Individualized orthotic alignment and footwear for balance and mobility in children with bilateral spastic cerebral palsy: A randomized trial.

AIM: To examine whether designed-to-be-rigid ankle-foot orthoses and footwear combinations with individualized alignment and footwear designs (AFO-FC/IAFD) would be more effective than designed-to-be-rigid AFO with non-individualized alignment and footwear designs (AFO-FC/NAFD) in children with cerebral palsy (CP). METHOD: Nineteen children with bilateral spastic CP were randomized to AFO-FC/NAFD (n = 10) or AFO-FC/IAFD (n = 9) groups. Fifteen were male, average age 6 years 11 months (range 4 years 2 months-9 years 11 months), classified in Gross Motor Function Classification System levels II (n = 15) and III (n = 4). The Pediatric Balance Scale (PBS), Gait Outcomes Assessment List (GOAL), Patient-Reported Outcomes Measurement Information System (PROMIS), and Orthotic and Prosthetic Users' Survey (OPUS) measures of satisfaction were collected at baseline and after 3 months' wear. RESULTS: Compared with the AFO-FC/NAFD group, those with AFO-FC/IAFD demonstrated greater change in PBS total scores (mean 12.8 [standard deviation 10.5] vs 3.5 [5.8]; p = 0.03) and GOAL total scores (3.5 [5.8] vs -0.44 [5.5]; p = 0.03). There were no significant changes in OPUS or PROMIS scores. INTERPRETATION: After 3 months, individualized orthosis alignment and footwear designs had a greater positive effect on balance and parent-reported mobility than a non-individualized approach. No effect was documented for the PROMIS and OPUS. Results may inform orthotic management for ambulatory children with bilateral spastic CP. WHAT THIS PAPER ADDS: Balance and parent-reported mobility increased more over time for the ankle-foot orthoses and footwear combinations with individualized alignment and footwear designs (AFO-FC/IAFD) group. Changes in balance over time suggest a therapeutic effect of the AFO-FC/IAFD approach.

"That's frustrating": Perceptions of ankle foot orthosis provision, use, and needs among people with cerebral palsy and caregivers.

BACKGROUND: Cerebral palsy (CP) affects roughly 3 per 1000 births in the United States and is the most common pediatric developmental motor disability. Ankle foot orthoses (AFOs) are commonly prescribed to provide support and improve function for individuals with CP. OBJECTIVES: The study objective was to evaluate the lived experiences of individuals with CP and their caregivers regarding AFO access, use, and priorities. We examined experiences around the perceived purpose of AFOs, provision process, current barriers to use, and ideas for future AFO design. STUDY DESIGN: Secondary qualitative data analysis. METHODS: Secondary data analysis was performed on semistructured focus groups that included 68 individuals with CP and 74 caregivers. Of the focus group participants, 66 mentioned AFOs (16 individuals with CP and 50 caregivers). Deidentified transcripts were analyzed using inductive coding, and the codes were consolidated into themes. RESULTS: Four themes emerged: 1) AFO provision is a confusing and lengthy process, 2) participants want more information during AFO provision, 3) AFOs are uncomfortable and difficult to use, and 4) AFOs can benefit mobility and independence. Caregivers and individuals with CP recommended ideas such as 3D printing orthoses and education for caregivers on design choices to improve AFO design and provision. CONCLUSIONS: Individuals with CP and their caregivers found the AFO provision process frustrating but highlight that AFOs support mobility and participation. Further opportunities exist to support function and participation of people with CP by streamlining AFO provision processes, creating educational materials, and improving AFO design for comfort and ease of use.

Physical Activity Measurement in Children Who Use Mobility Assistive Devices: Accelerometry and Global Positioning System.

PURPOSE: To explore the usefulness of combining accelerometry, global positioning systems, and geographic information systems, to describe the time spent in different locations and physical activity (PA) duration/count levels by location for 4 children with cerebral palsy (CP) who use assistive devices (AD). METHODS: A descriptive multiple-case study. RESULTS: Combining the 3 instruments was useful in describing and differentiating duration by location, and amount and location of PA across differing functional levels and AD. For example, the child classified with a Gross Motor Function Classification System (GMFCS) level II exhibited large amounts of PA in community settings. In contrast, the child classified with a GMFCS level V had small amounts of PA and spent most measured time at home. CONCLUSIONS: Combined accelerometry, global positioning system, and geographic information system have potential to capture time spent and amount/intensity of PA relative to locations within daily environments for children with CP who use AD.

