Louise E. Mitchell

Move it to improve it (Mitii): study protocol of a randomised controlled trial of a novel web-based multimodal training program for children and adolescents with cerebral palsy

Introduction Persons with cerebral palsy require a lifetime of costly and resource intensive interventions which are often limited by equity of access. With increasing burden being placed on health systems, new methods to deliver intensive rehabilitation therapies are needed. Move it to improve it (Mitii) is an internet-based multimodal programme comprising upper-limb and cognitive training with physical activity. It can be accessed in the clients home at their convenience. The proposed study aims to test the efficacy of Mitii in improving upper-limb function and motor planning. Additionally, this study hopes to further our understanding of the central neurovascular mechanisms underlying the proposed changes and determine the cost effectiveness of Mitii. Methods and analysis Children with congenital hemiplegia will be recruited to participate in this waitlist control, matched pairs, single-blind randomised trial. Children be matched at baseline and randomly allocated to receive 20 weeks of 30 min of daily Mitii training immediately, or waitlisted for 20 weeks before receiving the same Mitii training (potential total dose=70 h). Outcomes will be assessed at 20 weeks after the start of Mitii, and retention effects tested at 40 weeks. The primary outcomes will be the Assessment of Motor and Process Skills (AMPS), the Assisting Hand Assessment (AHA) and unimanual upper-limb capacity using the Jebsen-Taylor Test of Hand Function (JTTHF). Advanced brain imaging will assess use-dependant neuroplasticity. Measures of body structure and functions, activity, participation and quality of life will be used to assess Mitii efficacy across all domains of the International Classification of Functioning, Disability and Health framework. Ethics and dissemination This project has received Ethics Approval from the Medical Ethics Committee of The University of Queensland (2011000608) and the Royal Childrens Hospital Brisbane (HREC/11/QRCH/35). Findings will be disseminated widely through conference presentations, seminars and peer-reviewed scientific journals. Trial registration ACTRN12611001174976

The effect of virtual reality interventions on physical activity in children and adolescents with early brain injuries including cerebral palsy

Louise Mitchell, Jenny Ziviani, Stina Oftedal, Roslyn Boyd 1 Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, Faculty of Health Sciences, The University of Queensland, Queensland. 2 Royal Childrens Hospital, Herston, Brisbane, Queensland. 3 Queensland Childrens Medical Research Institute, Royal Childrens Hospital, Brisbane. 4 School of Health and Rehabilitation Sciences, The University of Queensland, Queensland, Australia. Correspondence to: louise.mitchell@uq.edu.au

Variability in measuring physical activity in children with cerebral palsy

INTRODUCTION This study aimed to establish the variability in the measurement of habitual physical activity using the ActiGraph® GT3X+ accelerometer in children with cerebral palsy (CP). METHOD Repeated measures: Independently ambulant children with unilateral CP (n = 30; age, 11 yr 3 months (2 yr 4 months)) completed standardized tasks over two consecutive days, wearing an ActiGraph® GT3X+ accelerometer and HR monitor. Testing protocol comprised 5 min of seated rest (REST), walking at light, moderate, and vigorous pace, and rapid stepping on/off a step. Agreement was calculated between days using intraclass correlation coefficients (ICC) (two-factor mixed agreement model). Minimum detectable difference was calculated (minimum detectable difference = [SD√1 - ICC] × 1.96√2). Performance variability: Participants (n = 102) wore an ActiGraph® GT3X+ accelerometer for 4 d in the community. Activity counts were converted into activity intensity using uniaxial-derived cut points to classify the time spent in moderate-to-vigorous physical activity (MVPA). Between-day intraclass reliability coefficients (R) and Spearman-Brown prophecy formula ([ICCdesired/(1 - ICCdesired)][(1 - ICCestimated)]/ICCestimated]) were calculated. RESULTS Agreement between repeated measures was strong for light physical activity and MVPA (ICC, 0.80). For MVPA, the minimum detectable difference was 1412 counts per minute. In the community, 345 d (87%) were recorded. Three days of monitoring produced acceptable variability estimates of MVPA (R = 0.63-0.73). Spearman-Brown prophecy analysis estimated that 3 d would achieve a reliability coefficient of 0.7 and 11 d would achieve 0.9. CONCLUSIONS Measurement of habitual physical activity using the ActiGraph® GT3X+ accelerometer is reliable under controlled walking and stepping conditions as well as in a community environment in independently ambulant children and adolescents with CP.

Habitual Physical Activity of Independently Ambulant Children and Adolescents With Cerebral Palsy: Are They Doing Enough?

Background Despite the health benefits of regular physical activity, children with cerebral palsy (CP) are thought to participate in reduced levels of physical activity. Objective The study objective was to assess physical activity and determine the proportion adhering to the recommended 60 minutes of moderate-to-vigorous physical activity (MVPA) daily in independently ambulant children and adolescents with unilateral CP. Design This was a cross-sectional study. Method Children (N=102; 52 boys, 50 girls; mean age=11 years 3 months, SD=2 years 4 months) with spastic hemiplegia classified at Gross Motor Function Classification System (GMFCS) levels I (n=44) and II (n=58) recorded physical activity over 4 days using an accelerometer. Activity counts were converted to daily and hourly time spent inactive and in light physical activity or MVPA using uniaxial cutpoints (inactive: ≤100 vertical counts·min−1, light: 101 to 2,295 vertical counts·min−1, MVPA: ≥2,296 vertical counts·min−1) and recorded step counts. Differences between groups were examined using t tests. Results Of a potential 396 days, 341 days (86%) were recorded. The average wear time was 11:44 (SD=1:56) hours. On a typical day, participants recorded 438 (SD=234) counts·min−1, took 7,541 (SD=3,894) steps, spent 8:36 (SD=1:09) hours inactive, spent 2:38 (SD=0:51) hours in light activity, and spent 0:44 (SD=0:26) hours in MVPA. Only 25% of participants met the recommended level of MVPA on at least one day. Physical activity was highest in boys (versus girls), in children (versus adolescents), and on weekdays (versus weekends). Limitations Participants were limited to children with unilateral spasticity who were classified at GMFCS levels I and II. Conclusions The majority of independently ambulant children with unilateral CP did not perform sufficient physical activity to meet public health recommendations.

