Learn 2 Move 16-24: effectiveness of an intervention to stimulate physical activity and improve physical fitness of adolescents and young adults with spastic cerebral palsy; a randomized controlled trial
© Slaman et al; licensee BioMed Central Ltd. 2010
Received: 6 July 2010
Accepted: 5 November 2010
Published: 5 November 2010
Persons with cerebral palsy (CP) are at risk for developing an inactive lifestyle and often have poor fitness levels, which may lead to secondary health complications and diminished participation and quality of life. However, persons with CP also tend not to receive structural treatment to improve physical activity and fitness in adolescence, which is precisely the period when adult physical activity patterns are established.
We aim to include 60 adolescents and young adults (16-24 years) with spastic CP. Participants will be randomly assigned to an intervention group or a control group (no treatment; current policy). The intervention will last 6 months and consist of three parts; 1) counselling on daily physical activity; 2) physical fitness training; and 3) sports advice. To evaluate the effectiveness of the intervention, all participants will be measured before, during, directly after, and at 6 months following the intervention period. Primary outcome measures will be: 1) physical activity level, which will be measured objectively with an accelerometry-based activity monitor during 72 h and subjectively with the Physical Activity Scale for Individuals with Physical Disabilities; 2) aerobic fitness, which will be measured with a maximal ramp test on a bicycle or armcrank ergometer and a 6-minute walking or wheelchair test; 3) neuromuscular fitness, which will be measured with handheld dynamometry; and 4 body composition, which will be determined by measuring body mass, height, waist circumference, fat mass and lipid profile.
This paper outlines the design, methodology and intervention of a multicenter randomized controlled trial (LEARN 2 MOVE 16-24) aimed at examining the effectiveness of an intervention that is intended to permanently increase physical activity levels and improve fitness levels of adolescents and young adults with CP by achieving a behavioral change toward a more active lifestyle.
Dutch Trial Register; NTR1785
Cerebral palsy (CP) occurs in 1.5 to 3.0 of 1000 live births and is the most common cause of physical disability in pediatric rehabilitation medicine . Representing a group of permanent disorders of the development of movement and posture, it causes activity limitation that is attributed to non progressive disturbances that occurred in the developing fetal or infant brain  which can lead to diminished quality of life, participation and health in adulthood [3–5].
Participation in regular physical activity (PA) provides psychological and physiological benefits in adolescents . In addition, it reduces both the deterioration of mobility-related activities  and the development of secondary health problems later in life . However, performing physical activities is often burdensome in adolescents and adults with CP due to reduced muscle mass and inefficient locomotion . This might, together with the distinctly subnormal fitness levels of persons with CP , explain why they are at risk of developing an inactive lifestyle. Such an inactive lifestyle has been found in several studies of bilateral spastic CP populations [11–13], but it contrasts with the more active lifestyle of individuals with unilateral spastic CP .
Persons develop their adult PA lifestyle in adolescence [15, 16]. Therefore, encouraging an active lifestyle and improving physical fitness at this age seems important. Nevertheless, in adolescence and young adulthood, persons with CP tend not to receive structural treatment to improve PA and fitness . A recent review shows that children and adolescents with CP may benefit from exercise programs to improve physical fitness . However, higher fitness levels do not automatically lead to a more active lifestyle [19, 20]. Some evidence exists for the effectiveness of interventions aimed at stimulating an active lifestyle through individual counselling in adult populations with physical disabilities in both the short term  and long term . It can be speculated that an intervention which combines individual counselling on daily PA with fitness training is ideal to increase PA and improve physical fitness in persons with CP. However, the effectiveness of such an intervention has, to our knowledge, never been evaluated in an adolescent or young adult population with CP.
The LEARN 2 MOVE 16-24 research project aims to evaluate the effectiveness and underlying working mechanisms on the short and long term of an Active Lifestyle and Sports Participation (ALSP) intervention. It is hypothesized that persons following the ALSP intervention will experience increased PA and improved physical fitness in both the short term and the long term (maintenance of effects) as the primary goal of the intervention is to achieve a behavioral change toward a more active lifestyle. The present paper describes the research design, methodology and intervention of the LEARN 2 MOVE 16-24 research project [23–25].