Accelerometer Measurements Indicate That Arm Movements of Children With Cerebral Palsy Do Not Increase After Constraint-Induced Movement Therapy (CIMT).

IMPORTANCE: Constraint-induced movement therapy (CIMT) is a common treatment for children with unilateral cerebral palsy (CP). Although clinic-based assessments have demonstrated improvements in arm function after CIMT, whether these changes are translated and sustained outside of a clinic setting remains unclear. OBJECTIVE: Accelerometers were used to quantify arm movement for children with CP 1 wk before, during, and 4 wk or more after CIMT; measurements were compared with those from typically developing (TD) peers. DESIGN: Observational. SETTING: Tertiary hospital and community. PARTICIPANTS: Seven children with CP (5 boys, 2 girls; average [AVE] age ± standard deviation [SD] = 7.4 ± 1.2 yr) and 7 TD peers (2 boys, 5 girls; AVE age ± SD = 7.0 ± 2.3 yr). INTERVENTION: 30-hr CIMT protocol. OUTCOMES AND MEASURES: Use ratio, magnitude ratio, and bilateral magnitude were calculated from the accelerometer data. Clinical measures were administered before and after CIMT, and parent surveys assessed parent and child perceptions of wearing accelerometers. RESULTS: During CIMT, the frequency and magnitude of paretic arm use among children with CP increased in the clinic and in daily life. After CIMT, although clinical scores showed sustained improvement, the children's accelerometry data reverted to baseline values. Children and parents in both cohorts had positive perceptions of accelerometer use. CONCLUSIONS AND RELEVANCE: The lack of sustained improvement in accelerometry metrics after CIMT suggests that therapy gains did not translate to increased movement outside the clinic. Additional therapy may be needed to help transfer gains outside the clinic. WHAT THIS ARTICLE ADDS: Accelerometer measurements were effective at monitoring arm movement outside of the clinic during CIMT and suggested that additional interventions may be needed after CIMT to sustain benefits.

Feasibility of using acceleration-derived jerk to quantify bimanual arm use.

BACKGROUND: Accelerometers have become common for evaluating the efficacy of rehabilitation for patients with neurologic disorders. For example, metrics like use ratio (UR) and magnitude ratio (MR) have been shown to differentiate movement patterns of children with cerebral palsy (CP) compared to typically-developing (TD) peers. However, these metrics are calculated from "activity counts" - a measure based on proprietary algorithms that approximate movement duration and intensity from raw accelerometer data. Algorithms used to calculate activity counts vary between devices, limiting comparisons of clinical and research results. The goal of this research was to develop complementary metrics based on raw accelerometer data to analyze arm movement after neurologic injury. METHOD: We calculated jerk, the derivative of acceleration, to evaluate arm movement from accelerometer data. To complement current measures, we calculated jerk ratio (JR) as the relative jerk magnitude of the dominant (non-paretic) and non-dominant (paretic) arms. We evaluated the JR distribution between arms and calculated the 50th percentile of the JR distribution (JR50). To evaluate these metrics, we analyzed bimanual accelerometry data for five children with hemiplegic CP who underwent Constraint-Induced Movement Therapy (CIMT) and five typically developing (TD) children. We compared JR between the CP and TD cohorts, and to activity count metrics. RESULTS: The JR50 differentiated between the CP and TD cohorts (CP = 0.578 ± 0.041 before CIMT, TD = 0.506 ± 0.026), demonstrating increased reliance on the dominant arm for the CP cohort. Jerk metrics also quantified changes in arm use during and after therapy (e.g., JR50 = 0.378 ± 0.125 during CIMT, 0.591 ± 0.057 after CIMT). The JR was strongly correlated with UR and MR (r = - 0.92, 0.89) for the CP cohort. For the TD cohort, JR50 was repeatable across three data collection periods with an average similarity of 0.945 ± 0.015. CONCLUSIONS: Acceleration-derived jerk captured differences in motion between TD and CP cohorts and correlated with activity count metrics. The code for calculating and plotting JR is open-source and available for others to use and build upon. By identifying device-independent metrics that can quantify arm movement in daily life, we hope to facilitate collaboration for rehabilitation research using wearable technologies.

Walking Performance, Physical Activity, and Validity of the Early Activity Scale for Endurance in Young Children with Cerebral Palsy.

