Physical and sedentary
produced by skeletal muscles that results in energy expendi-
activity in adolescents
with cerebral palsy
Carol A Maher* BPhysio (Hons);
Marie T Williams BASc (Physio) Grad Cert (Physio) PhD;
Tim Olds BA (Hons) BSpSc PhD;
Alison E Lane BOccuThy (Hons) PhD, University of South
Australia, Adelaide, SA, Australia.
*Correspondence to first author at C8-26, City East, University
of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia.
E-mail: carol.maher@postgrads.unisa.edu.au
Participation in regular physical activity (PA) provides
health, psychological, and physiological benefits for people
with and without a physical disability. This study investigated
the physical and sedentary activity patterns of adolescents
with cerebral palsy (CP). A cross-sectional, descriptive, postal
survey was used, consisting of the Physical Activity
Questionnaire for Adolescents (PAQ-A), self-reported level of
gross motor function (based on the Gross Motor Function
Classification System [GMFCS]), and specific questions
regarding weekly sedentary activities. Following piloting to
determine test–retest reliability (intraclass correlation [ICC]
for PA=0.90; total weekly sedentary time=0.84) and
concurrent validity (survey PA score vs pedometry, Pearson’s
r=0.24; survey PA score vs accelerometry, r=–0.21; survey
weekly sedentary time vs logbook, r=0.38), the survey was
mailed to all adolescents with CP in South Australia
registered with Novita Children’s Services (n=219). One
hundred and twelve valid surveys were returned (76 males, 36
females; age range 11–17y, mean age 13y 11mo [SD 23mo];
GMFCS Level I, n=42; Level II, n=27; Level III, n=10; Level
IV, n=17; Level V, n=15; level not reported, n=1). Results
were compared with recent normative age- and sex-matched
data sets. Key findings were that PA level of adolescents with
CP was related to level of gross motor function and inversely
related to age, and that adolescents with CP were less
physically active than their peers without disability.
Comparisons with normative data sets suggested that
adolescents with CP tend to participate in less structured and
lower intensity PA compared with non-disabled adolescents,
though sedentary activity patterns (TV and computer use) of
adolescents with and without CP were similar.
See end of paper for list of abbreviations.
450 Developmental Medicine & Child Neurology 2007, 49: 450–457
Physical activity (PA) may be defined as ‘any bodily movement
ture’.1 Participation in PA has been consistently associated with
health benefits in adults. While less is known about the effects
of PA in children and adolescents, a recent discussion paper
concerning children’s and adolescents’ participation in PA
identified a range of health, psychological, and physiological
benefits including favourable alteration in body composition,
skeletal health, and cardiorespiratory fitness, as well as imp-
rovement in symptoms of depression, anxiety, and self-con-
cept.2 Concern has been expressed about an apparent increase
in the time children spend in sedentary activities and reduction
in PA participation.3 Physical inactivity is a major public health
concern, evidenced by the ever-increasing number of govern-
ment or health organization-endorsed recommendations for
PA. More recent PA recommendations also include guidelines
for restricting the use of electronic media (TV/computer-
/video/internet)4 for recreational use, as excessive use of these
devices has been linked to various physical and psychosocial
disturbances.5
While the PA patterns of children and adolescents without
disabilities have been extensively studied,6,7 very few such
investigations have specifically considered young people
with cerebral palsy (CP) or physical disabilities in general. In
recent years, numerous studies have examined the effects of
muscular strength and cardiorespiratory fitness training in
young people with CP, and have concluded that beneficial
changes in strength and fitness can be achieved, as well as
modest functional improvement (e.g. improved gait speed).8
However, little is known about the broader effects of PA on
morbidity and mortality in young people with CP.
Knowledge concerning the daily activity patterns of young
people with CP is based on the small body of literature
exploring daily energy expenditure in specific subgroups of
the CP population,9–11 energy expenditure associated with
certain physical tasks (such as walking) in specific subgroups
of the CP population,12,13 or surveys of time use/leisure activ-
ities in children with disabilities.14–16 Taken together, these
studies suggest that young people with CP are less active
than their typically developing peers, have higher rates of
sedentary behaviours, engage in slower tempo activities, and
participate in a smaller variety of PAs.
These findings suggest that the physical and sedentary
behaviours of young people with CP are considerably different
