Addressing 24-Hour Activity Behaviours of Children With Cerebral Palsy

We all know the importance of the 24 hour postural management programme to promote a child’s functional development and improve or maintain body shape. Key elements of the programme include lying, sitting and standing, and incorporating these core positions into a child’s daily activities. With this in mind, it was disheartening to read, in a recent paper from by Hulst and colleagues¹that 0% of children with Cerebral Palsy (CP) at GMFCS Level III are reaching all the recommended guidelines for activity or sleep.

The recent study was undertaken to assess the 24-hour activity behaviours of ambulatory children (GMFCS Levels I-III), aged 3-12 years, measuring their daily activity and sleep levels using an accelerometer. The results showed high levels of physical inactivity among children with CP, with decreasing amounts of activity linked to increasing GMFCS level and only 5.9% of children across GMFCS Levels I-III meeting the recommended guidelines.

Furthermore, whilst the study focused on GMFCS Levels I-III, the results suggest that figures would have been even lower for children with GMFCS Levels IV and V. All of this evidence is consistent with other recent studies, and further emphasises the importance of 24 hour postural management for children with cerebral palsy; but the question remains, how can we increase awareness of this and support therapists, parents and carers of children with cerebral palsy to help them work towards these goals?

Moderate-to-Vigorous Physical Activity

In this study, the vast majority of children did not meet the guidelines of 60 minutes of moderate-to-vigorous physical activity (MVPA) for children, with only 13% of children with cerebral palsy meeting this target.

Whilst research suggests that MVPA recommendations are often not met across all paediatric populations, including -children who are typically developing, the consequences of this target not being met may be even more detrimental for children and young people with CP, such as loss of ambulatory skills in adulthood, and complications such as pain, fatigue, loss of strength, balance and reduced physical fitness².

With this in mind, the study suggests that there is an increased need to create opportunities for children with CP to become active, which is where supportive equipment can assist children at the more complex end of the GMFCS scale meet the guidelines. For example, walking frames or gait trainers, can provide children with opportunities for interaction and activity; and the MyWay Pedal, an elliptical attachment for the MyWay frame, further improves strength and functional activity, whilst giving children the opportunity to get active and have fun.

Light Physical Activity

Another point made from this study was the suggestion that, for many children with high levels of inactivity, it may be a more achievable starting point to consider breaking up sedentary time with light physical activity (LPA), rather than immediately increasing time spent engaging in higher intensity physical activities.

Disappointingly the study found that pre-school children engaged in significantly more LPA than school-aged children, at the expense of sedentary behaviour. However, it is worth remembering that light activity includes time spent in a standing frame or transferring into or out of a seating system, which are achievable targets within the school day, and small differences in routine such as these will have a positive effect on the 24 hour activity of children with more complexities.

Sleep

As expected, the findings of the sleep segment of the study were similar to those of daily activity, with almost two-thirds (64.7%) of children at GMFCS Levels I-III not meeting the age-appropriate recommendations for sleep, which is much lower than that of typically developing children.

Sleep is an essential component of any person’s life. Surprisingly limited concrete evidence supports the function of sleep; however, it is generally accepted that our bodies require long periods of sleep to restore and rejuvenate, grow and repair muscle and tissue and synthesise hormones. Without sleep a person’s cognitive and physical function will worsen, and sleep deprivation is linked to irritability and serious life-threatening medical conditions³.

A supportive sleep system has the potential to increase this percentage, by supporting children in a symmetric posture whilst asleep. By reducing the build-up of pressure points, a sleep system increases comfort and the likelihood of an undisturbed night’s sleep.

In summary, we are all aware of the benefits that increased activity and good sleeping patterns can have for children and particularly for the development of children with CP, which places a responsibility on therapists, parents and carers to tackle this challenge.

Whilst this study demonstrates that the majority of children with CP are not meeting the recommendations for physical activity, it does not discuss the barriers that children may face. However, by considering each child individually, tailoring their activities to their needs and being more inventive and creative with the methods of increasing activity, we can support children to achieve more and work towards these targets.

References:

1. Hulst, R. Y., Gorter, J. W., Obeid, J., Voorman, J. M., van Rijssen, I. M., Gerritsen, A., ... & Verschuren, O. (2022). Accelerometer‐measured physical activity, sedentary behavior, and sleep in children with cerebral palsy and their adherence to the 24‐hour activity guidelines. Developmental Medicine & Child Neurology.
2. Turk, M. A. (2009). Health, mortality, and wellness issues in adults with cerebral palsy. Developmental Medicine & Child Neurology, 51, 24-29.
3. Vyazovskiy, V. V. (2015). Sleep, recovery, and metaregulation: explaining the benefits of sleep. Nature and science of sleep, 7, 171.