Multicenter approval was granted by the Erasmus MC Medical Ethics Committee, The Netherlands. Local approval was granted by all participating centers.
The study has a multicenter randomized controlled design. The experimental group will receive the ALSP intervention. The control group will receive no intervention to improve PA and fitness, which is current policy. Erasmus MC (Rotterdam), Rijndam Rehabilitation Center (Rotterdam), VU Medical Center (Amsterdam), Rehabilitation Center Amsterdam (Amsterdam), Rehabilitation Center De Hoogstraat (Utrecht) and Sophia Rehabilitation (Den Haag/Delft) will participate in this study.
This study has a single-blind research design; all measurements will be performed by assessors who are blind for group allocation and who have no involvement in the recruitment, randomization procedure or intervention.
The ALSP intervention and the research measurements will be performed at each participant's house and at two university medical centers and four rehabilitation centers from which all participants will be recruited.
At least 50 participants are required to detect a difference of 30 minutes a day in PA level between the control and experimental group, with a power of 0.8 and an alpha of 0.05. To allow for dropouts, we aim to recruit at least 60 participants. This calculation is based on data from previous research conducted by our research group [13, 14].
Adolescents and young adults with spastic unilateral or bilateral CP are eligible for inclusion if they meet each of the following criteria
Age 16 - 24 years
Gross Motor Functioning Classification System (GMFCS ) level I-IV
Individuals will be excluded if they meet any of the following criteria
Disabilities other than CP that affect PA or fitness level
Contraindication for (maximal) exercise
Severe cognitive disorders and insufficient comprehension of the Dutch language that preclude understanding the purpose of the project and its testing methods
PA level at baseline exceeds the mean PA level + 2 SD of a CP population
Each participating center will compile a list of its patients aged 16 - 24 years and diagnosed with CP. All patients will be checked on inclusion and exclusion criteria by their rehabilitation physician. An information letter and invitation to participate was sent to eligible participants. A second letter was sent 3 weeks later to non-responders.
After baseline measurement, participants will be stratified according to their GMFCS level to obtain an equal distribution of gross motor functioning between the two groups. Within each stratum and for each participating center, participants will be randomly allocated (1:1) to the experimental or control group.
Intervention: Active Lifestyle and Sports Participation
Counselling on daily PA
Physical fitness training
1. Counselling on daily PA
Counselling on daily PA is the main component of the intervention and consists of six individual counselling sessions over a period of 6 months with a PA counsellor (e.g. physical therapist, movement therapist) who serves as a 'personal coach'. During these counselling sessions, participants will receive individual PA advice which primarily focuses on PA in daily life, and not necessarily on sports. The counselling sessions on daily PA are based on Motivational Interviewing (MI) which is defined as a directive, client-centered counselling style for eliciting behavioral changes by helping clients to explore and resolve ambivalence . Techniques that will be applied in the ALSP intervention to invoke the spirit of MI are reflective listening, rolling with resistance, asking open-ended questions, summarizing during a conversation, and showing empathy for the participant. The stages of behavioral change of the Transtheoretical model  describe the stages a person experiences when changing his or her health behavior. This model structures the clinical role of MI during the counselling sessions . The first counselling session will last 45 minutes. The five subsequent 20- to 30- minute sessions will be planned monthly. All counselling sessions for a participant will be supervised by the same counsellor. Each participating center will have its own counsellor and all involved counsellors will undertake two days of training to learn the basic principles of MI. The counsellors will also participate in a 1-day follow-up workshop to discuss their initial experiences and refresh their MI knowledge and skills. The first and last counselling session will be sound-recorded for latter analysis to ensure that MI had been applied correctly.