AIMS: To describe the walking performance and physical activity of children with cerebral palsy (CP) by Gross Motor Function Classification System (GMFCS) level, age, sex, and geographical location; and, to examine the concurrent validity of the 4-item Early Activity Scale for Endurance (EASE) to walking performance and physical activity scores. METHODS: Seventy-nine children with CP participated. Parents completed the 4-item EASE. All children wore an Actigraph monitor (n = 79), and children in GMFCS levels I - III also wore a StepWatch monitor (n = 50), for seven days. RESULTS: Only GMFCS level yielded significant differences in average strides taken per day, in strides per day taken faster than 30 strides per minute, in average physical activity counts per minute, and in minutes per day spent in moderate to vigorous physical activity. The 4-item EASE findings were moderately correlated with average physical activity counts per minute (.61, p< .001) and minutes per day spent in moderate to vigorous physical activity (.62, p < .001). CONCLUSIONS: GMFCS level is predictive of both walking performance and physical activity in children with CP. The 4-item EASE may provide a quick and valid way to monitor physical activity in children with CP.

Short-burst interval treadmill training walking capacity and performance in cerebral palsy: a pilot study.

PURPOSE: To examine the effect of short-burst interval locomotor treadmill training (SBLTT) on walking capacity and performance in cerebral palsy (CP). METHODS: Twelve children with spastic diplegic CP (average 8.6 years) across Gross Motor Function Classification System levels II (8) and III (4) were randomized to 20 SBLTT sessions over 4 or 10 weeks. SBLTT consisted of alternating 30 seconds of slow and fast walking for 30 minutes/session. Outcomes included the 10 m walk test, one-minute walk test (1MWT), and timed-up-and go (TUG) (capacity) and StepWatch (performance) collected at baseline, post, and 6 weeks post. RESULTS: Fast speed (+.11, p = .04; +.11 m/s, p = .006), 1MWT (+11.2; +11.7 m, p = .006) and TUG (-1.7; -1.9 seconds, p = .006) improved post SBLTT and 6 weeks, respectively. Walking performance increased: average strides/day (+948; +1712, p < .001) and percent time in high strides rates (+0.4, p = 0.07; +0.2, p = .008). CONCLUSIONS: Pilot study suggests SBLTT may improve short-term walking capacity and performance.

Utilization of Physical Therapy Services During Transition for Young People With Cerebral Palsy: A Call for Improved Care Into Adulthood.

Background: Many young adults with cerebral palsy (CP) face limited participation in activities, including employment and independent living. Physical therapy during the transition period can help to support participation through promotion of self-care, ambulation, and functional mobility. Thus, ensuring appropriate access to physical therapy services for young people who can benefit from them before, during, and after transition is imperative. Objective: The objective of this study was to identify factors contributing to the utilization of physical therapy services for youth with CP both during and after secondary school. Design: The design was a deidentified secondary analysis of the National Longitudinal Transition Study 2 (NLTS2). Methods: Multivariate regression models were run to examine demographic and disability characteristics influencing utilization of physical therapy services for youth with CP both during and after secondary school. Results: The total weighted population sample included 35,290 young people with CP. When all youth were in secondary school, 59.4% of the youth utilized physical therapy services; however, once all youth were out of school, only 33.7% of them were reported to have utilized physical therapy since leaving secondary school. For young people with difficulties accessing general disability support services, demographic characteristics, including sex, race, income, and parent education status, influenced use of physical therapy services in addition to disability characteristics. Limitations: This population sample included only young people in special education with Individual Education Plans (IEPs) and may not generalize to young people with CP in general education settings. Conclusions: Frequency of physical therapy services decreases drastically once young adults with CP leave secondary school. Future work should examine this trend in more depth to identify therapy intervention strategies to optimize participation in young adult life for persons with CP.

A Novel Protocol for Contact Isolation for Multidrug-Resistant Organisms in Children on Inpatient Rehabilitation and Effects on Functional Outcomes: A Noninferiority Study.