from their healthy peers. Given the apparent changes in physi-
cal and sedentary behaviour patterns in the general population
over the past decade, it is important to update our understand-
ing of the activity patterns of young people with CP. In addition,
previous studies have either focused on specific subgroups
within the CP population, or have reported CP as a homoge-
neous subset within a wider sample of people with a disability.
This is the first study dedicated to examining the PA patterns of
a broad adolescent CP population, and to identify potential
determinants or factors related to PA within adolescents with
CP. Additionally, the PA patterns (types of activities and overall
amount of PA) and sedentary activity patterns of adolescents
with CP will be compared with normative data sets.
Method
Ethical approval for this cross-sectional, descriptive, postal
survey was granted by the University of South Australia Human
Research Ethics Committee (HREC). Data collection took
place between October 2005 and January 2006. As per the
HREC requirements for postal surveys, provision of an infor-
mation letter, followed by return of the completed survey,
was regarded as informed consent.
PARTICIPANTS
Participants were recruited from Novita Children’s Services
(Novita), Adelaide, South Australia. Novita provides commu-
nity-based therapy, equipment, and family support services
to young people with physical disabilities aged 0 to 17 years
in South Australia, in both urban and rural areas. All young
people in the region with CP requiring support are regis-
tered with Novita. Young people with very mild CP, not
requiring any therapy or equipment support, may not be reg-
istered with Novita. All participants from Novita were eligible
for the study if they were aged between 11 and 17 years with
a primary diagnosis of CP.
INSTRUMENTS
A multitude of laboratory and field PA assessment tools exist,
but no one measure provides reliable and valid data in all
dimensions of PA (i.e. there is no criterion standard). Self-
report surveys were chosen for this study because they are
able to measure patterns and modes of PA (as opposed to
some methods that only measure total energy expenditure),
and also offer a feasible means of collecting data from a large
population.17 No single measure provides information on
both PA and sedentary behaviours in young people, there-
fore two surveys were used.
After reviewing approximately 30 potential PA surveys, the
Physical Activity Questionnaire for Adolescents (PAQ-A)18 was
selected on the basis of its relatively high validity and its 7-day
reference frame. It is a widely used, self-administered instru-
ment consisting of eight items which examine PA at different
times throughout the day (e.g. lunchtime at school, physical
education classes, after school, evenings, and weekends) in the
preceding 7 days. Each item contains five response options,
which are scored on the basis of the frequency or intensity with
which it is undertaken (where 1=minimal activity, and 5=high
level of activity). An overall PA score is calculated from the aver-
age of all item scores, with a higher overall PA score indicating a
greater PA level. Test–retest reliability of the PAQ-A has been
reported to be high (generalizability coefficient=0.90). Validity
is comparable with other self-report measures, and is fair19
(r=0.33) when the PAQ-A is compared with accelerometry.18
No appropriate existing instrument was identified for
reporting sedentary behaviours. For the purpose of this study,
sedentary behaviour was indexed by ‘screen time’: time spent
watching TV/videos/DVDs, playing video games, and playing
on the computer/internet, in accordance with the screen time
restrictions incorporated in the Australian PA guidelines.4 A
series of questions to investigate these activities over a period
of 7 days was developed for this study. Additionally, self-report
information was sought on the respondents’ level of gross
motor function (Gross Motor Function Classification System
[GMFCS]20).
To confirm the wording of the questions developed for
sedentary activities and to determine reliability (test–retest),
the survey instruments were piloted with 20 young people
with CP with a range of impairments (mean age 13y 9mo [SD
2y 1mo]; GMFCS Level I, n=7; Level II, n=3; Level III, n=4;
Level IV, n=5; and Level V, n=1) in two face-to-face sessions
Physical and Sedentary Activity in Adolescents with CP Carol A Maher et al.
separated by a week. Reliability of the two instruments was
confirmed for individual PAQ-A items (intraclass correlation
[ICC]=0.51–0.99 [moderate to excellent agreement19]); over-
all PA score (0.90 [excellent agreement19]); sedentary activity
items (0.30–0.95 [fair to excellent agreement19]); and total
weekly sedentary time (0.84 [good to excellent agreement19]).
Concurrent validity was examined by comparing overall PAQ-A
scores with pedometer step counts (Yamax Digi-Walker SW200;
Yamax Corporation, Tokyo, Japan) and accelerometer displace-
