The American Physical Therapy Association (APTA) Section on Pediatrics convened a task force to describe the scope of pediatric physical therapy (PT) practice in health promotion and fitness in youth with disabilities. The task force produced a fact sheet to guide the clinician and clinical researcher in designing, implementing, and evaluating outcomes of health promotion and fitness interventions, including community-based fitness programs.1 The primary purpose of this report is to expand on the fact sheet and to provide more evidence on health promotion and fitness strategies used in PT management of youth with disabilities. The following concepts are included in this article: (1) a rationale for incorporating health promotion and fitness strategies into PT practice, (2) specific health promotion and fitness outcomes and interventions for physical therapists to use for youth with disabilities, (3) physical therapist roles in adapted sports and other active recreation programs in community settings, and (4) reimbursement considerations.
DEFINING HEALTH PROMOTION AND FITNESS
To promote health and fitness in youth with disabilities, a therapist must address health behaviors (ie, physical activity [PA], exercise) and preferences (ie, swimming, dancing) for each child. Therapists have the opportunity to integrate promotion of healthy behaviors into the child's and family's therapy goals that can maximize the initiation and sustainability of healthy lifestyle changes.
Health promotion is defined as “the art and science of discovering synergies between core passions and optimal health, enhancing motivation to strive for optimal health, and supporting change in lifestyles to move toward a state of optimal health.”2(piv) Optimal health is a “dynamic balance of physical, emotional, social, spiritual and intellectual health.”2(piv) Health promotion includes health education, decision making, and supportive activities such as screening, self-care for individuals with disabilities, advocating for environmental change for positive health behaviors and choices, and supportive policies in work and community settings.3
The accepted definition of PA is “any bodily movement produced by skeletal muscles that result [sic] in energy expenditure” while exercise is “a subset of physical activity that is planned, structured, and repetitive and has as a final or intermediate objective of improvement or maintenance of physical fitness.”4(p126) Physical fitness is defined as “a set of attributes that are either health- or skill-related. The degree to which people have these attributes can be measured with specific tests.”4(p128) Health-related fitness is measured through body composition, cardiorespiratory endurance, flexibility, muscular endurance, and muscle strength, whereas skill-related fitness includes agility, balance, coordination, power, speed, and reaction time.5 In addition, physiological fitness includes non–performance-based metabolic and morphologic fitness and bone health.5 For additional information on fitness guidelines for children and adolescents, refer to the publication by the APTA Section on Pediatrics Taskforce on Fitness titled “Health-Related Fitness in Children and Adolescents.”6
RATIONALE FOR INCORPORATING HEALTH PROMOTION AND FITNESS STRATEGIES INTO PEDIATRIC PHYSICAL THERAPY
Concern is growing about unhealthy behaviors in youth including decreased PA levels, increased sedentary behaviors, increased consumption of calorie-dense foods, and increased prevalence of unhealthy weight among youth with and without disabilities. Decreased levels of PA and increased sedentary behaviors because of limited or inaccessible exercise options disproportionately affect youth with disabilities. Because of the high rates of physical inactivity, youth with disabilities are also more likely to be obese than peers with typical development (TD).7–9 As a result of physical inactivity and obesity, youth with disabilities may have a higher risk for associated comorbidities. Thus, this is a “call to action” for pediatric physical therapists to incorporate evidence-based health promotion and fitness strategies into patient/client management. Although evidence on long-term fitness interventions is not available, current evidence indicates that short-term fitness interventions for youth with disabilities are effective in promoting health and improving physical fitness and functional mobility.10–16
Physical therapy interventions emphasize increased participation, functional mobility and activity levels, and prevention or reduction of impairments of body structure and function. The ultimate goal is to achieve optimal functional mobility and participation. Physical therapy scope of practice is defined by the Guide to Physical Therapist Practice in terms of rehabilitation (restoration of function), prevention (prevent a decline in function or the development of secondary conditions), and health promotion (to improve function, fitness, and PA).17
GENERAL CONSIDERATIONS FOR HEALTH PROMOTION
Pediatric physical therapists often use health promotion strategies in patient management. These strategies may include health education, behavioral strategies, and goal setting to promote and support healthy choices and habits, and patient/client instruction to promote fitness and PA. To promote healthy changes and fitness in youth with disabilities, the physical therapist may employ some theories of health behavior change to determine the youth and family's “readiness to change.” The Stage of Change Model18–21 proposes that change occurs in incremental stages: (1) Precontemplation: The youth and family may not think that PA or fitness is important for youth with disabilities, and this can provide an opportunity for the therapist to give educational information to promote change; (2) Contemplation: The youth and family think that it may be important to start a PA or fitness program and the therapist can help identify actions to lead them in that direction; (3) Preparation: The youth and family may be “getting ready” to start a fitness program so the therapist might provide information about specific resources such as an adapted exercise class or active recreation activities within the community to support the plan to become more active; (4) Action: The youth and family have initiated participation in the “targeted health behavior” for less than 6 months so the therapist helps support and promote the behavior (ie, fitness) by designing interventions to increase frequency, duration, and intensity of the activities in clinical, community, or home settings; and (5) Maintenance: The youth and family participate in the “target behavior” on a long-term regular basis so that this is one of their “typical behaviors.” The therapist may take on a consulting or monitoring role to progress the program as goals are achieved and patients and families become more committed to the healthy change.
Some health education strategies that may be part of a health promotion program may include educating youth with disabilities and their families about expected responses to exercise and ways of increasing intensity to promote higher levels of fitness. Behavioral strategies and supports in health promotion programs may include identifying youth and family preferences and routines so the therapist can recommend activities that meet the family's needs. See Table 1 for health promotion strategies and recommendations for pediatric physical therapists to promote healthy, active lifestyles for youth with disabilities and their families.22
PT EXAMINATION AND EVALUATION: FOCUS ON HEALTH PROMOTION AND FITNESS
Physical therapists may include health promotion and fitness strategies in the PT examination. Health promotion examination techniques include interviews incorporating readiness to change, preferences and routines, and current fitness, PA, and participation levels to inform the examination findings and intervention design. For example, a parent of a youth with cerebral palsy (CP) classified as GMFCS level I may seek PT because the parent observes that the youth is not participating in playground activities for the same duration as his or her peers and spends more time in sedentary activities. The parent may have concerns that the youth has limited endurance and may need specific interventions. A systems review to identify specific limitations (ie, muscular and/or cardiovascular endurance) determines whether a full PT examination is warranted.17
The pediatric physical therapist may conduct specific tests and measures as part of a comprehensive examination that may include components of health-related or skill-based fitness such as functional strength testing to identify muscular endurance problems (sit-to-stand, lateral step ups, and half-kneel-to-stand)23 or functional aerobic capacity tests to determine aerobic endurance in children at GMFCS levels I, II or III (ie, the Shuttle Run Test I, II, or III).24–26 Skill-based fitness measures may be used to identify balance or power impairments (ie, Muscle Power Sprint Test, 10 × 5 Meter Sprint Test, or the Pediatric Berg Balance Test).27–30 Also, therapists may gather information about environmental factors and community resources to provide the family with opportunities for their youth to increase activity, fitness, and participation. Findings from such an examination session will inform intervention and home program design and potential referral to community-based programs. Table 2 provides a list of measures to consider when examining fitness status and outcome effectiveness.
The therapist's evaluation is based on sound clinical judgment and interpretation of all examination findings (history, systems review, test, and measures) to determine a prognosis, diagnosis, and plan of care. The therapist considers each personal level of the International Classification of Functioning, Disability and Health Model for Children and Youth31 (participation restrictions, activity limitations, and body function and structure impairments) and the contextual factors (personal/social and environmental) that may affect health and fitness. The therapist provides therapy services to achieve goals identified by the youth and family that are compatible with the youth's abilities. Once therapy goals have been achieved, the Guide recommends that physical therapists refer patients to other health practitioners (ie, community fitness staff) for continued health promotion, fitness, and wellness activities or programs as appropriate.17
Fitness Interventions for Youth With Disabilities
When designing a fitness intervention, therapists should incorporate recommendations from the 2008 Physical Activity Guidelines for Americans.32 The guidelines recommend that youth participate in a minimum of 60 minutes of moderate to vigorous PA (MVPA) each day. Physical activity should include 3 types of activity: (1) aerobic, (2) muscle strengthening, and (3) bone-strengthening. Vigorous aerobic exercise, muscle-strengthening, and bone-strengthening exercises should be performed at least 3 days per week. These guidelines can be incorporated into PT interventions or community-based programs for youth with disabilities. Although not a formal recommendation, individuals may achieve 60 minutes of MVPA in 10- to 15-minute bouts of activity throughout the day.
