# Exercise as it relates to Disease/Motivating physical activity in children with cerebral palsy

This is an analysis of the journal article "Participation predictors for leisure-time physical activity intervention in children with cerebral palsy" by Reedman et al. (2021)
This was written as an assessment item for the unit Health, Disease and Exercise at the University of Canberra, 2021.

## What is the background to this research?

Cerebral Palsy (CP) is an overarching term for a collection of disorders that stem from disturbances to the brain in the perinatal period of development.
While some reports show that children tend to have low levels of participation in physical activity (PA); in comparison with typically developing children, those with CP display even less involvement, lower intensities, and less activity diversity. To combat the general lack of PA there are a range of strategies to boost involvement, however, interventions directed at children with CP tend to focus on improving motor skills or fitness levels, without taking the child’s unique barriers into account.
Typical barriers encountered include:
* Access to suitable facilities and/or programmes
* Attitudes of others
* Relationships with peers
* Equipment availability
* Previous experiences with PA attempts
* Motivation (what motivates the childs participation?)
This study looked beyond the physical limitations of CP and considered the influence of the individual’s contextual barriers to motivating PA participation. Working in line with the Self-Determination Theory (SDT), this study looked at a child’s increased feelings of autonomy, competence, and relatedness to see how they may assist with overcoming barriers both real and perceived and the subsequent effect on PA participation.

## Where is the research from?

The ParticiPAte CP intervention was conducted at the University of Queensland in Brisbane, Australia. Dr Sarah Reedman led the research and analysis following other research in the field. The Cerebral Palsy Alliance funded but had no further role in the administration of the project; as such, no competing interests are declared. Peer review was externally conducted, providing further certainty of independent results. This study was published in the Journal of Developmental Medicine and Child Neurology in January 2021.

## What kind of research was this?

This study involved a randomised waitlist-controlled trial. Randomised controlled trials (RCT) are considered to be of high standard regarding research validity. Participants were recruited in cohorts of 6–12 with additional prospective participants being placed on a waitlist for the next cohort. This waitlist design allowed for comparison of the treatment cohort against their usual standard of care, without disadvantaging a control group by preventing them access to potentially successful treatment. Each cohort effectively became their own control and treatment group.

## What did the research involve?

The ParticiPAte CP intervention involved eight one-hour physiotherapy sessions spread over eight weeks, as an addition to the child’s regular treatments.
The sessions were built upon framework from the Self-Determination Theory (SDT) and Motivational Interviewing (MI), with the physiotherapist delivering the sessions being specifically trained in MI. The first and last sessions focussed on goal setting and goal-scoring, with the remaining six sessions working to identify and overcome barriers of PA participation while developing physical attributes conducive to PA. Key components of the intervention sessions involved MI with an emphasis on increasing feelings of autonomy, competence, and relatedness, in line with the SDT.
Interestingly, ParticiPAte CP took a different approach than most studies as each individual received a tailored intervention. The individualised sessions drew from a broad set of evidence-based strategies; however, as a minimum all participants received a combination of the following:
* Goal setting and goal-scoring of participation-focussed goals.
* Strategy development to overcome barriers to PA participation.
* Communications consistent with SDT and MI oriented at changing PA behaviour.
* Child-directed strategies to promote autonomy, sense of competence, and feeling of being supported.
* Environment-focussed strategies (e.g., potential funding sources for equipment, education of community members, site visits).
This research presents some limitations:
* The individualised approach creates difficulty in exact study replication.
* Physical activity levels were measured using triaxial accelerometers at set times, however improved activity ability was not measured.
* While the physiotherapists received two days of MI training, as this was a major focus of the intervention more experience in this field may have garnered greater results.
* Results were based upon information obtained immediately following the intervention, a long-term follow up would be needed to ascertain sustained behaviour changes.

## What were the basic results?

The Canadian Occupational Performance Measure (COPM) was the primary outcome measure and the ParticiPAte CP intervention led to meaningful increases in these scores. The improved COPM scores appear to be linked closely with Goal Attainment Scaling (GAS) scores with 74% of these goals achieving an 'expected' or 'greater than expected' rating, and a 33% increase in feelings of competency as measured by the Belief in Goal Self-competence Scale (BiGSS).
Goal Attainment Scaling was used to set, increment, and rate goals associated with any barriers the child may face, while the BiGSS was used to rate the child’s feeling of self-competence when challenged with achieving a goal.
While these scores show a positive outcome for the intervention, the authors note that much of the results align with behaviours shown in typically developing children, particularly with regard to the child's age reflecting their keenness to participate.
Of note, although the statistics demonstrate that environmental goals were the least met (34%), caregivers reported significant improvements in barrier reduction. This is most likely due to an inability to increment certain goals on the GAS, or time-constraints of the intervention not allowing for some factors to be addressed in time.