ment counts (uniaxial accelerometer, model 7164 MTI, cali-
brated as per manufacturer’s instructions; Computer, Science
and Applications Inc, Shalimar, FL, USA) over 1 week (n=16)
using Pearson’s correlation coefficient (PAQ-A score vs pedo-
meter step count r=0.24 [little to no correlation19], PAQ-A
score vs accelerometer displacement counts r=–0.21 [little to
no correlation19]). Similarly, responses to the sedentary behav-
iours survey were compared with a self-completed screen time
logbook (n=20) using Pearson’s correlation coefficient (sed-
entary behaviour survey questions vs logbook ranged from
r=–0.03 to 0.51 for individual sedentary activities [little to
good correlation19] and survey of total weekly screen time vs
logbook of total weekly screen time r=0.38 [fair to moderate
correlation19]).
SURVEY PROCEDURE
Clients of Novita meeting the inclusion criteria were identi-
fied from the Novita database which contains age, sex, con-
tact details, and primary diagnosis data for all clients. Surveys
were collated into individually-coded packages (including a
personalized covering letter and reply-paid envelopes) for
each client identified.21 A cinema voucher was provided to
participants who returned the survey irrespective of whether
it was completed.21 Surveys were coded to permit repeat
mail-outs to non-responders at 4 and 8 weeks21 and to allow
identification of non-responders’ characteristics to estimate
how representative the sample was and identify non-respon-
der bias.
Parents/guardians were instructed that it was preferable for
the young person with CP to complete the survey indepen-
dently. For participants whose physical or intellectual disability
prevented them from completing the surveys independently,
their parent/guardian was instructed to read the survey to
them and document their responses. In the case of partici-
pants with severe intellectual disability, the parent/guardian
was asked to complete the survey on their behalf. An item at
the end of the survey package recorded the level of assistance
required to complete the survey (independent, with assis-
tance, or proxy report).
ANALYSIS
Data were entered into SPSS for Windows (version 13.0).
Categorical data were described in terms of frequency of
responses and percentages of the total sample. Ratio data
were described using means, ranges, and SDs. Analysis of
covariance (ANCOVA) was used to identify relationships
between participants’ characteristics and physical and seden-
tary activity patterns, with p<0.05 accepted as significant.
Comparative normative data were obtained from a study
of PA (PAQ-A survey) and sedentary behaviours in 1809 South
Australian schoolchildren22 completed during the same time
frame as the current study. These children were recruited
through 52 schools that had agreed to assist with the study,
451
and written informed consent was gained from parents
before participation. Since activity patterns in the general
adolescent population are known to vary by age and sex, a
proportional number of 11- to 17-year-old participants with-
out CP were randomly selected by a computer program from
the comparative data set for each age and sex (n=566).
Comparisons were then made with the matched data set.
Results
The survey was sent to 229 potential participants and 118
responded (response rate 51.5%). This response rate is com-
parable with that reported by Longmuir and Bar-Or’s15 study
of children with disabilities (58.2%), and higher than that
reported by a recent South Australian study carried out with
typically developing children (36.4%).22 Of the 118
returned surveys, six were returned blank, leaving 112 com-
pleted surveys. Respondents’ characteristics are presented
in Table I. The respondents and non-respondents were com-
pared for demographic details of sex, age, type of school
attended, type of CP, and socioeconomic status ([SES], as cal-
culated from an Australian index of SES [Socio-Economic
Indexes for Areas – Index of Relative Disadvantage23] based
on postcode [national mean 1000, SD100]). No significant
difference was found between respondents and non-respon-
dents, suggesting that the respondents represented the
wider population of children with CP registered with Novita.
Additionally, the distribution of respondents’ sex, type of
CP, and GMFCS level were compared with distributions
reported in population-based studies conducted elsewhere in
Australia,24 in Sweden,25 and in other parts of Europe.26 No sig-
nificant difference was found between respondents in this
study and the population-based studies for distribution of type
of CP or GMFCS. However, a significantly higher ratio of males
to females participated in this study compared with those
published by Himmelmann et al.25 (p=0.03) and by the
Surveillance of Cerebral Palsy in Europe26 (p=0.03).
Item 1 of the PAQ-A is a checklist which records the specific
physical activities young people have participated in during