Chronological and developmental ages are important considerations when designing a conditioning program (strength or aerobic conditioning) for children and youth. Younger children tend to exercise in short bouts of up to 10 minutes, and older children and adolescents often can exercise for longer periods, depending on their interest and general level of fitness. For older children and adolescents with disabilities who are generally active but new to exercise programs, consider starting the program at 20 minutes and increasing to 40 to 60 minutes per session as tolerated over time.5,32,33
Youth with disabilities often have activity limitations and participation restrictions, which influence their ability to participate in physical activities. Therefore, it is important to design a program that will challenge them but still allow for incremental increase in time and intensity to promote fitness. Frequency, intensity, type, time, and enjoyment (FITTE) principles are important considerations when designing fitness programs.5
For the type of exercise, consider introducing land or aquatic exercise programs on the basis of the youth's disability, conditioning level, precautions, and preference.11,14,34–37 Importantly, the youth should enjoy the intervention design or he or she will not participate in the activities or continue them over time. Including age-appropriate activities, props, games, music, and movement that the youth enjoys will motivate and encourage participation.32
The following sections of this report provide the pediatric physical therapist with rationale and evidence to support fitness interventions that may focus on various components of health-related fitness (strength, aerobic endurance, flexibility, and body composition), performance-based fitness (anaerobic fitness), and bone health. These fitness components were chosen because evidence suggests that these are key factors to include in interventions to promote PA and fitness in youth with disabilities.
Strength Training for Youth With Disabilities
Muscle weakness is a common problem that negatively affects functional mobility in youth with physical and developmental disabilities. Lower extremity muscle strength is correlated to functional mobility in youth with CP,38–40 Down syndrome (DS),41 Duchenne muscular dystrophy (DMD),42 and spina bifida (SB).43 Muscle strengthening programs are important for improving functional mobility and muscular endurance in youth with disabilities. Well-designed and supervised strength training programs are generally safe and effective in increasing strength in youth with disabilities. These programs may include formal progressive resistive exercise (PRE) or functional strength programs such as described in the Brockport Physical Fitness Training Guide.44
The decision on “type” of strength training program is important to motivate the youth to participate. Progressive resistive exercise may be more appealing to youth who are older and more “competitive” as they work to continue to increase the number of repetitions, sets, and weight. These dimensions of PRE (reps, sets, and weights) provide measures for therapists to determine progress. Determining 1 repetition maximum (1 RM) weight as a starting point for the weight in the PRE program requires a systematic approach and has been described elsewhere.45–47
Although health care professionals have discussed the effectiveness of strength training for youth with CP, the overall consensus is that strength training is an effective intervention to promote strength and function. However, evidence is limited regarding optimal dosage (FITTE) in strength training protocols to increase functional strength and endurance and to improve functional mobility.48–52 Therefore, existing evidence and clinical expertise must be used in designing fitness programs and measuring outcome effectiveness. Table 3 provides information about strength training for 5 conditions commonly treated by pediatric physical therapists: CP, DS, SB, DMD, and autism.
Aerobic Fitness for Youth With Disabilities
Youth with disabilities can safely participate in aerobic exercise, but they may require exercise adaptations, adapted equipment, or assistance.35 Improvements in aerobic capacity and functional endurance have been reported for youth with disabilities after aerobic training interventions with sufficient intensity and duration.37,53–55 Aerobic exercise can be conducted in individual or group sessions and may include various activities such as walking, running, swimming, or propelling a wheelchair. Equipment used in aerobic conditioning may include gym equipment (treadmill, elliptical, rowing, or other exercise machines), sports equipment, playground games, or therapeutic exercises.
Because school-aged children and youth with and without disabilities spend 6 or more hours per day in their school setting, it is recommended that school physical education (PE) classes include structured aerobic exercise for 150 to 225 minutes per week, depending on the youth's age and grade.56 The type and intensity of PE activities may vary on the basis of the youth's disability or level of conditioning, but the recommended amount of structured exercise in PE classes is meant for all youth. Strategies to increase intensity of aerobic activities will depend on the youth's disability, conditioning level, and any cardiorespiratory or musculoskeletal precautions. Screening for any cardiac or pulmonary conditions is important, as is the revision of programs when indicated. Physical therapists working in the school setting may provide consultation to teachers and other school staff on ways to assist children with disabilities in safely achieving optimal PA levels during PE classes and during recess or active play opportunities.
Exercise intensity is an important component of aerobic exercise. Heart rate (HR) and perceived exertion are common methods used in clinical and community settings to monitor exercise intensity. General guidelines indicate that deconditioned youth who cannot sustain a movement activity for more than 10 minutes should work at an exercise intensity of 40% to 60% peak oxygen consumption or 55% to 65% maximum HR or perceived exertion of 5 to 6 on the Children's OMNI Scale of Perceived Exertion (OMNI Scale),57 Children's Effort Rating Table (PCERT),58 or Perceived Exertion Index with Faces (PEIF).59 The time in fitness sessions should be gradually increased and the number of days per week gradually increased from 2 to 4 or more days per week.5
For youth who can exercise for 10 minutes or longer, an exercise intensity of 50% to 85% peak oxygen consumption or 60% to 90% maximum HR or perceived exertion on the OMNI Scale/PCERT/PEIF of 6 to 9 can provide health benefits.5,60 Estimating peak HR using 220 minus age is not recommended for young children or youth with disabilities.61–64 Ideally, maximum and target HR values should be determined using an aerobic capacity test. The reference standard for determining aerobic capacity is an incremental exercise test (often on a treadmill or stationary bicycle) conducted in the laboratory with peak oxygen consumption and peak HR recorded. Field-based incremental exercise tests have also been developed to estimate peak oxygen consumption and to determine maximum HR. The Progressive Aerobic Cardiovascular Endurance Run (PACER) or shuttle-run tests have been developed specifically for youth without disabilities, youth with intellectual disabilities, visual impairments, or other disabilities with mild physical impairments,65,66 and youth with CP24–26 and SB.67
The OMNI Scale, PCERT, or PIEF can be used to dose and monitor exercise intensity. Perceived exertion scales have been validated for use with youth without disabilities.57–59,68–71 However, we are aware of only 2 studies to date, which validated the use of these scales for youth with CP who were ambulatory72 or who were wheelchair users.73 In our experience, most youth with disabilities require training to use a perceived exertion scale with accompanying information on their HR levels to ensure valid ratings of exertion to gauge exercise intensity.
Anaerobic Fitness for Youth With Disabilities
Anaerobic exercise is exercise of short duration and high intensity lasting from a few seconds up to about 2 minutes.5 The purpose of anaerobic exercise is to build speed and power. Short-term muscle power and agility are correlated (r = 0.7) to walking and gross motor skills in youth with CP. Anaerobic exercise interventions have the potential to improve fitness and function; however, very little evidence is available on the effects of anaerobic exercise for children with disabilities. Only 1 study74 focused specifically on anaerobic exercise for children with CP during the final 4 months of an 8-month exercise program. Participants in the intervention group made significant improvements in anaerobic capacity, agility, and gross motor function following the intervention. Another study75 included plyometric jumps in an exercise program for children and adolescents with DS. An increase in bone mass and lean body mass was found after the 21-week exercise intervention. Further research is needed to determine optimal anaerobic training protocols for improving function in children with disabilities.