## What conclusions can we take from this research?

This study highlights some of the many difficulties faced by children with CP regarding participation in physical activity. This study indicates that barriers encountered by children living with CP may be overcome with a plan that tends to psychological and physical needs. Due to each child’s unique situation, an individualised and goal-directed approach that considers what motivates the child and aims to minimise or remove barriers appears to result in the greatest increase in feelings of self-competence, overcoming of barriers, and a resultant increase in physical activity participation.

## Practical advice

Treatment for people with disabilities has shifted from disability minimisation to health promotion. What motivates people regardless of their physical ability must be taken into account when attempting to increase PA participation. The development of a treatment plan by a qualified health professional must consider that children are more likely to continue with something if they feel that:
* It is their choice (autonomy)
* They are well supported (relatedness)
* They have the skills and ability to be effectively involved (self competence)
Children with CP display similar behaviours as other children with regard to PA but have different barriers to overcome. The use of MI and goal setting puts the client/patient in control and breaks barriers down (both real and perceived). This should lead to increased feelings of self-competency while greatly assisting with developing habitual involvement in PA.

## Further information/resources

Cerebral palsy alliance: https://cerebralpalsy.org.au
Cerebral palsy guidance: https://www.cerebralpalsyguidance.com/cerebral-palsy/
Information on exercising with cerebral palsy for children: https://exerciseright.com.au/exercise-right-kids-cerebral-palsy/
General information on exercising with cerebral palsy: https://activeability.com.au/exercise-physiology/cerebral-palsy-gait-training-exercise-program/
Self determination theory: https://www.verywellmind.com/what-is-self-determination-theory-2795387
Understanding motivational interviewing: https://motivationalinterviewing.org/understanding-motivational-interviewing
Basic SMART goal information: https://www.active.com/fitness/articles/how-to-set-s-m-a-r-t-goals

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Reedman SE, Boyd RN, Ziviani J, Elliott C, Ware RS, & Sakzewski L. Participation predictors for leisure‐time physical activity intervention in children with cerebral palsy. Developmental Medicine and Child Neurology [online]. 2021 Jan [cited 2021 August 18]; 63(5), 566–575. https://doi.org/10.1111/dmcn.14796
* 1 2 3 4 5 6 7 8 9 10 Reedman SE, Boyd RN, Elliott C, Sakzewski L. ParticiPAte CP: a protocol of a randomised waitlist controlled trial of a motivational and behaviour change therapy intervention to increase physical activity through meaningful participation in children with cerebral palsy. BMJ Open [online]. 2017 [cited 2021 Aug 20];7(8), e015918–e015918. https://doi.org/10.1136/bmjopen-2017-015918
* ↑ Jaarsma EA, Dijkstra PU, Geertzen, JHB, & Dekker, R. Barriers to and facilitators of sports participation for people with physical disabilities: A systematic review. Scandinavian Journal of Medicine & Science in Sports [online]. 2014 [cited Sep 8 2021]; 24(6), 871–881. https://doi.org/10.1111/sms.12218
* ↑ Bedell G, Coster W, Law M, Liljenquist K, Kao Y-C, Teplicky R, Anaby D, & Khetani MA. Community Participation, Supports, and Barriers of School-Age Children With and Without Disabilities. Archives of Physical Medicine and Rehabilitation [online]. 2013 [cited Sep 8 2021]; 94(2), 315–323. https://doi.org/10.1016/j.apmr.2012.09.024
* ↑ Colver A, Thyen U, Arnaud C, Beckung E, Fauconnier J, Marcelli M, McManus V, Michelsen S I, Parkes J, Parkinson K, & Dickinson HO. Association Between Participation in Life Situations of Children With Cerebral Palsy and Their Physical, Social, and Attitudinal Environment: A Cross-Sectional Multicenter European Study. Archives of Physical Medicine and Rehabilitation [online], 2012 [cited Sep 8 2021]; 93(12), 2154–2164. https://doi.org/10.1016/j.apmr.2012.07.011
* ↑ Boyd RN, Davies PS, Ziviani J, Trost S, Barber L, Ware R, Rose S, Whittingham K, Sakzewski L, Bell K, Carty C, Obst S, Benfer K, Reedman S, Edwards P, Kentish M, Copeland L, Weir K, Davenport C, … Scuffham PA. PREDICT-CP: study protocol of implementation of comprehensive surveillance to predict outcomes for school-aged children with cerebral palsy. BMJ Open [online]. 2017 7(7), e014950–e014950. https://doi.org/10.1136/bmjopen-2016-014950
* ↑ Alderazi Y, & Bomprezzi R. Are randomized, blind clinical trials enough to guide individualized decisions for patients with neurologic diseases? Neurology: Clinical Practice [online]. 2014 [cited 2021 Aug 18]; 4. 319-328. https://doi.org/10.1212/CPJ.0000000000000046
* ↑ Maher CA, Williams MT, Olds T, & Lane AE. An internet‐based physical activity intervention for adolescents with cerebral palsy: a randomized controlled trial. Developmental Medicine and Child Neurology [online]. 2010 May [cited 2021 Aug 23]; 52(5), 448–455. https://doi.org/10.1111/j.1469-8749.2009.03609.x