Table I: Demographic characteristics of participants with cerebral palsy (n=112)

Demographic characteristic Type of report Total,

Independent Self-report Proxy n (%)
self-report with assistance report

Sex
Male 11 38 27 76 (67.9)
Female 5 20 11 36 (32.1)
Age, y
11 2 9 5 16 (14.3)
12 1 8 6 15 (13.4)
13 4 10 7 21 (18.8)
14 2 7 7 16 (14.3)
15 3 7 7 17 (15.1)
16 2 9 3 14 (12.5)
17 2 8 3 13 (11.6)
Type of school attended (from Novita database)
Mainstream 16 51 15 82 (73.2)
Speciala 0 4 18 22 (19.6)
Disability unitb 0 1 2 3 (2.7)
Other 0 1 3 4 (3.6)
Use of AAC (n=110)
Yes 0 4 12 16 (15.2)
No 15 54 26 94 (84.8)
Type of CP (from Novita database)
Hemiplegia 7 21 5 33 (29.5)
Diplegia 9 23 6 38 (33.9)
Quadriplegia 0 6 19 25 (22.3)
Athetoid 0 2 3 5 (4.5)
Ataxia 0 2 3 5 (4.5)
Unspecified 0 4 2 6 (5.4)
GMFCS level (n=111)
I 11 26 5 42 (37.8)
II 4 15 8 27 (24.3)
III 1 5 4 10 (9.0)
IV 0 9 8 17 (15.3)
V 0 2 13 15 (13.5)
Socioeconomic statusc
Mean 972.62
SD 85.14
aSpecial school for children with intellectual disability. bDisability unit for children with disabilities in a mainstream

school. cAustralian national mean is 1000 (SD 100). AAC, augmentative or alternative communication; CP, cerebral
palsy; GMFCS, Gross Motor Function Classification System.

452 Developmental Medicine & Child Neurology 2007, 49: 450–457

the preceding 7 days. The primary function of this item is to
prompt participants’ recall of PA in the preceding period.
Items 2 to 8 of the PAQ-A asked participants to recall PA dur-
ing different periods throughout the preceding week. The
frequency of responses and mean scores are shown in Table II.
Of note, the least physically active response was the most
common response reported by the participants with CP for
all items. It is also interesting to observe that the participants
with CP reported lower average levels of PA for every time
period of the preceding week compared with the adoles-
cents without CP of a similar age.
Recreational screen time patterns were investigated using
a series of specific questions which sought information on
the typical time spent on weekdays and weekends doing var-
ious recreational sedentary activities. In total, respondents
accrued a mean 28.49 hours (SD 14.79; range 0–66.00h) of
screen time per week. This equated to an average of 3.46
hours (SD 1.87; range 0–8.40h) each weekday, and 5.97
hours (SD 3.09, range 0–13.00h) each day of the weekend.
The relationships between respondent characteristics (such
as age, sex, and level of impairment) and overall PA score and
overall screen time were examined using ANCOVA (Table III).