2. Physical fitness training
Physical fitness training will consist of 12 weekly supervised sessions and 12 home sessions. These training sessions of approximately one hour consist of aerobic endurance, aerobic interval and strength training. Over these 12 weeks, aerobic exercise duration and aerobic intensity (as determined by the Karvonen formula ) are gradually increased. The peak heart rate (HR), which is required for the Karvonen formula, will be determined during a maximal ramp protocol. The required resting HR will be determined after 5 minutes of rest in a sitting position. During training, HR will be recorded using a Garmin Forerunner 60 heart rate monitor (Garmin Ltd., Olathe, KS, USA). The exercise program starts at a HR of 40% of the heart rate reserve (HRR) on a treadmill, cycle or armcrank ergometer. This will increase to a HR of 80% of the HRR at week 12 . Also, strength exercises of the large muscle groups are included. The training load will be based on a percentage of the baseline 1 repetition maximum (1RM), which is the maximum load that a person can lift once. The training load will begin with one set of 10 to 15 repetitions at 30% of 1RM during week 1 and will increase toward three sets of 15 to 20 repetitions at 75% of 1RM during week 12 . Slight adaptations to these guidelines will be allowed to ensure that the training is both feasible and challenging for each participant. Fitness equipment is available for upper extremities, lower extremities and abdominal muscles. For the training at home, participants will be instructed to perform aerobic exercises (walking/running, cycling, hand-cycling, wheelchair-driving, or swimming) and strength exercises (using Thera-Bands; Hygenic Corporation, Akron, OH, USA) of similar duration and intensity as the supervised training session. HR will also be recorded during home training sessions to evaluate whether participants accomplish the exercise instructions in terms of duration and intensity. After 12 weeks of supervised fitness training the possibilities will be explored to continue the fitness training in the day-to-day environment of each individual.
3. Sports Advice
Sports advice includes sports counselling and sport-specific training. Sports counselling is based on the Rehabilitation & Sports Program [21, 22]. During 2 to 4 sessions of approximately 30 minutes, sports history, preferences, possibilities, barriers and facilitators will be identified. This will result in an individualized sports advice, including information on available, accessible and appropriate sports facilities in the person's day-to-day environment. Aspects as transportation, finances, and supervision are also taken into account to ensure long-term benefits. Sport-specific training includes practicing the required skills to perform the sport and ensuring practice opportunities to match sports to each participant's interests and abilities. Examples of the sports to be included in the sport specific training are swimming, soccer, rowing, basketball, climbing, golf, hockey and racket sports. Participation in the sport-specific training sessions will depend on the interests and physical abilities of the participant.
International Classification of Functioning, Disability and Health
Time schedule of the Active Lifestyle and Sports Participation intervention.
Counselling on daily PA
Fitness training Supervised
PA session 1
Sports session 1
PA session 2
PA session 3
Sports session 2
Post-test 1 (T3)
PA session 4
(Sports session 3)
PA session 5
(Sports session 4)
PA session 6
Post-test 2 (T6)
Follow-up test (T12)
Primary outcome measures
Level of daily physical activity
For ambulatory participants 3 recorders will be used. One recorder will be attached to each thigh to detect acceleration in anterior-posterior direction while standing and a third recorder will be attached to the sternum to detect acceleration in the anterior-posterior direction and in the longitudinal direction. For participants who use wheelchairs, one additional recorder will be attached to each wrist to detect acceleration in the longitudinal direction while seated with the forearm horizontal in the mid-pronation/supination position. Participants will wear the VM system for 72 hours on randomly selected weekdays while performing their ordinary activities with the exception of swimming and bathing. In addition, the VM system will not be worn during periods of sleep. The recorders will be attached to the body by using elastic belts. The VM system will be set up at each participant's home to minimize influencing the normal PA pattern. To avoid measurement bias, we will instruct the participants to continue their ordinary daily life activities. The principles of the activity monitor will be explained to the participants after all measurements have been made.
The following data will be analyzed from these measurements: (1) duration of dynamic activities as a percentage of a 24-hour period; (2) number of transitions (includes all transitions except lying transitions between the prone and supine positions); (3) intensity of activities: (3a) mean motility (in gravitational acceleration (g)); (3b) motility during walking; (3c) motility during wheelchair-driving; and (4) distribution of continuous dynamic activity periods (5-10 sec; 10-30 sec; 30-60 sec; 1-2 min; 2-5 min; 5-10 min; or > 10 min).