BACKGROUND: The incidence of contact isolation for multidrug-resistant organisms is increasing in acute hospitals and inpatient rehabilitation units alike. There is limited evidence on the effect of contact isolation on functional outcomes during inpatient rehabilitation. OBJECTIVE: To determine whether the use of a modified contact isolation protocol (MCI) resulted in noninferior functional outcomes compared with children without contact isolation (NCI) on inpatient rehabilitation. DESIGN: This is a retrospective noninferiority study. SETTING: One academically affiliated pediatric inpatient rehabilitation unit located in a children's hospital. PATIENTS: All children with any diagnosis admitted to inpatient rehabilitation from January 1, 2007, to December 31, 2014. METHODS OR INTERVENTIONS: We compared functional outcomes for 2 groups of children. MAIN OUTCOME MEASUREMENTS: Primary outcome measures included the Functional Independence Measure for Children (WeeFIM) efficiency and the change in the Developmental Functional Quotient (DFQ) for the WeeFIM. Noninferiority margins of 0.63 for the WeeFIM efficiency and 0.092 for the change in DFQ for the WeeFIM were used. RESULTS: There were a total of 949 patients of whom 899 were NCI, 48 MCI, and 2 excluded due to missing information. Patients with MCI had functional outcomes that were noninferior to those with NCI including the WeeFIM efficiency (mean difference 0.002, 95% CI -0.38 to 0.404) and the change in DFQ for the WeeFIM (mean difference -0.05, 95% CI -0.058 to 0.003). CONCLUSIONS: The modified contact isolation protocol, having resulted in noninferior functional outcomes in inpatient rehabilitation may provide adequate contact isolation while allowing for noninferior functional outcomes. This may be a guide in the face of an ever-increasing need for contact isolation. LEVEL OF EVIDENCE: III.

Physical activity and walking performance: Influence on quality of life in ambulatory children with cerebral palsy (CP).

PURPOSE: To examine the relationship of physical activity (PA) and walking performance to QOL in ambulatory children with CP, as function is not consistently associated with QOL in this population. METHODS: A secondary analysis of a cross-sectional cohort of 128 ambulatory children with CP, ages 2.2-9.9 years and GMFCS levels I-III, was employed. Individual multivariate regression models were developed for physical, psychosocial, and total domains of QOL as measured by the Pediatric Quality of Life Inventory (PedsQL) controlling for physical activity and walking performance, participation level and frequency, topography of CP, walking capacity, age, and satisfaction with participation. RESULTS: Physical, psychosocial and total QOL averaged 52.2, 60.9, and 56.5 respectively. PA was positively associated with physical (0.64, p < 0.01) and total QOL (0.54, p < 0.01). Walking performance was associated with physical QOL (0.16, p = 0.05), participation level was positively related to psychosocial (0.44, p < 0.01), and age negatively for all QOL domains (> -0.43, p < 0.01). CONCLUSIONS: Physical activity, walking performance, and level of participation in daily life are associated with varying domains of QOL. Future work should explore factors that influence the relationship of daily physical/walking activity and participation to QOL in children with ambulatory CP as they age.

The effect of supported physical activity on parental-reported sleep qualities and pain severity in children with medical complexity.

PURPOSE: To study the impact of a 5-week supported physical activity (PA) intervention on parental report of sleep qualities, sleep duration, and pain severity in children with medical complexity (CMC). METHODS: Twenty-nine CMC participated in 180 minutes of daily supported PA on weekdays over 5 weeks. A pre- and post-test design was used to collect sleep qualities (Children's Sleep Habits Questionnaire) and pain severity (Faces Pain Scale- Revised) as reported by parents. Using a repeated measures design, weekly sleep diaries captured sleep duration. RESULTS: Children with medical complexity experienced no adverse effects, including pain, with the supported PA intervention. Significant improvements in sleep problems, sleep duration, and pain severity (P< 0.05) were demonstrated. CONCLUSION: Short-term supported PA did not interfere with sleep or pain in CMC, and in fact, seems to have enhanced parental report of sleep qualities, sleep duration, and pain severity. Supported PA appears safe for CMC and healthcare professionals should explore methods to expand opportunities for supported PA participation.

The effect of supported physical activity on parental-reported health-related quality of life in children with medical complexity.

PURPOSE: To investigate the impact of a 5-week supported physical activity (PA) intervention on parental report of health-related quality of life (HRQL) in children with medical complexity (CMC). METHODS: Twenty-nine CMC participated in 180 minutes of supported PA daily. A pre- and post-test design was used to assess HRQL total and domain scores as reported by parents. The relationship between supported PA duration and HRQL was also examined. RESULTS: Children with medical complexity experienced no adverse effects with the supported PA intervention. Significant improvements in HRQL scores (P < 0.05) were demonstrated. A 5- to 8-point HRQL improvement occurred when CMC engaged in an average of 40 minutes of PA daily. CONCLUSION: Short-term, supported PA enhanced parental report of HRQL in children with medical complexity. Supported PA appears safe for CMC and rehabilitation therapists should explore methods to expand opportunities for participation.