By nature, younger children tend to engage in frequent short fast bursts of activity (anaerobic exercise) like running, jumping, or hopping. However, children with physical disabilities often have limitations in performing these types of anaerobic activities. Youth may not tolerate many repetitions of anaerobic exercises because of the intensity of the activity but these exercises are important to improve power. The therapist may modify a running activity to promote speed and agility by having the child participate in an “all-out” effort while running between cones so that a change of direction (agility) is included. Therapists may suggest alternative activities or methods for anaerobic exercise such as cycling, using an adapted tricycle or arm cycle, or using adaptive equipment for active play such as a gait trainer, walker, or wheelchair. For older youth, anaerobic activities may include interval running on a treadmill with or without body weight support, running over ground with or without assistive devices, or pedaling on a stationary leg or arm bicycle or adapted tricycle at various speeds and with varied resistance. Increased exercise capacity, strength, and lung function in people with disabilities resulting from aerobic and anaerobic physical training have been reported, which makes this an important component of exercise programming for this population.12
Therapists may provide instruction and home programs for youth and their families on how to further develop speed, agility, and power for gross motor skills such as running, jumping, and hopping. For some youth with more severe disabilities, these activities may not be appropriate and pediatric physical therapists may assist youth and families with modifying the activities. These modifications could include providing equipment such as a gait trainer or lower extremity orthotics to achieve better alignment. If these modifications are not sufficient, the therapist may also need to provide suggestions for appropriate activities for youth with disabilities.76
Formal anaerobic tests such as the Wingate77 may be appropriate for some youth, but these tests are often very strenuous. Measuring anaerobic fitness is often done by timing the activity and documenting the type of activity, repetitions, and resistance. Formalized anaerobic capacity testing can be done using laboratory- or clinic-based tests.27,28,77–80
Flexibility for Youth With Disabilities
Flexibility is an important component of fitness for youth with disabilities because muscle tightness and the development of contractures are common in this population. In general, dynamic stretching is recommended at the beginning of an exercise session to assist with warming up the muscles and getting ready for more strenuous exercise and static stretching is recommended at the end of an exercise session to increase stretch tolerance.33
For youth without disabilities, static stretching performed several times per week is sufficient to maintain or increase flexibility,6 whereas for youth with disabilities and muscle imbalance, muscle weakness and/or spasticity additional flexibility exercises as well as other interventions may be necessary. For youth with specific conditions (CP, SB, or DMD), equipment to promote prolonged stretch, including night splints, dynamic splinting (eg, UltraflexTM and DynasplintTM), lower extremity orthotics, ankle foot orthoses (AFOs), standers, floor sitters, and abductor chairs, may be recommended to increase or maintain joint and muscle flexibility.81,82
Body Composition for Youth With Disabilities
Body composition is defined as the percentage of body mass comprised of fat and fat-free tissue, or lean body mass. Laboratory or clinic measures are available to measure body composition or to determine weight status/categories.5 Youth with disabilities are at increased risk for obesity (increased body fat) compared to their peers with TD.8,9,83 However, some youth with more severe disabilities may be underweight with decreased body fat due to poor oral-motor function or gastrointestinal or endocrine problems. Therefore, youth with disabilities should be measured for body composition to identify precautions and determine design of a fitness program. Dual-energy x-ray absorptiometry is the reference standard laboratory measure for body composition. However, this equipment is usually available only in medical or research centers due to expense and space needs.6 In clinical settings, skin fold measures may be used to estimate body composition.84,85
Body mass index (BMI) may be used to screen for body composition. Body mass index values do not provide information on percent body fat but do identify if a child is in a healthy or unhealthy weight category on the basis of height and weight. However, therapists should be aware that BMI may incorrectly identify youth as overweight or obese when the youth are fit with high fat-free or lean body mass. In addition, anthropometric measures of waist circumference and height may be documented to determine distribution of fat mass because visceral adiposity is associated with negative health and metabolic outcomes.86
Youth who are underweight (BMI < 5th percentile) may need to be referred to a pediatrician or dietician for a nutrient-rich diet to increase weight so that the child can exercise and improve fitness levels. For youth who are overweight (BMI ≥ 85th percentile) or obese (BMI ≥ 95th percentile), therapists should consider referring the child for medical and dietary consultation for a weight loss or weight maintenance program.87 When using BMI to determine weight category as a proxy for body composition in youth with DS, evidence suggests that the obesity weight category with a cut-point of ≥95th percentile is a better cut-point than the overweight category of 85th-94th percentile in identifying increased body fat in youth with DS.88
Bone Strengthening for Youth With Disabilities
Bone-strengthening activities are important for youth because the greatest gains in bone mass occur during the years just before and during puberty. The 2008 Physical Activity Guidelines for Americans provides recommendations for high-impact exercise (ie, running, jumping rope, basketball, tennis, and hopscotch) as examples of bone-strengthening activities for youth.89
For some youth with disabilities who have good bone health and good bony alignment, high-impact exercises may be safe. For this group of children, focusing on skill-based fitness activities to promote balance, coordination, power, and agility for successful participation in bone-strengthening activities may be important. Therapists may provide instruction and home programs to youth and their families on how to further develop these skills. For youth with more severe disabilities, however, these activities may not be appropriate. In these cases, pediatric physical therapists can assist youth and their families with activity modification by providing equipment such as a gait trainer or lower extremity orthotics to achieve better alignment or by providing suggestions for other more appropriate activities for youth with more severe disabilities.
Youth and adults with developmental disabilities, especially those with limitations in mobility, are at risk for low bone density and fractures.90,91 The majority of research on bone density in individuals with developmental disabilities has focused on youth with CP. Children with CP are at risk for low bone density because of decreased mobility, inadequate nutrition, use of antiseizure medications, low vitamin D levels, and irregularities in skeletal maturation.92,93 Low bone mineral density (BMD) places children with CP at risk for fractures. Children at GMFCS levels I to II tend to be at less risk for fractures than children classified at GMFCS levels III to V. The majority of research on intervention for youth with CP at risk for osteoporosis is focused on vitamin D and calcium supplementation and biphosphonate administration.94 Weight-bearing intervention studies are limited in number and design, and at this time sufficient evidence is not available to inform clinical recommendations on the optimal type, frequency, and duration of a weight-bearing program. Preliminary evidence suggests that weight-bearing using adapted equipment may increase bone density in children with CP who engage in limited ambulation.95–98
Three studies have evaluated the effects of exercise on bone density for youth with disabilities who are ambulatory. Gonzalez-Aguero et al75 studied the effects of a 2 times per week exercise program lasting 21 weeks for youth with DS. In this small, randomized clinical trial (RCT), the intervention group demonstrated an increase in hip and total bone density after participating in a combined resistance training and plyometric exercises program. Hemayattalab99 studied the effects of physical training and calcium intake on BMD in boys aged 7 to 10 years with intellectual disabilities. In this RCT, the intervention was delivered 3 times per week for 6 months. Results indicated that the training group achieved greater BMD than the calcium supplement group. Chen et al100 conducted an RCT to examine the efficacy of home-based virtual cycling training on BMD for youth with CP. Findings suggest that participants in the training group had higher BMD than those in the control group.
PHYSICAL THERAPISTS' ROLES IN ADAPTED SPORTS AND COMMUNITY-BASED PROGRAMS
Daily MVPA is important to elicit health benefits. Youth with TD often participate with their peers in informal modes of PA (eg, climbing on a playground structure, riding a bike, or playing tag or catch) as well as formal modes of PA (eg, taking a gymnastics class or playing on a soccer team). Youth with disabilities tend to get less daily MVPA than their peers without disabilities.76,101–104 Also, they often experience barriers to participation in both formal and informal opportunities for daily active recreation.105 Therapists have an important role in promoting participation in PA for these youth. Barriers to PA participation often involve restrictions in body structure and function (ie, decreased muscle flexibility, strength, and motor control), making it difficult for them to ride a bicycle, run fast enough to keep up with peers in sports, or use playground equipment. Other barriers may be related to the social and physical environment (ie, neighborhood resources, climate, safety, and parent or health provider attitudes).
Depending on the youth's abilities and goals, a therapist might provide PT interventions to improve running speed and endurance, climbing agility, and bicycle-riding skills to achieve participation goals. For some youth, equipment or activity modifications (ie, physical assistance or structuring the activity for safety) may be important. Family members or other caregivers should be instructed on efficient ways to assist youth for optimal participation. Instructing caregivers in the use of good body mechanics to prevent injury when they are participating with their children in active recreation is important. For others, the use of adapted equipment such as walkers, gait trainers, or adapted bicycles might be important to enable youth to participate with peers in PA in their community.
Physical therapists should provide education to youth and families about the importance of daily PA and what specialized programs or other resources are available locally for youth with physical, behavioral, or intellectual challenges. Therapists should be knowledgeable about the medical status of youth in their care and provide guidelines related to orthopedic, cardiac, and respiratory restrictions or refer the family to the appropriate medical professional for further testing or recommendations.