Self-reported level of physical activity
To measure the self-reported level of PA the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD)  will be administered. The PASIPD is a 7-day recall questionnaire developed for people with a physical disability and consists of questions on leisure time, and household- and work-related PA. The questionnaire is translated into Dutch and question 10 (lawn work or yard care) and 11 (outdoor gardening) are combined into a single question, which better represents the Dutch situation. The total score of the PASIPD is created by multiplying the average hours per day for each item by a metabolic equivalent (MET) value associated with the intensity of the activity. The test-retest reliability of the PASIPD is good and its validity is comparable to well-established self-report PA questionnaires for the general population .
A) Physical fitness: Aerobic capacity
The aerobic capacity will be measured during a maximal ramp protocol. This test will be performed on an electronically braked cycle ergometer or electronically braked armcrank ergometer depending on the main mode of ambulation during daily life, as this elicits the highest oxygen uptake . The test will be preceded by a 3-minute warm-up without resistance. The resistance will be increased every 12 seconds during the test. The magnitude of this increase in resistance depends on the GMFCS level and gender of the participant and ranges from 1 to 6 watts, ensuring that total exercise time will range from 8 to 12 minutes. The target pedal rate during the test is 70 rpm. Strong verbal encouragement will be given throughout the test. The test will be terminated when the participant voluntarily stops due to exhaustion, or when the participant is unable to maintain the initial pedal/crank rate. Gas exchange and heart rate (HR) will be measured continuously using a breath-by-breath analyzing system, which will be calibrated prior to each measurement. Aerobic capacity is defined as the highest mean oxygen uptake during 30 seconds of exercise (VO2peak in ml·min-1 and ml·kg-1·min-1). Subjective strain will be measured immediately after the final stage by the Borg Scale for Rating of Perceived Exertion . Determining a participant's contra-indications for PA will be assessed prior to the test by use of the Physical Activity Readiness Questionnaire .
B) Physical fitness: sub-maximal aerobic capacity
The 6 minute walking test  will be employed as a measure of sub-maximal aerobic capacity. Patients will be instructed to walk, not run, as far as they can along a 30-meter marked track during a 6-minute period. Non-ambulant participants will perform the test in their wheelchair. Patients are allowed to stop and rest during the test, but will be instructed to resume walking/wheelchair driving as soon as they feel able to do so. The average HR during the test and the covered distance will be registered.
C) Physical fitness: Muscle strength
Muscle strength will be measured with a hand-held dynamometer (MicroFet, Hoggan Health Industries Inc, West Jordan, UT, USA) using the "break" testing method. The strength of the hip flexors, hip abductors and knee extensors will be measured in individuals whose main mode of ambulation is walking. The strength of shoulder abductors and elbow extensors will be measured in non-ambulant individuals. The applicator of the dynamometer is held against the distal part of the limb segment, and participants will be asked to build up their maximum force against it. When maximum is reached the examiner applies sufficient resistance to overcome the force exerted by the participant. Both the left and right side will be measured. The lever arm from the joint to the dynamometer will be kept constant by marking the position of the dynamometer on each participant's leg. Each trial lasts approximately 4 seconds, and three repetitions will be performed with 1 minute of rest in between. The average value of the three repetitions will be analyzed.
D) Physical fitness: Body composition
Height will be measured barefoot in a standing position. In case of joint contractures, measurements will be performed from joint to joint in a lying position. Body mass of ambulatory participants will be obtained while standing barefoot on a scale and of non-ambulatory participants while sitting on an electronic scale. Body mass index (BMI, kg·m-2) will be calculated from height and body mass. Waist circumference (cm) will be measured mid-way between the lowest rib and the iliac crest while standing. Waist circumference will be measured in a sitting position in persons using a wheelchair. Thickness of four skin folds (biceps, triceps, subscapular and suprailiac) will be measured twice on the left side of the body with a Harpenden calliper (Burgess Hill, UK). The mean of the two measurements will be used as representative. Percentage body fat will be predicted from skin fold thickness according to the method of Durnin and Womersley . Non-fasting blood samples of approximately 10 ml will be drawn from the vena antecubiti with a Vacutainer needle and collected into an evacuated serum separator tune II (SST II tube) while the participants are seated. Total serum cholesterol, high density lipoprotein cholesterol and low density lipoprotein cholesterol will be determined from this blood sample.