Table II: Responses and mean scores for items 2 to 8 of Physical Activity Questionnaire for Adolescents

Survey item and responses Number (%) of sample giving responsea

CP (n=112) Non-CP (n=566)

Item 2: Physical education class at school

1. I don’t do physical education 39 (35.5) 107 (19.8)
2. Hardly ever 8 (7.3) 13 (2.4)
3. Sometimes 25 (22.7) 55 (10.2)
4. Quite often 25 (22.3) 198 (36.7)
5. Always 13 (11.8) 167 (30.9)
Mean score (SD) 2.68 (1.45) 3.56 (1.45)
Item 3: Lunchtime at school
1. Sat down (talking, reading, doing homework) 39 (36.8) 72 (13.2)
2. Stood around or walked around 26 (24.5) 134 (24.6)
3. Ran or played a little bit 13 (12.3) 116 (21.3)
4. Ran around and played quite a bit 15 (14.2) 136 (25.0)
5. Ran and played hard most of the time 13 (12.3) 87 (16.0)
Mean score (SD) 2.40 (1.42) 3.06 (1.29)
Item 4: After school
1. None 60 (54.5) 88 (15.9)
2. 1 time last week 16 (14.5) 101 (18.3)
3. 2–3 times last week 22 (20.0) 199 (36.1)
4. 4 times last week 4 (3.6) 76 (13.8)
5. 5 times last week 8 (7.3) 88 (15.9)
Mean score (SD) 1.95 (1.25) 2.95 (1.26)
Item 5: Evenings during the week
1. None 55 (49.5) 194 (35.1)
2. 1 time last week 27 (22.5) 148 (26.8)
3. 2–3 times last week 25 (20.7) 147 (26.6)
4. 4 times last week 5 (4.5) 30 (5.4)
5. 5 times last week 4 (3.6) 34 (6.1)
Mean score (SD) 1.91 (1.13) 2.21 (1.16)
Item 6: Weekend
1. None 50 (45.0) 70 (12.6)
2. 1 time last week 27 (24.3) 119 (21.5)
3. 2–3 times last week 25 (22.5) 235 (42.4)
4. 4 times last week 5 (4.5) 74 (13.4)
5. 5 times last week 4 (3.6) 56 (10.1)
Mean score (SD) 1.97 (1.09) 2.87 (1.11)
Item 7: General description for entire week
1. Little physical activity 44 (39.6) 57 (10.4)
2. Sometimes did physical activity 30 (27.0) 142 (25.8)
3. Often did physical activity 18 (16.2) 163 (29.6)
4. Quite often 11 (9.9) 113 (20.5)
5. Very often 8 (7.2) 75 (13.6)
Mean score (SD) 2.18 (1.26) 3.01 (1.19)
Item 8: General description for each day of past week
Weekday mean score (SD) 2.37 (1.05) 3.98 (0.91)
Weekend day mean score (SD) 2.41 (1.25) 3.13 (1.13)
Mean score (SD) 2.40 (1.09) 3.00 (0.85)
aNumber of respondents for individual items may be less than total sample due to missing responses.

CP, cerebral palsy.