Therapists may also consult with existing community-based programs to suggest program modifications, exercise modifications, exercise progressions, or specialized equipment that will allow the youth to optimally and safely participate.35,106–108 Some youth may require program adaptation (more time to complete an activity or a creative way to complete an activity such as moving the target lower, using a lighter ball, or raising a surface to get objects for a relay race) to participate in sports and active recreation with their peers. Others may require specialized equipment such as an ice-skating walker or ice sled to participate in the activity. Overall program modifications should minimize barriers and maximize participation in specialized sports and active recreation programs as well as promote inclusive programs.
Health promotion and fitness interventions may be indicated to achieve and maintain PT goals. Reimbursement for interventions and the number of billable sessions to achieve these identified goals will differ depending on the youth's medical diagnosis, the family's health care plan, proof of medical necessity, the PT setting (clinic, school, and early intervention), and achievement or maintenance of the goals. The extent of the intervention and the episodes of care will differ according to the youth's and family's needs. Health promotion strategies are more aligned with education and communication interventions, whereas fitness strategies are more likely to be delivered in procedural or direct intervention sessions. It is important for the pediatric physical therapist to determine if a billable PT International Classification of Diseases, Ninth Revision (ICD-9) medical reference code related to the body structure and function impairment or activity limitation is available to submit for health insurance coverage.
Pediatric physical therapists have an important role in developing, implementing, and providing support to sustain participation in health promotion and fitness programs for youth with disabilities. As professionals, physical therapists have expertise in key areas that are essential in the creation, implementation, and evaluation of these programs. This report is a supplement to the APTA Section on Pediatrics Task Force on Health Promotion, Fitness and Wellness Fact Sheet,1 which was produced as a guide for physical therapists who may want information on methods to incorporate health promotion and fitness strategies into practice. This report and the Fact Sheet are resources for clinicians and clinical researchers to promote active recreation and fitness for the children, youth, and families they serve.
The need to address health and fitness in youth with disabilities is urgent, because barriers that make it difficult to achieve the recommended levels of daily PA often disproportionately affect youth with disabilities. To address these barriers, pediatric physical therapists must assess individual needs and design accessible programs to promote participation in daily PA. Specifically, for youth with disabilities within school settings, this may mean providing consultation to youth and school staff information on strategies and modifications to make recess and PE classes accessible and active. Also, it may include assessing and providing information on adaptations to make community activities accessible to families and youth with disabilities. This report provides evidence-based information on physical fitness tests and measures and PA and exercise interventions for children and youth with disabilities. This information can serve as a basis for pediatric physical therapists to assess, implement, and evaluate programs within their intervention sessions or to promote healthy, active recreation for the children and their families in their homes or communities.
This report provides recommendations for future research that could guide dosage for interventions for children with specific conditions, diagnoses, and goals. More evidence is needed to evaluate the effectiveness of fitness training interventions for youth with disabilities in promoting strength, aerobic capacity, and functional mobility. Research on the effect of fitness interventions on overall health indicators is critical for this population. Very little research is available on fitness training protocols for youth with progressive neuromuscular disorders that address maintenance of function and prevention of functional decline. Further research is also needed to examine the validity of PA tests and measures for youth with different types of mobility disorders, especially those with severe impairments.
The APTA's Section on Pediatrics has demonstrated commitment to providing information to pediatric physical therapists through mechanisms such as Task Force Fact Sheets,1 on key topics such as health promotion, fitness, and obesity in youth with and without disabilities,6 and numerous articles on health promotion and fitness in Pediatric Physical Therapy. In a recent editorial, the importance of health promotion and the role of pediatric physical therapists were highlighted.109 The APTA's Section on Pediatrics has also sponsored 3 research summits over the past 8 years. These Research Summits (RS I—Promotion of Fitness and Prevention of Secondary Complications for Children with Cerebral Palsy110; RS II—Early Intervention for Children with or At Risk for Physical Disabilities; and RS III—Dosing of Interventions for Children with an Injured Brain) have also addressed the topics of health promotion and dosing of exercise interventions (including FITTE principles) for youth with disabilities.111
The need is critical for youth with disabilities to participate in health promotion and fitness programs to develop active, healthy lifestyles into adulthood. Pediatric physical therapists must take a leadership role and advocate for these programs for the youth and families they serve.
1. O'Neil M, Fragala-Pinkham M, Miles C, Rowland J; Health Promotion Fitness and Wellness Work Groups. American Physical Therapy Association, Section on Pediatrics Fact Sheet: The Role and Scope of Pediatric Physical Therapy in Fitness, Wellness, and Health Promotion, and Prevention. Section on Pediatrics, American Physical Therapy Association, Alexandria, VA: 2012.
2. O'Donnell M. Definition of health promotion 2.0: embracing passion, enhancing motivation, recognizing dynamic balance, and creating opportunities. Am J Health Promot. 2009;24(1):iv.
3. Edelman C, Mandle C, eds. Health Promotion Throughout the Lifespan. 6th ed. St Louis, MO: Mosby; 2006.
4. Caperson C, Powell K, Christenson G. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100(2):126–131.
5. American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
6. Ganley K, Paterno M, Miles C, et al. Health-related fitness in children and adolescents. Pediatr Phy Ther. 2011;23:208–220.
7. Rimmer J, Rowland J, Yamaki K. Obesity and secondary conditions in adolescents with disabilities: addressing the needs of an underserved population. J Adolesc Health. 2007;41(3):224–229.
8. Bandini L, Curtin C, Hamad C, Tybor D, Must A. Prevalence of overweight children with developmental disorders in the National Health and Nutrition Examination Survey (NHANES) 1999-2002. J Pediatr. 2005;146(6):738–743.
9. Curtin C, Anderson S, Must A, Bandini L. The prevalence of obesity in children with autism: a secondary data analysis using nationally representative data from the National Survey of Children's Health. BMC Pediatr. 2010;10:1–5.
10. Damiano D. Activity, activity, activity: rethinking our physical therapy approach to cerebral palsy. Phys Ther. 2006;86:1534–1540.
11. Van Brussel M, van der Net J, Hulzebos E, Helders P, Takken T. The Ultrecht approach to exercise in chronic childhood conditions: the decade in review. Pediatr Phy Ther. 2011;23:2–14.
12. Morris P. Physical activity recommendations for children and adolescents with chronic disease. Cur Sports Med Rep. 2008;7(6):353–358.
13. Johnson C. The benefits of physical activity for youth with developmental disabilities: a systematic review. Am J Health Promot. 2009;23(3):157–167.
14. Sowa M, Meulenbroek R. Effects of physical exercise on autism spectrum disorders: a meta-analysis. Res Autism Spect Disord. 2012;6:46–57.
15. González-Agüero A, Vicente-Rodríguez G, Moreno L, Guerra-Balic M, Ara I, Casajús J. Health-related physical fitness in children and adolescents with Down syndrome and response to training. Scand J Med Sci Sports. 2010;20(5):716–724.
16. Short K, Frimberger D. A review of the potential for cardiometabolic dysfunction in youth with spina bifida and the role for physical activity and structured exercise [published online ahead of print June 14, 2012]. Int J Pediatr. 2012;2012:541363.
17. American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. American Physical Therapy Association; 2014. http://guidetoptpractice.apta.org/
. Accessed October 8, 2014.
18. Verschuren O, Wiart L, Ketelaar M. Stages of change in physical activity behavior in children and adolescents with cerebral palsy. Disabil Rehabil. 2013;35(19):1630–1635.
19. Rhee K, De Lago C, Arscott-Mills T, Mehta S, Davis R. Factors associated with parental readiness to make changes for overweight children. Pediatr Clin North Am. 2005;116:e94–e101.
20. Prochaska J, Redding C, Evers K. Health behavior and health education: theory, research, and practice. In: Glanz K, Lewis F, Rimer B, eds. The Transtheoretical Model and Stages of Change. 2nd ed. San Francisco, CA: Jossey-Bass; 1997:60–84.
21. Hutchinson A, Breckon J, Johnston L. Physical activity behavior change interventions based on the transtheoretical model: a systematic review. Health Educ Behav. 2009;36:829–845.
22. Bernstein H, ed. Pediatrics in Practice: A Health Promotion Curriculum for Child Health Professionals. New York, NY: Springer Publishing Co; 2005.
23. Verschuren O, Ketelaar M, Takken T, Van Brussel M, Helders P, Gorter J. Reliability of hand-held dynamometry and functional strength tests for the lower extremity in children with cerebral palsy. Dis Rehabil. 2008;30(18):1358–1366.