Secondary outcome measures
The secondary outcome measures will be assessed for descriptive reasons and to get insight into the working mechanisms of the ALSP intervention. These secondary outcome measures will not be fully described, but will only be mentioned here; spasticity (Ashworth Scale ), selectivity , fatigue (Fatigue Severity Scale , Checklist Individual Strength , Visual Analog Scale ), manual ability (MACS ), sports activities, social participation (Life-H 3.0 ), health related quality of life (Short-Form-36 ), age, gender, level of education, attitude towards PA, general self efficacy (Generalized Self Efficacy scale ), intrinsic motivation (Intrinsic Motivation Inventory ), and social support for exercise behaviour (Social support for exercise behaviour Scale ).
To evaluate the change in PA level and physical fitness, as well as the secondary outcome measures, multilevel regression analyses will be applied, because these analyses allow for missing values. Another advantage of these analyses is that patient data can be clustered within the participating centers. For all multilevel analyses, MLwiN (Version 1.1, Institute of Education, London, UK) software will be used.
This paper outlines the design, methodology and intervention of a multicenter randomized controlled trial that examines the effectiveness of an intervention that aims to achieve a permanent increase in PA level and improve the fitness level of adolescents and young adults with CP by promoting a behavioral change toward a more active lifestyle. The results of this trial are expected to be presented in 2012.
This project is part of the Dutch LEARN 2 MOVE research program and is supported financially by ZonMw, Johanna Kinderfonds, Stichting Rotterdams Kinderrevalidatie Fonds Adriaanstichting, Revalidatiefonds, Phelps Stichting, Revalidatie Nederland and the Nederlandse Vereniging van Revalidatieartsen.
- Surveillance of cerebral palsy in Europe: a collaboration of cerebral palsy surveys and registers. Surveillance of Cerebral Palsy in Europe (SCPE).
- Rosenbaum P PN, Leviton A, Goldstein M, Bax M, Damiano D, Dan B, Jacobsson B: A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007, 109: 8-14.PubMedGoogle Scholar
- Turk MA: Health, mortality, and wellness issues in adults with cerebral palsy. Dev Med Child Neurol. 2009, 51 (Suppl 4): 24-29. 10.1111/j.1469-8749.2009.03429.x.View ArticlePubMedGoogle Scholar
- Donkervoort M, Roebroeck M, Wiegerink D, van der Heijden-Maessen H, Stam H, Transition Research Group South West Netherlands: Determinants of functioning of adolescents and young adults with cerebral palsy. Disabil Rehabil. 2007, 29 (6): 453-463. 10.1080/09638280600836018.View ArticlePubMedGoogle Scholar
- Roebroeck M, Jahnsen R, Carona C, Kent RM, Chamberlain MA: Adult outcomes and lifespan issues for people with childhood-onset physical disability. Dev Med Child Neurol. 2009, 51: 670-678. 10.1111/j.1469-8749.2009.03322.x.View ArticlePubMedGoogle Scholar
- Trost SG: Discussion Paper for the development of Recommendations for Children's and Youth's Participation in Health Promoting Physical Activity. Canberra: Australian Department of Health and Ageing. 2005Google Scholar