Physical and Sedentary Activity in Adolescents with CP Carol A Maher et al. 453
For these analyses, age was treated as a covariate. The other
respondent characteristics were organized into nominal
groups based on sex, GMFCS level, and SES (lower, middle,
and upper tertiles). Approximately 36% of the variation in
overall PA, and only 4% of variation in weekly screen time, was
associated with respondents’ characteristics. A strong associa-
tion was found between overall PA and level of gross motor
function, with greater gross motor function associated with
greater PA. There was a weaker, but significant, inverse associ-
ation between overall PA and age (i.e. PA decreased with
increasing age). A significant sex effect was observed for week-
ly screen time, where males with CP accrued significantly
more screen time than females. There was no association
between PA and sex, or SES, nor between weekly screen time
and age, level of gross motor function, or SES.
Discussion
Key findings of this study were that, within the adolescent CP
population, PA participation was related to level of gross motor
function, and PA decreased with increasing age. Compared
with age- and sex-matched adolescents without impairment,
adolescents with CP were less physically active in all time
periods over a week, and completed less overall PA in a week.
This was the first study to consider the effect of gross
motor function, age, sex, and SES on PA patterns in the ado-
lescent CP population. A strength of the current study was
that it used an existing, widely used, and recognized PA mea-
surement tool that allowed comparison with large normative
data sets and also provided baseline data for future studies of
PA patterns of the adolescent CP population. Additionally,
the sampling method, in which all known members of the
South Australian adolescent CP population were invited to
participate, permitted better representation of this popula-
tion as opposed to a convenience sample.
Before contemplating the implications of the results, a
cautionary note is needed concerning the limitations of the
study. Data were collected using self-report surveys – by far
the most popular method for assessing PA, but one which is
susceptible to under- or overestimation. While the pilot
study indicated that participants consistently reported physi-
cal and sedentary behaviour patterns (i.e. good reliability),
how accurately these self-reports reflected active participa-
tion in PA is unclear.
Activity monitors (pedometers and accelerometers) typical-
ly correlate weakly but significantly with self-reported PA in
young non-disabled people (e.g. in 85 adolescents without a
disability the correlation between PAQ-A, overall PA score, and
accelerometry was r=0.3318). The poor relationship is consid-
ered to be due in part to recall bias (a drawback of all self-report
measures), and in part to the activity monitors’ inability to
record certain PA (e.g. cycling and swimming). In this study, a
very poor linear relationship was calculated between overall PA
score and pedometry and accelerometry (r=0.24 and r=–0.21
respectively). The most obvious explanation for this poor rela-
tionship is our use of standardized hip placement of the
pedometers and accelerometers. It appears likely that such
placement did not accurately record PA in individuals who
used wheelchairs (GMFCS Levels III–V; seven of the 16 valida-
tion study participants). A further limitation of this study is that
it only provides a ‘snapshot’ of the PA patterns of respondents

Table III: Relationships between cerebral palsy population participants’ demographic characteristics
and overall Physical Activity (PA) scorea and weekly screen time

Mean overall ANCOVA Mean weekly ANCOVA

PA score F p screen time (h) F p

Ageb, y
11 2.63 4.91 0.03c 27.5 1.91 0.17
12 2.09 28.7
13 2.38 27.4
14 1.72 21.1
15 2.11 31.8
16 1.83 35.3
17 1.91 28.8
Sex
Male 2.16 0.48 0.49 30.5 6.31 0.01c
Female 2.03 24.3
GMFCS level
I 2.61 8.05 <0.01c 28.7 1.74 0.15
II 2.16 28.4
III 1.91 36.4
IV 1.78 30.9
V 1.23 20.6
SES, tertile
Lower 1.96 0.26 0.77 29.0 0.03 0.97
Middle 2.01 26.8
Upper 2.39 29.7
Adjusted R2 0.36 0.04
aPhysical Activity Questionnaire for Adolescents; bage was treated as a covariate; cstatistically significant when

p<0.05. Adjusted R2: values of 0.36 and 0.04 indicate that 36% of variation in overall PA score and 4% of
variation in weekly screen time is explained by demographic characteristics. ANCOVA, analysis of covariance;
GMFCS, Gross Motor Function Classification System; SES, socioeconomic status.