24. Verschuren O, Bloemen M, Kruitwagen C, Takken T. Reference values for aerobic fitness in children, adolescents, and young adults who have cerebral palsy and are ambulatory. Phys Ther. 2010;90(8):1148–1156.
25. Verschuren O, Bosma L, Takken T. Reliability of a shuttle run test for children with cerebral palsy who are classified at Gross Motor Function Classification System Level III. Dev Med Child Neurol. 2011;53(5):470–472.
26. Verschuren O, Takken T, Ketelaar M. Reliability and validity of data for 2 newly developed shuttle run tests in children with cerebral palsy. Phys Ther. 2006;86(8):1107–1117.
27. Verschuren O, Takken T, Ketelaar M, Gorter J, Helders P. Reliability for running tests for measuring agility and anaerobic muscle power in children and adolescents with cerebral palsy. Pediatr Phy Ther. 2007;19(2):108–115.
28. de Groot S, Janssen T, Evers M, van der Luijt P, Nienhuys K, Dallmeijer A. Feasibility and reliability of measuring strength, sprint power, and aerobic capacity in athletes and non-athletes with cerebral palsy. Dev Med Child Neurol. 2012;54:647–653.
29. Franjoine M, Gunther J, Taylor M. Pediatric Balance Scale: a modified version of the Berg Balance Scale for the school-age child with mild to moderate motor impairment. Pediatr Phys Ther. 2003;15(2):114–128.
30. Kembhavi G, Darrah J, Magill-Evans J, Loomis J. Using the Berg Balance Scale to distinguish balance abilities in children with cerebral palsy. Pediatr Phys Ther. 2002;14(2):92–99.
31. World Health Organization. ICF: International Classification of Functioning, Disability and Health. Geneva, Switzerland: World Health Organization; 2001.
32. US Department of Health and Human Services. Physical Activity Guidelines for Americans. http://www.health.gov/Paguidelines/guidelines/Chapter3.aspx
. Published October 16, 2008. Accessed January 16, 2013.
33. Faigenbaum A, Kraemer W, Blimkie C, et al. Youth resistance training: updated position statement paper from the National Strength and Conditioning Association. J Strength Cond Res. 2009;23(suppl 5):S60–S79.
34. Fragala-Pinkham M, Haley S, Rabin J, Kharasch V. Case report: a fitness program for children with disabilities. Phys Ther. 2005;85(11):1182–1200.
35. Fragala-Pinkham M, Haley S, Goodgold S. Evaluation of a community-based group fitness program for children with disabilities. Pediatr Phys Ther. 2006;18(2):159–167.
36. Gorter J, Currie S. Aquatic exercise programs for children and adolescents with cerebral palsy: what do we know and where do we go from here? Int J Pediatr. 2011;2011:712165.
37. Rogers A, Furler B, Brinks S, Darrah J. A systematic review of the effectiveness of aerobic exercise interventions for children with cerebral palsy: an AACPDM evidence report. Dev Med Child Neurol. 2008;50(11):808–814.
38. Kramer J, MacPhail H. Relationships among measures of walking efficiency, gross motor ability, and isokinetic strength in adolescents with cerebral palsy. Pediatr Phys Ther. 1994;6:3–8.
39. Ross S, Engsberg J. Relationships between spasticity, strength, gait, and the GMFM-66 in persons with spastic diplegia cerebral palsy. Arch Phys Med Rehabil. 2007;88(9):1114–1120.
40. Hong W, Chen H, Shen I, Chen C, Chen C, Chung C. Knee muscle strength at varying angular velocities and associations with gross motor function in ambulatory children with cerebral palsy. Res Dev Disabil. 2012;33(6):2308–2316.
41. Cowley P, Ploutz-Snyder L, Baynard T, et al. Physical fitness predicts functional tasks in individuals with Down syndrome. Med Sci Sports Exerc. 2010;42(2):388–393.
42. Scott O, Hyde S, Goddard C, Dubowitz V. Quantitation of muscle function in children: a prospective study in Duchenne muscular dystrophy. Muscle Nerve. 1982;5:291–301.
43. Schoenmakers M, de Groot J, Gorter J, Hillaert J, Helders P, Takken T. Muscle strength, aerobic capacity and physical activity in independent ambulating children with lumbosacral spina bifida. Disabil Rehabil. 2009;31(4):259–266.
44. Winnick J, Short F. The Brockport Physical Fitness Training Guide. Champaign, IL: Human Kinetics Publishers Inc; 1999.
45. Faigenbaum A, Westcott W, Long C, LaRosa Loud R, Delmonico M, Micheli L. Relationship between repetitions and selected percentages of the one repetition maximum in healthy children. Pediatr Phys Ther. 1998;10:110–113.
46. Faigenbaum A, Westcott W. Youth Strength Training. Champaign, IL: Human Kinetics; 2009.
47. Faigenbaum A, Milliken L, Westcott W. Maximal strength testing in healthy children. J Strength Cond Res. 2003;17(1):162–166.
48. Mockford M, Caulton J. Systematic review of progressive strength training in children and adolescents with cerebral palsy who are ambulatory. Pediatr Phys Ther. 2008;20(4):318–333.
49. Scianni A, Butler J, Ada L, Teixeira-Salmela L. Muscle strengthening is not effective in children and adolescents with cerebral palsy: a systematic review. Aus J Physio. 2009;55(2):81–87.
50. Taylor N. Is progressive resistive exercise ineffective in increasing muscle strength in young children with cerebral palsy? Aus J Physio. 2009;55:222.
51. Verschuren O, Ada L, Maltais D, Gorter J, Scianni A, Ketelaar M. Muscle strengthening in children and adolescents with spastic cerebral palsy: considerations for future resistance training protocols. Phys Ther. 2011;91(7):1130–1139.
52. Franki I, Desloovere K, De Cat J, et al. The evidence-base for basic physical therapy techniques targeting lower limb function in children with cerebral palsy: a systematic review using the International Classification of Functioning, Disability and Health as a conceptual framework. J Rehabil Med. 2012;44(5):385–395.
53. de Groot J, Takken T, van Brussel M, et al. Randomized controlled study of home-based treadmill training for ambulatory children with spina bifida. Neurorehabil Neural Repair. 2011;25(7):597–606.
54. Verschuren O, Ketelaar M, Takken T, Helders P, Gorter J. Exercise programs for children with cerebral palsy: a systematic review of the literature. Am J Phys Med Rehabil. 2008;87(5):404–417.
55. Verschuren O, Ketelaar M, Gorter J, Helders P, Uiterwaal C, Takken T. Exercise training programs in children and adolescents with cerebral palsy. Arch Pediatr Adolesc Med. 2007;161(11):1075–1081.
56. National Association for Sport and (PE). Physical Education Is Critical to Educating the Whole Child [Position Statement]. Reston, VA: National Association for Sport and (PE); 2011.
57. Robertson R, Goss F, Boer N, et al. Children's OMNI Scale of Perceived Exertion: mixed gender and race validation. Med Sci Sports Exerc. 2000;32:452–458.
58. Yelling M, Lamb K, Swaine I. Validity of a pictorial perceived exertion scale for effort estimation and effort production during stepping exercise in adolescent children. Eur Phys Educ Rev. 2002;8(2):157–175.
59. Cassady S, Kaufman B, Kelly C, Eisenmann S, Wentzien J. Validity of a new perceived exertion scale for children. Cardiopulm Phys Ther. 1998;9(1):3–9.
60. Hui S, Chan J. The relationship between heart rate reserve and oxygen uptake reserve in children and adolescents. Res Q Exerc Sport. 2006;77:41–49.
61. Epstein L, Paluch R, Kalakanis L, Goldfield G, Cerny F, Roemmich J. How much activity do youth get? A quantitative review of heart-rate measured activity. Pediatrics. 2001;108(3):1–10.
62. Mahon A, Marjerrison A, Lee J, Woodruff M, Hanna L. Evaluating the prediction of maximal heart rate in children and adolescents. Res Q Exerc Sport. 2010;81(4):466–471.
63. Machado F, Denadai B. Validity of maximum heart rate prediction equations for children and adolescents. Arq Bras Cardiol. 2011;97(2):136–140.
64. Verschuren O, Maltais D, Takken T. The 220 - age equation does not predict maximum heart rate in children and adolescents. Dev Med Child Neurol. 2011;53(9):861–864.