- Jahnsen R, Villien L, Egeland T, Stanghelle JK, Holm I: Locomotion skills in adults with cerebral palsy. Clin Rehabil. 2004, 18 (3): 309-316. 10.1191/0269215504cr735oa.View ArticlePubMedGoogle Scholar
- Crespo: Exercise in the prevention of chronic disabling illness. Exercise in rehabilitation medicine. Edited by: Frontera et al. 1999, Human Kinetics, Champaign, ILGoogle Scholar
- Heath GW, Fentem PH: Physical activity among persons with disabilities--a public health perspective. Exercise and sport sciences reviews. 1997, 25: 195-234. 10.1249/00003677-199700250-00010.View ArticlePubMedGoogle Scholar
- Rimmer JH: Physical fitness levels of persons with cerebral palsy. Dev Med Child Neurol. 2001, 43 (3): 208-212.View ArticlePubMedGoogle Scholar
- van Eck M, Dallmeijer AJ, Beckerman H, van den Hoven PA, Voorman JM, Becher JG: Physical activity level and related factors in adolescents with cerebral palsy. Pediatric exercise science. 2008, 20 (1): 95-106.PubMedGoogle Scholar
- van den Berg-Emons HJ, Saris WH, de Barbanson DC, Westerterp KR, Huson A, van Baak MA: Daily physical activity of schoolchildren with spastic diplegia and of healthy control subjects. The Journal of pediatrics. 1995, 127 (4): 578-584. 10.1016/S0022-3476(95)70115-X.View ArticlePubMedGoogle Scholar
- Nieuwenhuijsen C, van der Slot WM, Beelen A, Arendzen JH, Roebroeck ME, Stam HJ, van den Berg-Emons RJ, Transition Research Group South West Netherlands: Inactive lifestyle in adults with bilateral spastic cerebral palsy. J Rehabil Med. 2009, 41 (5): 375-381. 10.2340/16501977-0340.View ArticlePubMedGoogle Scholar
- van der Slot WM, Roebroeck ME, Landkroon AP, Terburg M, Berg-Emons RJ, Stam HJ: Everyday physical activity and community participation of adults with hemiplegic cerebral palsy. Disability and rehabilitation. 2007, 29 (3): 179-189. 10.1080/09638280600747686.View ArticlePubMedGoogle Scholar
- Powell KE, Dysinger W: Childhood participation in organized school sports and physical education as precursors of adult physical activity. American journal of preventive medicine. 1987, 3 (5): 276-281.PubMedGoogle Scholar
- Telama R, Yang X, Viikari J, Valimaki I, Wanne O, Raitakari O: Physical activity from childhood to adulthood: a 21-year tracking study. American journal of preventive medicine. 2005, 28 (3): 267-273. 10.1016/j.amepre.2004.12.003.View ArticlePubMedGoogle Scholar
- Rimmer JH: Health promotion for people with disabilities: the emerging paradigm shift from disability prevention to prevention of secondary conditions. Phys Ther. 1999, 79 (5): 495-502.PubMedGoogle Scholar
- Verschuren O, Ketelaar M, Takken T, Helders PJ, Gorter JW: Exercise programs for children with cerebral palsy: a systematic review of the literature. American journal of physical medicine & rehabilitation/Association of Academic Physiatrists. 2008, 87 (5): 404-417.View ArticleGoogle Scholar
- van den Berg-Emons R, Balk A, Bussmann H, Stam H: Does aerobic training lead to a more active lifestyle and improved quality of life in patients with chronic heart failure?. Eur J Heart Fail. 2004, 6 (1): 95-100. 10.1016/j.ejheart.2003.10.005.View ArticlePubMedGoogle Scholar
- Van den Berg-Emons RJ, Van Baak MA, Speth L, Saris WH: Physical training of school children with spastic cerebral palsy: effects on daily activity, fat mass and fitness. Int J Rehabil Res. 1998, 21 (2): 179-194. 10.1097/00004356-199806000-00006.View ArticlePubMedGoogle Scholar