454 Developmental Medicine & Child Neurology 2007, 49: 450–457

with CP from one Australian state. In all, the results appear
consistent with those reported by previous studies, thus the
findings are likely to be relevant to young CP populations else-
where, but it is essential to acknowledge that climate, seasonal
variation, culture,2 and health service factors also play an
important role.
This is the first Australian study to compare the PA of adoles-
cents with CP with their non-disabled peers. Australian adoles-
cents with CP accrued less PA than their healthy peers, which is
consistent with the findings of several other studies conduct-
ed in the US,9,11 the Netherlands,10 Canada,14,15,27,28 and
Israel.29 Most previous studies analyzed the data from their CP
participants as a homogenous group,9,10,27–29 or even as part
of a broader group of ‘physical disability’ or ‘children with a
disability’.14,15 One study recognized that activity patterns may
vary within the CP population in its methodology, analyzing
results separately for ‘ambulant’ and ‘non-ambulant’ partici-
pants.11 However, this broad grouping does not account for
changes in mobility method, depending on the task or envi-
ronmental context. This study is the first to consider PA pat-
terns in relation to GMFCS level and has established a clear
relationship between these variables. Compared with demo-
graphic factors commonly associated with PA level in the
healthy population (e.g. sex, age, SES), the overwhelming
determinant of PA level in the CP population in this study was
level of gross motor function.
There was also a significant inverse relationship between PA
level and age within the adolescent CP group. This mirrors the
decline in PA levels recognized to occur in the healthy adoles-
cent population2 and is consistent with the age-related pattern
identified by Law et al.,16 where leisure participation of young
Canadians with physical disabilities declined from childhood to
adolescence. Other demographic factors frequently associated
with increased PA levels are male sex and higher SES.2 In this
study, these were not statistically significant determinants.
25
20
Mean hours per week
15
10
5
0 indicates expected level activities would fall on if they had
Watching TV/DVDs/ Playing on Playing video
videos computer
Sedentary pursuits
Figure 1: Weekly time spent in sedentary pursuits in
participants with and without cerebral palsy (CP).
However, visual inspection of the data collected from the
adolescents with CP did reflect trends in the directions
expected, so it is possible that the lack of statistical signifi-
cance was a product of the relatively small sample size (i.e.
insufficient power).
In contrast to PA patterns, the only significant determi-
nant of sedentary behaviour within the CP respondents was
sex. There was no apparent relationship between sedentary
behaviour and gross motor function, age, or SES. Furthermore,
sedentary behaviour appeared independent of PA level.
Some previous studies of children without disabilities have
reported a weak inverse relationship between recreational
screen time and PA level;2 however, in this current study,
these factors appeared unrelated to overall PA level.
Adolescents with CP in this study reported spending an
average of 28.49 hours per week engaging in recreational
screen time. This is similar to the normative values reported by
Ridley et al.30 who found that South Australian children
accrued 26.15 hours of recreational screen time per week.
Figure 1 displays the time spent by adolescents with and with-
out CP on the various sedentary activities comprising recre-
ational screen time, and shows that the sedentary activity
patterns of the adolescents with and without CP were very sim-
ilar. On the face of it, this contrasts with two previous survey
studies that concluded that young people with CP and other
causes of physical disability were significantly more sedentary
than their peers without disabilities.15,28 However, these stud-
ies defined ‘sedentariness’ on the basis of a relative absence of
Higher rank
Playing with animals
Ranking of activity for adolescents with CP
Walking
Playing with younger
children Running/mucking
Swimming around
Tag
Riding a bike
CP Soccer
Non-CP Basketball
Cricket
Wrestling with friends
Playground
equipment Dodgeball
Dancing
Football
Tennis
Trampoline
Lower rank
Netball
Table tennis
Aerobics
Skipping
Martial arts
Ranking of activity for adolescents without CP
Lower rank Higher rank
Figure 2: Rankings for activities undertaken in past week by
adolescents with and without cerebral palsy (CP). Dotted line
same rank for adolescents with and without CP. Activities
games that are more highly ranked for adolescents with CP than
those without CP are positioned above dotted line and vice
versa. The greater the distance that an activity is situated
from this line, the greater the discrepancy in its ranking for
adolescents with CP and those without CP.
Physical and Sedentary Activity in Adolescents with CP Carol A Maher et al. 455
PA, rather than explicitly considering sedentary activities, such
as TV and computer use. The only study to measure actual
sedentary activities in young people with disabilities, includ-
ing CP, was that carried out by Brown and Gordon,14 which
measured time spent on ‘TV’ and ‘inactivity’ (what constituted
‘inactivity’ was not defined). They reported there was no sig-
nificant difference between their samples with and without a
disability for time spent on ‘TV’ and ‘inactivity’ when com-
pared as an entire group (age range 6–19y), but that there
was a significant age-by-disability status relationship for time
spent watching TV. Time spent watching TV increased signifi-
cantly with increasing age within their sample with a dis-
ability, but not within their healthy sample. It is difficult to
compare these findings with our results, particularly given
that activities that are considered core in the current view of
sedentariness (video games and recreational computer and
internet use) were not measured in Brown and Gordon’s
1987 study.4
It is interesting to consider the types of PAs reported by
the adolescents with and without CP. The activities reported
by adolescents with CP in this study have been ranked according
to the frequency with which they were reported, and plotted
against the frequency with which they were reported by age-
and sex-matched healthy comparisons in a recent study of
South Australian children by Ridley et al.30 (Fig. 2). While
some activities were ranked similarly for adolescents with
and without CP (walking, tag, riding a bicycle, tennis, tram-
polining, and martial arts), there were distinct differences in
many activities reported. Playing with animals, playing with
younger children, swimming, and playing on playground
equipment (i.e. activities that are typically unstructured and rea-
sonably low intensity) were far more frequently reported
among adolescents with CP than they were among their
healthy peers. Conversely, soccer, basketball, football, and
skipping (relatively structured and higher intensity activi-
ties) were far more frequently reported by healthy adoles-
cents than they were by those with CP. This is consistent with
Brown and Gordon’s 1987 findings that children with physi-
cal disabilities tended to take part in slower tempo activities
relative to their healthy peers.14
This study identified differences in the PA patterns of ado-
lescents with and without CP, and highlighted a relationship
between PA behaviours and level of impairment within adoles-
cents with CP. The questions of how much activity is required
to be considered to be fully participating within an activity,
how level of gross motor function alters participation rates,
and how participation is altered by opportunity all remain to
be explored. Although they are resource-intensive, direct
observation studies (often considered the criterion standard
in PA measurement) would provide a means to explore these
areas and would reduce the potential for bias inherent in self-
reported data, particularly in this population where differing
perceptions concerning participation in PA may exist.
Given the many health, social, and psychological benefits
of PA, and the probable additional functional benefits for
people with physical disability, the finding that young people
with CP report themselves to be less active than their healthy
peers is of concern, but based on previous studies, perhaps
not surprising. It appears that adolescents with CP are taking
part in a variety of physical activities, however, there is a ten-
dency towards participation in low-intensity, relatively soli-
tary activities. The ongoing challenge is to assist these young
456 Developmental Medicine & Child Neurology 2007, 49: 450–457
people to participate in PA that is not only enjoyable, but also
of sufficient intensity to achieve physiological benefits, while
maximizing opportunities for socialization.
Accepted for publication 22nd December 2006.
Acknowledgements:
Thanks to Novita Children’s Services, for advice and for giving
permission to contact clients; and to Wallis Cinemas for donating
cinema vouchers.
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List of abbreviations
PA Physical activity
PAQ-A Physical Activity Questionnaire for Adolescents
SES Socioeconomic status