65. Winnick J, Short F. The Brockport Physical Fitness Test Manual. Champaign, IL: Human Kinetics Publishers Inc; 1999.
66. Short F, Winnick J. Test items and standards related to aerobic functioning on the Brockport Physical Fitness Test. Adapt Phys Act Q. 2005;22:333–355.
67. de Groot J, Takken T, Gooskens R, et al. Reproducibility of maximal and submaximal exercise testing in “normal ambulatory” and “community ambulatory” children and adolescents with spina bifida: which is best for the evaluation and application of exercise training? Phys Ther. 2011;91(2):267–276.
68. Utter A, Robertson R, Nieman D, Kang J. Children's OMNI Scale of Perceived Exertion: walking/running evaluation. Med Sci Sports Exerc. 2002;34(1):139–144.
69. Pfeiffer K, Pivarnik J, Womack C, Reeves M, Malina R. Reliability and validity of the Borg and OMNI rating of perceived exertion scales in adolescent girls. Med Sci Sports Exerc. 2002;34(12):2057–2061.
70. Robertson R, Goss F, Aaron D, et al. Observation of perceived exertion in children using the OMNI Pictorial Scale. Med Sci Sports Exerc. 2006;38(1):158–166.
71. Roemmich J, Barkley J, Epstein L, Lobarinas C, White T, Foster J. Validity of PCERT and OMNI walk/run ratings of perceived exertion. Med Sci Sports Exerc. 2006;38(5):1014–1019.
72. Birk TJ, Mossing M. Relationship of perceived exertion to heart rate and ventilation in active teenagers with cerebral palsy. Adapt Phys Activ Q. 1988;5:154–164.
73. Ward D, Bar-Or O, Longmuir P, Smith K. Use of Rating of Perceived Exertion (RPE) to prescribe exercise intensity for wheelchair-bound children and adults. Pediatr Exerc Sci. 1995;7:94–102.
74. Verschuren O, Ketelaar M, Gorter J, Helders P, Takken T. Relation between physical fitness and gross motor capacity in children and adolescents with cerebral palsy. Dev Med Child Neurol. 2009;51:866–871.
75. Gonzalez-Aguero A, Vincente-Rodriquez G, Gomez-Cabello A, Moreno L, Casajus J. A 21-week bone deposition promoting exercise programme increases bone mass in young people with Down syndrome. Dev Med Child Neurol. 2012;54(6):552–556.
76. Rimmer J, Rowland J. Physical activity for youth with disabilities: a critical need in an underserved population. Dev Neurorehab. 2008;11(2):141–148.
77. Dallmeijer A, Scholtes V, Brehm M, Becher J. Test-retest reliability of the 20-sec Wingate Test to assess anaerobic power in children with cerebral palsy. Am J Phys Med Rehabil. 2013;92(9):762–767.
78. Verschuren O, Zwinkels M, Obeid J, Kerkhof N, Ketelaar M, Takken T. Reliability and validity of short-term performance tests for wheelchair-using children and adolescents with cerebral palsy. Dev Med Child Neurol. 2013;55(12):1129–1135.
79. Balemans A, van Wely L, de Heer S, et al. Maximal aerobic and anaerobic exercise responses in children with cerebral palsy. Med Sci Sports Exerc. 2013;45(3):561–568.
80. Balemans A, Fragala-Pinkham M, Lennon N, et al. Systematic review of the clinimetric properties of laboratory and field-based aerobic and anaerobic fitness measures in children with cerebral palsy. Arch Phys Med Rehabil. 2013;94:287–301.
81. Pin T, Dyke P, Chan M. The effectiveness of passive stretching in children with cerebral palsy. Dev Med Child Neurol. 2006;48(10):855–862.
82. Bushby K, Finkel R, Birnkraut D, et al. Diagnosis and management of Duchenne muscular dystrophy, part 2: implementation of multidisciplinary care. Lancet. 2010;9(2):177–189.
83. Rogozinski B, Davids J, Davis R, et al. Prevalence of obesity in ambulatory children with cerebral palsy. J Bone Joint Surg. 2007;89(11):2421–2426.
84. Gurka M, Kuperminc M, Busby M, et al. Assessment and correction of skinfold thickness equations in estimating body fat in children with cerebral palsy. Dev Med Child Neurol. 2010;52(2):e35–e41.
85. Slaughter M, Lohman T, Boileau R, et al. Skinfold equations for estimation of body fatness in children and youth. Hum Biol. 1988;60(5):709–723.
86. Li C, Ford E, Mokdad A, Cook S. Recent trends in waist circumference and waist-height ratio among US children and adolescents. Pediatrics. 2006;118(5):1390–1398.
87. Spear B, Barlow S, Ervin C, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(suppl 4):S254–S288.
88. Bandini L, Fleming R, Scampini R, Gleason J, Must A. Is body mass index a useful measure of excess body fatness in adolescents and young adults with Down syndrome? J Intellect Disabil Res. 2013;57(11):1050–1057.
89. US Department of Health and Human Services. Promoting Better Health for Young People Through Physical Activity and Sports. Washington, DC: US Department of Health and Human Services; 2000.
90. Jasien J, Daimon C, Maudsley S, Shapiro B, Martin B. Aging and bone health in individuals with developmental disabilities. Int J Endocrin. 2012;2012:10.
91. Henderson R, Berglund L, May R, et al. The relationship between fractures and DXA measures of BMD in the distal femur of children and adolescents with cerebral palsy or muscular dystrophy. J Bone Miner Res. 2010;25:520–526.
92. Henderson R, Kairalla J, Barrington J, Abbas A, Stevenson R. Longitudinal changes in bone density in children and adolescents with moderate to severe cerebral palsy. J Pediatr. 2005;146(6):769–775.
93. Mergler S, Evenhuis H, Boot A, et al. Epidemiology of low bone mineral density and fractures in children with severe cerebral palsy: a systematic review. Dev Med Child Neurol. 2009;51:773–778.
94. Fehlings D, Switzer L, Agarwal P, et al. Informing evidence-based clinical practice guidelines for children with cerebral palsy at risk of osteoporosis: a systematic review. Dev Med Child Neurol. 2012;54(2):106–116.
95. Chad KE, Bailey DA, McKay HA, Zello GA, Snyder RE. The effect of weight-bearing physical activity program on bone mineral content and estimated volumetric density in children with spastic cerebral palsy. J Pediatr. 1999;135(1):115–117.
96. Chad K, McKay H, Zello G, Bailey D, Faulkner R, Snyder R. Body composition in nutritionally adequate ambulatory and non-ambulatory children with cerebral palsy and a healthy reference group. Dev Med Child Neurol. 2000;42(5):334–339.
97. Caulton J, Ward K, Alsop C, Dunn G, Adams J, Mughal M. A randomised controlled trial of standing programme on bone mineral density in non-ambulant children with cerebral palsy. Arch Dis Child. 2003;89(2):131–135.
98. Wren T, Lee D, Hara R, et al. Effect of high-frequency, low-magnitude vibration on bone and muscle in children with cerebral palsy. J Pediatr Orthop. 2010;30(7):732–738.
99. Hemayattalab R. Effects of physical training and calcium intake on bone mineral density of students with mental retardation. Res Dev Disabil. 2010;31(3):784–789.
100. Chen C, Chen C, Liaw M, Chung C, Wang C, Hong W. Efficacy of home-based virtual cycling training on bone mineral density in ambulatory children with cerebral palsy. Osteoporos Int. 2013;24(4):1399–1406.
101. Foley J, Bryan R, McCubbin J. Daily physical activity levels of elementary school-aged children with and without mental retardation. J Dev Phys Disabil. 2008;20:365–378.
102. Pan C. School time physical activity of students with and without autism spectrum disorders during PE and recess. Adapt Phys Activity Q. 2008;25(4):308–321.
103. Phillips A, Holland A. Assessment of objectively measured physical activity levels in individuals with intellectual disabilities with and without Down's syndrome. PLoS ONE. 2011;6(12):e28618.
104. Carlon S, Taylor N, Dodd K, Shields N. Differences in habitual physical activity levels of young people with cerebral palsy and their typically developing peers: a systematic review. Disabil Rehabil. 2013;35(8):647–655.
105. Rimmer J, Riley B, Wang E, Rauworth A, Jurkowski J. Physical activity participation among persons with disabilities: barriers and facilitators. Am J Prev Med. 2004;26(5):419–425.