Characteristics associated with physical activity among independently ambulant children and adolescents with unilateral cerebral palsy

This study aimed to quantify the contribution of physical, personal and environmental characteristics to physical activity among independently ambulant children with unilateral cerebral palsy (CP).

A systematic review of the clinimetric properties of measures of habitual physical activity in primary school aged children with cerebral palsy.

Regular participation in physical activity is an important determinant of health for children and adolescents with cerebral palsy (CP). However, there is little consensus on the most valid or reliable method to measure physical activity in this population. This study aimed to systematically review the psychometric properties of habitual physical activity (HPA) measures in primary school-aged children with CP. Databases were systematically searched for measures assessing physical activity over more than one day and had evidence of validity, reliability and/or clinical utility in children aged 6-12 years with CP. Ten measures met inclusion criteria and their quality was assessed in twelve studies. Quality of the included studies was appraised using the consensus-based standards for the selection of health measurement instruments (COSMIN) checklist. Measures were moderately to strongly correlated to criterion measures, with study quality rated as Fair (+) to Poor (0). Only four measures had evidence of reliability. Accelerometers provide a valid measure of HPA with good clinical utility; however they do not have documented reliability in this population. No one measure appears ideal to record HPA in primary school-age children with CP and further research is necessary to determine the psychometric properties of HPA measurement instruments in this population.

A systematic review of the clinimetric properties of habitual physical activity measures in young children with a motor disability.

Aim. To identify and systematically review the clinimetric properties of habitual physical activity (HPA) measures in young children with a motor disability. Method. Five databases were searched for measures of HPA including: children aged <6.0 years with a neuromuscular disorder, physical activity defined as “bodily movement produced by skeletal muscles causing caloric expenditure”, reported HPA as duration, frequency, intensity, mode or energy expenditure, and evaluated clinimetric properties. The quality of papers was assessed using the COSMIN-checklist. A targeted search of identified measures found additional studies of typically developing young children (TDC). Results. Seven papers assessing four activity monitors met inclusion criteria. Four studies were of good methodological quality. The Minimod had good ability to measure continuous walking but the demonstrated poor ability to measure steps during free-living activities. The Intelligent Device for Energy Expenditure and Activity and Ambulatory Monitoring Pod showed poor ability to measure activity during both continuous walking and free-living activities. The StepWatch showed good ability to measure steps during continuous walking in TDC. Interpretation. Studies assessing the clinimetric properties of measures of HPA in this population are urgently needed to allow assessment of the relationship between HPA and health outcomes in this group.

A randomized controlled trial of web-based training to increase activity in children with cerebral palsy

To determine the efficacy of web‐based training on activity capacity and performance in children with unilateral cerebral palsy (CP).

Measurement of physical activity in children and adolescents with cerebral palsy: the way forward

Participation in regular physical activity is recognized as a necessary contributor to health and well-being for children and adolescents with cerebral palsy (CP). Over recent years the number of papers on this topic has increased, attesting to the importance being afforded this issue. Despite this interest, research investigating the psychometric properties of measures of physical activity in individuals with CP has been relatively limited. This is of concern, as the underpinning of a good study design lies in the selection of measures which are known to be valid, reliable, and responsive to change in the population studied. Research in typically developing children supports the use of pedometers and accelerometers to accurately record physical activity. However, differences in gait biomechanics and energy expenditure means that specific validation is required for children and adolescents with CP. Systematic reviews on measurement of physical activity in individuals with CP have drawn limited conclusions other than to plead for additional high quality research. When the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria have been applied, studies investigating the validity of measures of physical activity ranged from Fair to Poor in quality, with little evidence to support the reliability of these measures in children with CP. Maher et al. answer this call, providing a robust evaluation of the NL-1000 pedometer (New Lifestyles Inc., Lee’s Summit, MO, USA). The authors have carefully considered their study design and reporting, enabling readers to interpret these results with confidence. Application of the COSMIN criteria to this paper rates the overall study quality as Excellent, with the exception of the description of missing data handling (which was Good). Rigorous statistical testing has been applied, sample size justified, and their findings carefully interpreted to highlight that the results apply to independently ambulant children, classified at Gross Motor Functional Classification System (GMFCS) levels I or II, and under controlled settings only. The accuracy of the NL-1000 in an individual classified at GMFCS level III, who walks with an external support and typically in a more crouched position, may be quite different and should be investigated separately. Future research that considers the measurement of physical activity in individuals across all GMFCS levels is required, but when doing so it is important to consider if step counts provide a relevant measure of physical activity for all. For an individual using primarily wheeled mobility, a step counting device is of limited use, given that the majority of physical activity performed would be missed by a pedometer. Accelerometers have an advantage in that they can be either wrist or waist mounted, meaning they are appropriate for children across all GMFCS levels, and most importantly provide data on activity intensity, which has been validated against energy expenditure in ambulant children and adolescents with CP. In addition, preliminary work in typically developing children suggests that pat-