Move it to improve it: using a web-based therapy program to increase physical activity in independently ambulant children and adolescents with unilateral cerebral palsy

Abstract

Background: Cerebral palsy (CP) is defined as a group of disorders of the development of movement and posture, causing activity limitations. Despite the known benefits of engaging in regular physical activity, children with cerebral palsy (CP) are less physically active than their typically developing peers. Active video games are gaining attention as a means of increasing physical activity in children with CP. ‘Move it to improve it’ or Mitii™ is a novel web-based multi-modal training program comprising upper-limb and visual perceptual training within the context of physical activity which uses virtual therapists to deliver an individualised therapy program. Should Mitii™ be effective in increasing physical activity it has the potential to reduce secondary health complications associated with physical inactivity.Aim: The primary aim of this doctoral program was to test the efficacy of Mitii™ to increase physical activity capacity and performance in independently ambulant children and adolescents with unilateral CP. Additional aims were to: i) determine the efficacy of virtual reality technologies to increase physical activity; ii) determine the clinimetric properties of measures of habitual physical activity; and iii) describe patterns of physical activity and characteristics associated with physical activity, in independently ambulant children and adolescents with CP.Research design and methodology: A matched pairs, waitlist controlled randomised trial was chosen to assess Mitii™ in independently ambulant children and adolescents aged eight to 17 years with unilateral CP. Participants (n=102) were allocated to receive 20 weeks of 6 days per week Mitii™ training (potential total dose 60 hours) immediately, or waitlisted receiving usual care. Outcomes were assessed at baseline and post-intervention (20 weeks). Physical activity capacity was recorded using functional strength (a series of maximal repetition exercises) and walking endurance (six-minute walk test); physical activity performance was recorded using ActiGraph® tri-axial accelerometers. Secondaryoutcomes were mobility limitations (Mobility Questionnaire 28) and recreational participation (recreation domain of the Assessment of Life Habits).Results: Two systematic reviews were performed prior to commencement of the randomised trial. The first investigated the effect of virtual reality interventions to increase physical activity in children with CP. Included studies were of low methodological quality meaning few conclusions were able to be drawn, though there appeared to be a positive effect of virtual reality training. The second described the clinimetric properties of measures of physical activity in primary school aged children with CP. Accelerometers were found to be the most valid and clinically useful tool to measure physical activity however, evidence for their reliability in children with CP was lacking. This led to a study examining the reliability of measuring physical activity in children with unilateral CP using accelerometers. Conclusions reached from this study were that three days of monitoring was required to produce reliable estimates (>0.7) of moderate to vigorous physical activity (MVPA) and agreement between repeated measures was good for light and MVPA (intraclass correlation coefficient [ICC]=0.80). In combination with the systematic review, this study confirmed that accelerometers would be used to objectively measure physical activity performance over four days in the Mitii™ randomised trial.Analysis of cross sectional data collected during baseline assessments for the randomised trial found that independently ambulant children with unilateral CP performed insufficient MVPA to meet national recommendations of 60 minutes daily, recording on average 0:44hrs per day. Characteristics associated with physical activity performance were age and sex, with younger children and males recording more physical activity than adolescents and females. Increased walking endurance and the frequency of participation in home and community environments (measured using the Participation and Environment Measure for Children and Youth) were significantly associated with increased physical activity. These findings suggest that physical inactivity is a problem in children with unilateral CP and that an intervention targeting an increase in physical activity capacity and/or participation could result in improved levels of physical activity.The randomised trial found a significant difference favouring the intervention group at 20 weeks on assessment of functional strength and walking endurance, but not physical activity performance, recreational participation or mobility limitations. The response for walking endurance was dose dependent, indicating a positive training effect.Conclusions: Delivering training using the web-based program Mitii™ and virtual trainers was effective at increasing physical activity capacity assessed using functional strength and walking endurance in independently ambulant children with unilateral CP. Improvements in physical activity capacity did not translate into improvements in physical activity performance or reduce inactivity. This reinforces the view that physical activity capacity and performance represent separate constructs requiring different treatment approaches. Mitii™ may have a role in increasing physical activity in children with CP; however may need to be considered in the context of multi-dimensional interventions which incorporate behavioural change strategies to overcome the barriers associated with participating in increased physical activity.