European Academy of Childhood Disability

19th Annual Meeting
Development and Differentiation in
Childhood Disability
Groningen, the Netherlands June 14–16 2007

The Meeting will focus on children and adolescents with disabilities, in particular on their
development and possibilities to achieve their full potential as adults in modern society. The theme
will cover issues in three main areas of paediatric rehabilitation. It will provide the opportunity: (1) to
learn from typical and atypical patterns in the development of children and adolescents with specific
disorders; (2) to evaluate the pros and cons of old and new professional concepts; and (3) to learn
from the ever-changing, complex, and multicultural environment, in Europe and across the world.
The Meeting should point the way forward for us to promote and extend research in all aspects of
childhood disability.

Keynote lectures and workshops will include:

• Neurodevelopmental events in the human cerebral cortex
• Programming of the brain by early nutrition?
• Nature and nurture in motor development
• Childhood disability in a developmental and differential perspective
• New attitudes and advances in paediatric rehabilitation
• Participation and inclusion of children with disabilities
• To treat or not to treat in childhood disability: are there limitations to treatment?
New is the opportunity for attendees to contribute with specific information to the programme
(instructional courses and dedicated papers) and guided Poster Walks.

President of the meeting: Mijna Hadders-Algra

For more information see the website: www.eacd2007.nl

Physical and Sedentary Activity in Adolescents with CP Carol A Maher et al. 457