Relationship between sleep disturbance and functional outcomes in daily life habits of children with Down syndrome.

OBJECTIVES: The goal of this study was to describe sleep patterns and accomplishment of daily life habits in children with Down syndrome (DS) and to investigate the relationship between subjective indicators of sleep disturbance with functional outcomes in daily life. DESIGN: Cross-sectional study with an Internet sample. SETTING: Online survey filled out at home. PARTICIPANTS: 110 parents of children with DS and 29 parents of children with typical development (TD), age 5 to 18 years. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Children's Sleep Habits Questionnaire was employed to collect information about sleep disturbances in 8 domains (subscales) and a total score. The Life Habits (Life-H) questionnaire sampled information about daily life habits in 11 domains. Multivariable regression modeling was used to assess the associations between sleep disturbances and the accomplishment of daily life habits. Sleep disordered breathing (SDB) was a significant explanatory factor in 10 of 11 daily life habits and the total Life-H score. Sleep anxiety and parasomnias significantly influenced the accomplishment of life habits in children with DS as compared to children with typical development. When evaluated in multivariable models in conjunction with the other 7 domains of sleep disturbances, SDB was the most dominant explanatory factor for accomplishment of life habits. CONCLUSIONS: Sleep disturbances are negatively related to accomplishment of daily life functions. Prevention and treatment of sleep problems, particularly sleep disordered breathing, in children with DS may lead to enhanced accomplishment of daily life habits and activities.

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.

Relation of stride activity and participation in mobility-based life habits among children with cerebral palsy.

OBJECTIVE: To examine the relation between walking performance and participation in mobility-related habits of daily life in children with cerebral palsy (CP). To date, walking outcomes in CP have been capacity-based (what a child does in structured setting). Physical activity performance (what a child really does in daily life) has been documented to affect the relation of capacity-based gross motor measures and participation. DESIGN: Cross-sectional prospective cohort study. SETTING: Regional pediatric specialty care centers. PARTICIPANTS: A cohort of ambulatory children with CP (N=128; age, 2 to 9y; 41% girls; 49% having hemiplegia) participated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Walking performance was quantified from a 5-day sample of accelerometry data. Stride activity was summarized through the outcomes of the average number of total strides per day (independent of intensity) and the average number of total strides per day at >30 strides/min (marker of intensity). Mobility-based participation was assessed by using the Assessment of Life Habits for Children questionnaire categories of personal care, housing, mobility, and recreation. Regression models were developed controlling for sex, age, cognition, communication, pain, and body composition. RESULTS: The average number of total strides per day was positively associated with the personal care, housing, mobility, and recreation Assessment of Life Habits for Children questionnaire categories (ß=.34-.41, P<.001). The average number of total strides per day at >30 strides/min was associated with all categories (ß=.54-.60, P<.001). CONCLUSIONS: Accelerometry-based walking activity performance is significantly associated with levels of participation in mobility-based life habits for ambulatory children with CP. Evaluation of other factors and the direction of the relation within the International Classification of Functioning, Disability and Health is warranted to inform rehabilitation strategies.

Walking activity patterns in youth with cerebral palsy and youth developing typically.

PURPOSE: To describe daily walking stride rate patterns of young children with cerebral palsy (CP) as compared to a typically developing youth (TDY) cohort relative to age and functional level. METHOD: A cross-sectional comparison cohort study compared 209 youth with CP with 368 TDY aged 2-13 years. Youth with CP had Gross Motor Function Classification System (GMFCS) levels I-III with 60% bilateral involvement and 79% spastic. Five days of StepWatch data were averaged and classified into low, moderate and high stride rates. Group differences were examined by t-test and analysis of variance. RESULTS: Children with CP walk significantly less each day than TDY (F = 245, p ≤ 0.001) and differ by GMFCS (F = 1.51, p < 0.001). TDY walk a similar number of strides in low and moderate stride rates each day while youth with CP do not. TDY attained high stride rates (>60 strides/min) for 8 min/d with levels I-III at 4.0, 3.2 and 0.53 min/d, respectively. CONCLUSIONS: The relative relationship of walking intensity levels within total daily stride activity differs for youth with CP as compared to TDY. The influence of functional walking ability on walking stride activity levels and intensity does not appear to differ significantly across age groups. IMPLICATIONS FOR REHABILITATION: Limitation in the ability to attain moderate stride-rate intensity, regardless of total number of strides taken each day for ambulatory youth with CP, is a potential area of focus for intervention. Understanding of stride activity levels and intensity in youth with CP may be employed to focus rehabilitation strategies to enhance habitual walking activity. Community-based stride rate data has potential as an effectiveness outcome for rehabilitation strategies focused on walking (i.e. orthopedic surgery, orthoses and injections therapies).

