- A Delphi study.

The International Paralympic Committee (IPC) mandates Paralympic Sports to develop evidence-based classification systems that allocate athletes into 'classes' according to the impact of their impairment on sport-specific performance. In wheelchair-basketball, a panel of classifiers assesses athlete's performance through observation. One key barrier to evidence-based classification is the absence of defined eligible impairments, including clear guidelines on how to assess them and their impact on wheelchair basketball performance. This study aims to reach expert consensus on issues specific to wheelchair basketball that can benefit from evidence-based classification. It offers recommendations for refining the classification manual, thus improving adherence to the IPC classification code. A three-round Delphi study was conducted with 29 experts in wheelchair basketball. The experts agreed with the new definition for the aim of wheelchair basketball classification, which is in line with the IPC code. Cases identified as having the highest risk for disagreement between classifiers included classifying players with upper limb deficiency or with impaired coordination. The panel failed to agree on changing the classification procedures and on defining the eligible impairment list. This study identifies issues specific to wheelchair basketball classification to be addressed in future research. Additional discussions need to take place to promote further resolution.

Validity of the Apple Watch® for monitoring push counts in people using manual wheelchairs.

Objective: A recent Apple Watch® activity-monitoring innovation permits manual wheelchair users to monitor daily push counts. This study evaluated the validity of the Apple Watch® push count estimate.Design: Criterion validity.Setting: Southern Finland and Southeast Queensland, Australia.Participants: Twenty-six manual wheelchair users from Finland and Australia were filmed completing a standardized battery of activities while wearing the Apple Watch® (dominant wrist).Outcome Measures: Wheelchair pushes as determined by the Apple Watch® were compared to directly observed pushes.Results: Agreement between Apple Watch® push counts and directly observed pushes was evaluated using Intraclass correlation coefficients (ICC), Pearson correlations and Bland-Altman analyses. Apple Watch® pushes and directly observed push counts were strongly correlated (ICC = 0.77, P < 0.01) (r = 0.84, P < 0.01). Bland Altman plots indicated that the Apple Watch® underestimated push counts (M = -103; 95% ULoA = 217; LLoA = -423 pushes). Mean absolute percentage error was 13.5% which is comparable to studies evaluating agreement between pedometer-based step counts and directly observed steps.Conclusion: Apple Watch® push-count estimates are acceptable for personal, self-monitoring purposes and for research entailing group-level analyses, but less acceptable where accurate push-count measures for an individual is required.

Differentiating maximal and submaximal voluntary strength measures for the purposes of medico-legal assessments and para sport classification: A systematic review.

Measurement of maximum voluntary muscle contractions are effort-dependent - valid measurement requires maximal voluntary effort (MVE) from participants. Submaximal efforts (SMEs) yield invalid and potentially misleading results. This is particularly problematic in medico-legal and Para sport assessments where low strength scores may confer a personal advantage. Therefore, objective methods for accurately differentiating MVE and SME are required. This systematic review aimed to identify, appraise and synthesise evidence from scientific studies evaluating the validity of objective methods for differentiating MVE from SME during maximal voluntary contractions. Four electronic databases were searched for original research articles published in English and secondary references appraised for relevance yielding 25 studies for review. Methods were categorised based on eight distinct underlying theories. For isokinetic strength assessment, methods based on two theories - Strength-measure Ratios and Inter-Trial Strength Consistency - correctly classified 100% MVE and > 92% SME. Consequently, research evaluating the relative suitability of these methods for translation into practice is warranted. During isometric strength assessments, methods based on Deceptive Visual Feedback and Force-length properties warrant further investigation. Both methods yielded statistically significant differences between MVE and SME, with minimal overlap in values, but their sensitivity and specificity have not been evaluated.

Biomechanics of starting, sprinting and submaximal running in athletes with brain impairment: A systematic review.

OBJECTIVES: Para athletes with brain impairment are affected by hypertonia, ataxia and athetosis, which adversely affect starting, sprinting and submaximal running. The aim was to identify and synthesise evidence from studies that have compared the biomechanics of runners with brain impairments (RBI) and non-disabled runners (NDR). DESIGN: Systematic review. METHODS: Five journal databases were systematically searched from inception to March 2020. Included studies compared the biomechanics of RBI (aged>14 years) and NDR performing either block-starts, sprinting, or submaximal running. RESULTS: Eight studies were included, analysing a total of 100 RBI (78M:22F; 18-38 years) diagnosed with either cerebral palsy (n=44) or traumatic brain injury (n=56). Studies analysed block-starts (n=3), overground sprinting (n=3) and submaximal running (n=2), and submaximal treadmill running (n=1). Horizontal velocity during starts, sprinting and self-selected submaximal speeds were lower in RBI. During sprinting and submaximal running, compared with NDR, RBI had shorter stride length, step length, and flight time, increased ground-contact time, increased cadence, and reduced ankle and hip range of motion. In submaximal running, RBI had decreased ankle-power generation at toe-off. CONCLUSIONS: There is limited research and small sample sizes in this area. However, preliminary evidence suggests that RBI had lower sprint speeds and biomechanical characteristics typical of submaximal running speeds in NDR, including increased ground-contact times and reduced stride length, step length, and flight times. Meaningful interpretation of biomechanical findings in RBI is impeded by impairment variability (type, severity and distribution), and methods which permit valid, reliable impairment stratification in larger samples are required.

Evaluation of a novel intervention to improve physical activity for adults with whiplash associated disorders: Protocol for a multiple-baseline, single case experimental study.

Half of individuals with a whiplash injury experience ongoing pain and disability. Many are insufficiently active for good health, increasing their risk of preventable morbidity and mortality, and compounding the effects of the whiplash injury. This paper describes a protocol for evaluating the efficacy of a physical activity promotion intervention in adults with whiplash associated disorders. A multiple-baseline, single case experimental design will be used to evaluate the effects of a physical activity (PA) intervention that includes evidence-based behaviour change activities and relapse prevention strategies for six adults with chronic whiplash. A structured visual analysis supplemented with statistical analysis will be used to analyse: accelerometer-measured PA, confidence completing PA in the presence of neck pain, and pain interference.