106. Hunter K, Piner S, Rosenberg A. Pediatric physical therapists' consultation with a community dance instructor: a case report. Pediatr Phys Ther. 2004;16(4):222–229.
107. O'Neil M, Fragala-Pinkham M, Ideishi R, Ideishi S. Community-based programs for children and youth: our experiences in design, implementation, and evaluation. Phys Occup Ther Pediatr. 2012;32(2):111–119.
108. Fragala-Pinkham M, Dumas H, Boyce M, Peters C, Haley S. Evaluation of an adaptive ice skating programme for children with disabilities. Dev Neurorehabil. 2009;12(4):215–223.
109. Van Sant AF. Backpacks, computer games, and triple burgers with cheese revisited. Pediatr Phy Ther. 2013;25(1):1.
110. Fowler E, Kolobe TH, Damiano D, et al. Promotion of physical fitness and prevention of secondary conditions for children with cerebral palsy: Section on Pediatrics Research Summit Proceedings. Phys Ther. 2007;87(11):1495–1510.
111. Kolobe TH, Christy J, Gannotti M, et al. Research summit III proceedings on dosing in children with an injured brain or cerebral palsy: executive summary. Phys Ther. 2014;94(7):907–920.
112. Verschuren O, Takken T. Aerobic capacity in children and adolescents with cerebral palsy. Res Dev Disabil. 2010;31(6):1352–1357.
113. Verschuren O, Zwinkels M, Ketelaar M, Reijnders-van Son F, Takken T. Reproducibility and validity of the 10-Meter Shuttle Ride Test in wheelchair-using children and adolescents with cerebral palsy. Phys Ther. 2013;93(7):967–974.
114. Fernhall B, McCubbin J, Pitetti K. Prediction of maximal heart rate in individuals with mental retardation. Med Sci Sports Exerc. 2001;33(10):1655–1660.
115. Johnston TE, Smith BT, Betz RR, Lauer RT. Exercise testing using upper extremity ergometry in pediatric spinal cord injury. Pediatr Phys Ther. 2008;20(2):146–151.
116. Rose J, Gamble J, Lee J, Lee R, Haskell W. The Energy Expenditure Index: a method to quantitate and compare walking energy expenditure for children and adolescents. J Pediatr Orthop. 1991;11:571–578.
117. Wiart L, Darrah J. Test-retest reliability of the energy expenditure index in adolescents with cerebral palsy. Dev Med Child Neurol. 1999;41:716–718.
118. Haley S, Coster W, Dumas H, et al. Accuracy and precision of the Pediatric Evaluation of Disability Inventory computer adapted tests (PEDI-CAT). Dev Med Child Neurol. 2011;53(12):1100–1106.
119. Jansen M, De Jong M, Coes H, Eggermont F, Van Alfen N, de Groot I. The assisted 6-Minute Cycling Test to assess endurance in children with a neuromuscular disorder. Muscle Nerve. 2012;46(4):520–530.
120. Faigenbaum A, Westcott S, LaRosa Loud R, Long C. The effects of different resistance training protocols on muscular strength and endurance development in children. Pediatrics. 1999;104(1):5–11.
121. Shields N, Taylor NF, Wee E, Wollersheim D, O'Shea SD, Fernhall B. A community-based strength training programme increases muscle strength and physical activity in young people with Down syndrome: a randomised controlled trial. Res Dev Disabil. 2013;34(12):4385–4394.
122. Shields N, Taylor N. A student-led progressive resistance training program increases lower limb muscle strength in adolescents with Down syndrome: a randomised controlled trial. J Physiother. 2010;56:187–193.
123. Berry E, Giuliani C, Damiano D. Intrasession and intersession reliability of handheld dynamometry in children with cerebral palsy. Pediatr Phys Ther. 2004;16(4):191–198.
124. Crompton J, Galea M, Phillips B. Hand-held dynamometry for muscle strength measurement in children with cerebral palsy. Dev Med Child Neurol. 2007;49(2):106–111.
125. Stuberg W, Metcalf W. Reliability of quantitative muscle testing in healthy children and in children with Duchenne Muscular Dystrophy using a hand-held dynamometer. Phys Ther. 1988;68:977–982.
126. Brussock C, Haley S, Munsat T, Bernhardt D. Measurement of isometric force in children with and without Duchenne's Muscular Dystrophy. Phys Ther. 1992;72(2):105–114.
127. Mahony K, Hunt A, Daley D, Sims S, Adams R. Inter-tester reliability and precision of manual muscle testing and hand-held dynamometry in lower limb muscles of children with spina bifida. Phys Occup Ther Pediatr. 2009 29(1):44–59.
128. Buffart LM, Van Den Berg-Emons RJG, Van Wijlen-Hempel MS, Stam HJ, Roebroeck ME. Health-related physical fitness of adolescents and young adults with myelomeningocele. Eur J App Physiol. 2008;103(2):181–188.
129. Wuang YP, Su CY. Reliability and responsiveness of the Bruininks-Oseretsky Test of Motor Proficiency–Second Edition in children with intellectual disability. Res Dev Disabil. 2009;30(5):847–855.
130. Pan C-Y. Motor proficiency and physical fitness in adolescent males with and without autism spectrum disorders. Autism. 2014;18(2):156–165.
131. Bruininks R, Bruininks B. Bruininks-Oseretsky Test of Motor Proficiency. 2nd ed. Minneapolis, MN: NCS Pearson Inc; 2005.
132. Verschuren O, Bongers B, Obeid J, Ruyten T, Takken T. Validity of the muscle power sprint test in ambulatory youth with cerebral palsy. Pediatr Phy Ther. 2013;25(1):25–28.
133. Jin-Gang H, Ji-Hea W, Jooyeon K. Reliability of the Pediatric Balance Scale in the assessment of the children with cerebral palsy. J Phys Ther Sci. 2012;24(4):301–305.
134. Yi S, Hwang J, Kim S, Kwon J. Validity of pediatric balance scales in children with spastic cerebral palsy. Neuropediatrics. 2012;43(6):307–313.
135. Chen C, Shen I, Chen C, Wu C, Liu W, Chung C. Validity, responsiveness, minimal detectable change, and minimal clinically important change of Pediatric Balance Scale in children with cerebral palsy. Res Dev Diabil. 2013;34:916–922.
136. Niznik T, Turner D, Worrell T. Functional reach as a measurement of balance for children with lower extremity spasticity. Phys Occup Ther Pediatr. 1995;15(3):1–15.
137. Donahoe B, Turner D, Worrell T. The use of functional reach as a measurement of balance in boys and girls without disabilities ages 5 to 15 years. Pediatr Phys Ther. 1994;6:189–193.
138. Wheeler A, Shall M, Lewis A, Shepherd J. The reliability of measurements obtained using Functional Reach in children with cerebral palsy aged 3-16 years. Pediatr Phys Ther. 1996;8:182–183.
139. Gan S, Tung L, Tang Y, Wang C. Psychometric properties of functional balance assessment in children with cerebral palsy. Neurorehabil Neural Repair. 2008;22:745–753.
140. Wright FV, Ryan J, Brewer K. Reliability of the Community Balance and Mobility Scale (CB&M) in high-functioning school-aged children and adolescents who have an acquired brain injury. Brain Inj. 2010;24(13/14):1585–1594.
141. Kowalski K, Crocker P, Faulkner R. Validation of the physical activity questionnaire for older children. Pediatr Exerc Sci. 1997;9:174–186.
142. Kowalski K, Crocker P, Donen R. The Physical Activity Questionnaire for Older Children (PAQ-C) and Adolescents (PAQ-A) Manual. Saskatoon, SK, Canada: College of Kinesiology, University of Saskatchewan; 2004. http://www.dapa-toolkit.mrc.ac.uk/documents/en/PAQ/PAQ_manual.pdf
143. Kowalski K, Crocker P, Kowalski N. Convergent validity of the Physical Activity Questionnaire for Adolescents. Pediatr Exerc Sci. 1997;9:342–352.
144. Maher C, Williams M, Olds T, Lane A. Physical and sedentary activity in adolescents with cerebral palsy. Dev Med Child Neurol 2007;49(6):450–457.
145. Sallis J. Self-report measures of children's physical activity. J Sch Health. 1991;61(5):215–219.
146. Trost S. Measurement of physical activity in children and adolescents. Am J Life Med. 2007;1(4):299–314.
147. Pate R, Ross R, Dowda M, Trost S, Sirard J. Validation of a 3-Day Physical Activity Recall instrument in female youth. Pediatr Exerc Sci. 2003;15(3):257–265.