Capacity to participation in cerebral palsy: evidence of an indirect path via performance.

OBJECTIVE: To examine the hypothesis that the influence of physical activity capacity on participation is mediated through activity performance. DESIGN: Secondary analysis of a prospective cross-sectional study sample. SETTING: Regional pediatric specialty care hospital. PARTICIPANTS: Children (N=128; 59% boys; age range, 2-9y) with cerebral palsy with Gross Motor Function Classification System levels I to III; 49% had hemiplegia, and 72% had spasticity. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Activity capacity was measured with the Gross Motor Function Measure-66, performance was measured with the Activities Scale for Kids, and participation was measured with the Assessment of Life Habits. Children's Assessment of Participation and Enjoyment and the Assessment of Preschool Children's Participation assessed diversity participation. Regression equations and Sobel z test were used to examine the mediated effect via performance. RESULTS: Physical activity performance mediates 74.9% (ß=.83, P<.001) of the effect of activity capacity on total participation levels and 52.8% (ß=.47, P=.001) of the effect of capacity on diversity participation. CONCLUSIONS: The relation between what an ambulatory child with cerebral palsy is able to perform in a clinical setting and their participation in life is significantly mediated by what they actually do motorically in day-to-day life. Results suggest that interventions focusing on improving what they actually do every day, regardless of their capacity to perform (what they can do when tested), may positively influence participation.

Reliably measuring ambulatory activity levels of children and adolescents with cerebral palsy.

OBJECTIVE: To identify sources of variance in step counts and to examine the minimum number of days required to obtain a stable measure of habitual ambulatory activity in the cerebral palsy (CP) population. DESIGN: Cross-sectional. SETTING: Free-living environments. PARTICIPANTS: Children and adolescents with CP (N=209; mean age ± SD, 8y, 4mo ± 3y, 4mo; n=118 boys; Gross Motor Function Classification System [GMFCS] levels I-III) were recruited through 3 regional pediatric specialty care hospitals. INTERVENTIONS: Daily walking activity was measured with a 2-dimensional accelerometer over 7 consecutive days. An individual information-centered approach was applied to days with <100 steps, and participants with ≥3 days of missing values were excluded from the study. Participants were categorized into 6 groups according to age and functional level. Generalizability theory was used to analyze the data. MAIN OUTCOME MEASURES: Mean step counts, relative magnitude of variance components in total step activity, and generalizability coefficients (G coefficients) of various combinations of days of the week. RESULTS: Variance in step counts attributable to participants ranged from 33.6% to 65.4%. For youth ages 2 to 5 years, a minimum of 8, 6, and 2 days were required to reach acceptable G coefficient (reliability) of ≥.80 for GMFCS levels I, II, and III, respectively. For those ages 6 to 14 years, a minimum of 6, 5, and 4 days were required to reach stable measures of step activity for GMFCS levels I, II, and III, respectively. CONCLUSIONS: The findings of the study suggest that an activity-monitoring period should be determined based on the GMFCS levels to reliably measure ambulatory activity levels in youth with CP.

StepWatch stride counting: accuracy, precision, and prediction of energy expenditure in children.

INTRODUCTION: Accuracy and precision of the StepWatch (SW) was tested in typically developing youth (TDY) with the prediction of oxygen consumption derived from stride counts. METHODS: Ten TDY (5 boys, 5 girls) with an average age 14.1 years (SD=2.2) enrolled. Participants underwent treadmill cardiopulmonary exercise testing (CPET) wearing two SW devices at 1, 2, 3, and 4 miles per hour (mph). RESULTS: Average sign-corrected disagreement for strides counted between the 2 monitors was 0.4 (0.52), 0.2 (0.42), 0.1 (0.32), and 0.1 (0.32) for 1, 2, 3, and 4 mph, respectively. The ratio of SW counts to observed manual counts averaged 100.03% with ICC=0.995. Oxygen consumption equations were derived from resting and walking VO(2), age, gender, and stride counts. CONCLUSIONS: Excellent accuracy and precision was documented for treadmill walking speeds up to 4 mph while VO(2) per number of strides taken appears to decrease with age and is lower in girls.