- van der Ploeg HP, Streppel KR, van der Beek AJ, van der Woude LH, Vollenbroek-Hutten MM, van Harten WH, van Mechelen W: Counselling increases physical activity behaviour nine weeks after rehabilitation. British journal of sports medicine. 2006, 40 (3): 223-229. 10.1136/bjsm.2005.021139.View ArticlePubMedPubMed CentralGoogle Scholar
- van der Ploeg HP, Streppel KR, van der Beek AJ, van der Woude LH, Vollenbroek-Hutten MM, van Harten WH, van Mechelen W: Successfully improving physical activity behavior after rehabilitation. Am J Health Promot. 2007, 21 (3): 153-159.View ArticlePubMedGoogle Scholar
- Hielkema T, Hamer EG, Reinders-Messelink HA, Maathuis CGB, Bos AF, Dirks T, van Doormaal L, Verheijden JMA, Vlaskamp C, Lindeman E, Hadders-Algra M: LEARN 2 MOVE 0-2 years: effects of a new intervention program in infants at very high risk for cerebral palsy; a randomized controlled trial. BMC Pediatrics. 2010.Google Scholar
- Ketelaar M, Kruijsen AJA, Verschuren O, Jongmans MJ, Gorter JW, Verheijden J, Reinders-Messelink HA, Lindeman E: LEARN 2 MOVE 2-3: a randomized controlled trial on the efficacy of child-focused intervention and context-focused intervention in preschool children with cerebral palsy. BMC Pediatrics. 2010.Google Scholar
- van Wely L, Becher JG, Reinders-Messelink HA, Lindeman E, Verschuren O, Verheijden J, Dallmeijer AJ: LEARN 2 MOVE 7-12 years: a randomized controlled trial on the effects of a physical activity stimulation program in children with cerebral palsy. BMC Pediatrics. 2010.Google Scholar
- Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH: Content validity of the expanded and revised Gross Motor Function Classification System. Dev Med Child Neurol. 2008, 50 (10): 744-750. 10.1111/j.1469-8749.2008.03089.x.View ArticlePubMedGoogle Scholar
- Buffart L, van den Berg-Emons HJG, van Mechelen W, van Meeteren J, van der Slot W, Stam HJ, Roebroeck ME: Promoting physical activity in an adolescent and a young adult with physical disabilities. Disability and Health Journal. 2009, 3 (2): 86-92. 10.1016/j.dhjo.2009.08.005.View ArticlePubMedGoogle Scholar
- Rollnick S, Miller WR: What is motivational interviewing?. Behavioural and Cognitive Psychotherapy. 1995, 23: 325-334. 10.1017/S135246580001643X.View ArticleGoogle Scholar
- Prochaska JO, DiClemente CC: Stages and processes of self-change of smoking: toward an integrative model of change. Journal of consulting and clinical psychology. 1983, 51 (3): 390-395. 10.1037/0022-006X.51.3.390.View ArticlePubMedGoogle Scholar
- Miller WR, Rollnick S: Ten things that motivational interviewing is not. Behav Cogn Psychother. 2009, 37 (2): 129-140. 10.1017/S1352465809005128.View ArticlePubMedGoogle Scholar
- Karvonen J, Vuorimaa T: Heart rate and exercise intensity during sports activities. Practical application. Sports medicine (Auckland, NZ. 1988, 5 (5): 303-311. 10.2165/00007256-198805050-00002.View ArticleGoogle Scholar
- American College of Sports Medicine Position Stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Medicine and science in sports and exercise. 1998, 30 (6): 975-991. 10.1097/00005768-199806000-00032.