148. Lubans D, Morgan P, Tudor-Locke C. A systematic review of studies using pedometers to promote physical activity among youth. Prev Med. 2009;48(4):307–315.
149. Lubans D, Morgan P, Collins C, Boreham C, Callister R. The relationship between heart rate intensity and pedometer step counts in adolescents. J Sports Sci. 2009;27(6):591–597.
150. Maher C, Kenyon A, McEvoy M, Sprod J. The reliability and validity of a research-grade pedometer for children and adolescents with cerebral palsy. Dev Med Child Neurol. 2013;55(9):827–833.
151. Tudor-Locke C, Washington T, Hart T. Expected values for steps/day in special populations. Prev Med. 2009;49(1):3–11.
152. Tudor-Locke C, McClain J, Hart T, Sisson S, Washington T. Expected values for pedometer-determined physical activity in youth. Res Q Exerc Sport. 2009;80(2):164–174.
153. McDonald CM, Widman LM, Walsh DD, Walsh SA, Abresch RT. Use of step activity monitoring for continuous physical activity assessment in boys with Duchenne muscular dystrophy. Arch Phys Med Rehabil. 2005;86(4):802–808.
154. Capio C, Sit C, Abernethy B, Rotor E. Physical activity measurement instruments for children with cerebral palsy: a systematic review. Dev Med Child Neurol. 2010;52(10):908–916.
155. Capio C, Sit C, Abernethy B. Physical activity measurement using MTI (actigraph) among children with cerebral palsy. Arch Phys Med Rehabil. 2010;91(8):1283–1290.
156. Clanchy K, Tweedy S, Boyd R. Measurement of habitual physical activity performance in adolescents with cerebral palsy: a systematic review. Dev Med Child Neurol. 2011;53(6):499–505.
157. Clanchy K, Tweedy S, Boyd R, Trost S. Validity of accelerometry in ambulatory children and adolescents with cerebral palsy. Eur J Appl Physiol. 2011;111(12):2951–2959.
158. Gorter J, Noorduyn S, Obeid J, Timmons B. Accelerometry: a feasible method to quantify physical activity in ambulatory and nonambulatory adolescents with cerebral palsy [published online ahead of print June 26, 2012]. Int J Pediatr. 2012;2012:329284.
159. Maher C, Williams M, Olds T. The Six Minute Walk Test for children with cerebral palsy. Int J Rehabil Res. 2008;31(2):185–188.
160. Thompson P, Beath T, Bell J, et al. Test-retest reliability of the 10-Meter Fast Walk Test and 6-Minute Walk Test in ambulatory school-aged children with cerebral palsy. Dev Med Child Neurol. 2008;50(5):370–376.
161. Hassan J, Van der Net J, Helders P, Prakken B, Takken T. Six-Minute Walk Test in children with chronic conditions. Br J Sports Med. 2010;44:270–274.
162. Henricson E, Abresch R, Han J, et al. Percent-predicted 6-minute walk distance in Duchenne muscular dystrophy to account for maturational influences. PLOS Curr. 2012;4(Version 2):RRN1297 .
163. Casey A, Wang X, Osterling K. Test-retest reliability of the 6-Minute Walk Test in individuals with Down syndrome. Arch Phys Med Rehabil. 2012;93(11):2068–2074.
164. Bartels B, de Groot JF, Terwee CB. The Six-Minute Walk Test in chronic pediatric conditions: a systematic review of measurement properties. Phys Ther. 2013;93(4):529–541.
165. Beets MW, Pitetti KH. Criterion-referenced reliability and equivalency between the PACER and 1-Mile Run/Walk for high school students. J Phys Activity Health. 2006;3:S21–S33.
166. Fernhall B, Pitetti K, Stubbs N, Stadler L. Validity and reliability of the 1/2 mile run-walk as an indicator of aerobic fitness in children with mental retardation. Pediatr Exerc Sci. 1996;8:130–142.
167. O'Connell D, Barnhart R, Parks L. Muscular endurance and wheelchair propulsion in children with cerebral palsy or myelomeningocele. Arch Phys Med Rehabil. 1992;73(8):709–711.
168. O'Connell D, Barnhart R. Improvement in wheelchair propulsion in pediatric wheelchair users through resistance training: a pilot study. Arch Phys Med Rehabil. 1995;76:368–372.
169. Verschuren O, Ketelaar M, de Groot J, Vila Nova F, Takken T. Reproducibility of two functional field exercise tests for children with cerebral palsy who self-propel a manual wheelchair. Dev Med Child Neurol. 2013;55(2):185–190.
170. King G, Law M, King S, et al. Children's Assessment of Participation and Enjoyment (CAPE) and Preferences for Activities of Children (PAC). San Antonio, TX: Harcourt Assessment Inc; 2004.
171. King G, Law M, King S, et al. Measuring children's participation in recreation and leisure activities: construct validation of the CAPE and PAC. Child Care Health Dev. 2007;33:28–39.
172. Imms C. Review of the children's assessment of participation and enjoyment and the preferences for activity of children. Phys Occup Ther Pediatr. 2008;28(4):386–401.
173. Law M, Baptiste S, Carswell A, McColl M, Polatajko H, Pollock N. Canadian Occupational Performance Measure. 4th ed. Ottawa, Ontario, Canada: CAOT Publications; 2005.
174. Verkerk G, Wolf M, Louwers A, Meester-Delver A, Nollet F. The reproducibility and validity of the Canadian Occupational Performance Measure in parents of children with disabilities. Clin Rehabil. 2006;20(11):980–988.
175. Potvin M, Snider L, Prelock P, Kehayia E, Wood-Dauphinee S. Children's assessment of participation and enjoyment/preference for activities of children: psychometric properties in a population with high-functioning autism. Am J Occup Ther. 2013;67(2):209–217.
176. Steele K, Damiano D, Eek M, Unger M, Delp S. Characteristics associated with improved knee extension after strength training for individuals with cerebral palsy and crouch gait. J Pediatr Rehabil Med. 2012;5(2):99–106.
177. Lewis C, Fragala-Pinkham M. Effects of aerobic conditioning and strength training on a child with Down syndrome: a case study. Pediatr Phys Ther. 2005;17(1):30–36.
178. Gajdosik C, Ostertag S. Cervical instability and Down syndrome: review of the literature and implications for physical therapists. Pediatr Phys Ther. 1996;8:31–36.
179. Fernhall B, Pitetti K, Rimmer J, et al. Cardiorespiratory capacity of individuals with mental retardation including down syndrome. Med Sci Sports Exerc. 1996;28(3):366–371.
180. Mendonca G, Pereira F, Fernhall B. Reduced exercise capacity in persons with Down syndrome: cause, effect, and management. Ther Clin Risk Manage. 2010;6:601–610.
181. Mukherjee S. Spina bifida—physical activity guidelines. http://www.ncpad.org/222/1445/Spina∼Bifida∼-∼Physical∼Activity∼Guidelines
. Published 2014. Accessed March 21, 2014.
182. Liusuwan R, Widman L, Abresch R, Johnson A, McDonald C. Behavioral intervention, exercise, and nutrition education to improve health and fitness in adolescents with mobility impairment due to spinal cord dysfunction. J Spinal Cord Med. 2007;30:S119–S126.
183. Jansen M, van Alfen N, Geurts AC, de Groot IJ. Assisted bicycle training delays functional deterioration in boys with Duchenne muscular dystrophy: the randomized controlled trial “no use is disuse.” Neurorehabil Neural Repair. 2013;27(9):816–827.
184. Swann-Guerrero S, Cajigas M. Autism and Considerations in Recreation and Physical Activity Settings. National Center on Health, Physical Activity and Disability; 2009. http://www.ncpad.org/315/1452/Autism∼and∼Considerations∼in∼Recreation∼and∼Physical∼Activity∼Settings
. Accessed January 22, 2013.
185. Petrus C, Adamson S, Block L, Einarson S, Sharifnejad M, Harris S. Effects of exercise interventions on stereotypic behaviors in children with autism spectrum disorder. Physiother Can. 2008;60(2):134–145.
186. Srinivasan SM, Pescatello LS, Bhat AN. Current perspectives on physical activity for children and adolescents with autism spectrum disorders. Phys Ther. 2014;94:875–899.