- WHO: International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization. 2001Google Scholar
- Bussmann J, Martens WL, Tulen JH, Schasfoort FC, van den Berg-Emons HJ, Stam HJ: Measuring daily behavior using ambulatory accelerometry: the Activity Monitor. Behav Res Methods Instrum Comput. 2001, 33: 349-356.View ArticlePubMedGoogle Scholar
- Postma K, van den Berg-Emons HJ, Bussmann JB, Sluis TA, Bergen MP, Stam HJ: Validity of the detection of wheelchair propulsion as measured with an Activity Monitor in patients with spinal cord injury. Spinal Cord. 2005, 43: 550-557. 10.1038/sj.sc.3101759.View ArticlePubMedGoogle Scholar
- Washburn R, Zhu W, McAuley E, Frogley M, Figoni SF: The physical activity scale for individuals with physical disabilities: development and evaluation. Arch Phys Med Rehabil. 2002, 83 (2): 193-200. 10.1053/apmr.2002.27467.View ArticlePubMedGoogle Scholar
- van der Ploeg HP, Streppel KR, van der Beek AJ, van der Woude LH, Vollenbroek-Hutten M, van Mechelen W: The Physical Activity Scale for Individuals with Physical Disabilities: test-retest reliability and comparison with an accelerometer. Journal of physical activity & health. 2007, 4 (1): 96-100.Google Scholar
- Bhambhani YN, Holland LJ, Steadward RD: Maximal aerobic power in cerebral palsied wheelchair athletes: validity and reliability. Arch Phys Med Rehabil. 1992, 73 (3): 246-252.PubMedGoogle Scholar
- Borg GA: Psychophysical bases of perceived exertion. Medicine and science in sports and exercise. 1982, 14 (5): 377-381.View ArticlePubMedGoogle Scholar
- Chisholm DMM, Collis L, Kulak LL, Davenport W, N G: Physical activity readiness. Br Col Med J. 1975, 17: 375-378.Google Scholar
- Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO, Taylor DW, Berman LB: The 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Canadian Medical Association journal. 1985, 132 (8): 919-923.PubMedPubMed CentralGoogle Scholar
- Durnin JV, Womersley J: Body fat assessed from total body density and its estimation from skinfold thickness: measurements on 481 men and women aged from 16 to 72 years. The British journal of nutrition. 1974, 32 (1): 77-97. 10.1079/BJN19740060.View ArticlePubMedGoogle Scholar
- Bohannon RW, Smith MB: Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987, 67 (2): 206-207.PubMedGoogle Scholar
- Voorman JM, Dallmeijer AJ, Knol DL, Lankhorst GJ, Becher JG: Prospective longitudinal study of gross motor function in children with cerebral palsy. Arch Phys Med Rehabil. 2007, 88 (7): 871-876. 10.1016/j.apmr.2007.04.002.View ArticlePubMedGoogle Scholar
- Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD: The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of neurology. 1989, 46 (10): 1121-1123.View ArticlePubMedGoogle Scholar
- Vercoulen JH, Swanink CM, Fennis JF, Galama JM, van der Meer JW, Bleijenberg G: Dimensional assessment of chronic fatigue syndrome. Journal of psychosomatic research. 1994, 38 (5): 383-392. 10.1016/0022-3999(94)90099-X.View ArticlePubMedGoogle Scholar
- McCormack HM, Horne DJ, Sheather S: Clinical applications of visual analogue scales: a critical review. Psychological medicine. 1988, 18 (4): 1007-1019. 10.1017/S0033291700009934.View ArticlePubMedGoogle Scholar
- Eliasson AC, Krumlinde-Sundholm L, Rosblad B, Beckung E, Arner M, Ohrvall AM, Rosenbaum P: The Manual Ability Classification System (MACS) for children with cerebral palsy: scale development and evidence of validity and reliability. Dev Med Child Neurol. 2006, 48 (7): 549-554. 10.1017/S0012162206001162.View ArticlePubMedGoogle Scholar
- Fougeyrollas P NL, St-Michel G: Life Habits measure -- Shortened version (LIFE-H 3.0). Lac St-Charles, Quebec, Canada CQICIDH. 2001Google Scholar
- Ware JE, Sherbourne CD: The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical care. 1992, 30 (6): 473-483. 10.1097/00005650-199206000-00002.View ArticlePubMedGoogle Scholar
- Schwarzer R JM: Generalized Self-Efficacy scale. Measures in health psychology: A user's portfolio Causal and control beliefs. Edited by: Weinman J, Wright S, & Johnston M. 1995, 35-37.Google Scholar
- McAuley E, Duncan T, Tammen VV: Psychometric properties of the Intrinsic Motivation Inventory in a competitive sport setting: a confirmatory factor analysis. Research quarterly for exercise and sport. 1989, 60 (1): 48-58.View ArticlePubMedGoogle Scholar
- Stevens M, Bakker van Dijk A, de Greef MH, Lemmink KA, Rispens P: A Dutch version of the Social Support for Exercise Behaviors Scale. Perceptual and motor skills. 2000, 90 (3 Pt 1): 771-774. 10.2466/PMS.90.3.771-774.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/10/79/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.