Clinician’s Commentary on Daly et al.

For children, developing motor and cognitive skills, finding individualized interests, and making friends are products of participation. However, for children with disabilities, as the level of severity of disabilities increases, their participation declines.^2,3 In addition, they participate in activities that are less diverse, often occur in solitude, and commonly occur at home.^4,5 What children and families want are active and skill-based opportunities to participate.^6,7 By implementing an adaptive cycling programme, Daly and colleagues gave children with disabilities an active, skill-based opportunity to participate in the school environment alongside their peers and teachers.¹

Daly and colleagues promoted activity-based participation for all children with disabilities, even those with a higher level of severity.¹ Addressing the need for physical activity and reducing sedentary behaviors in children with more severe disabilities is important because, as Verschuren and colleagues pointed out,⁸ for children with cerebral palsy at Level IV on the Gross Motor Function Classification System (GMFCS),⁹ participation in moderate to vigorous physical activity is basically nonexistent, light physical activity is extremely low, and sedentary behavior is unfortunately high. In Daly and colleagues’ study, children at GMFCS Level IV successfully participated in light physical activity, which most likely decreased their sedentary behaviors. In addition, the cycling activity did not cause harm and appears to have improved gross motor function.

Physical Activity in Schools

The Centers for Disease Control and Prevention in Atlanta, Georgia, has recommended a Comprehensive School Physical Activity Program consisting of 60 minutes of daily physical activity before, during, and after the school day. This physical activity can occur before and after school, during physical education, and during school with staff involvement and community engagement.¹⁰ Statistics have suggested that the majority of typically developing children do not participate in 60 minutes of daily physical activity, so it is reasonable to expect that this is true, if not worse, for children with disabilities at GMFCS Level IV.¹¹ Daly and colleagues addressed this gap by successfully implementing physical activity using a cycling programme for children at GMFCS Level IV in a school setting.¹ The success of their programme may inspire others to expand the opportunities to participate in cycling to and from home and school, to and from the bus and classroom, and to and from the classroom and school library, as well as during physical education classes and field trips. Reaching for the stars, maybe there is an opportunity to start cycling clubs for children with and without disabilities before and after school. Replicating, expanding, and extending the work of Daly and associates may make it possible to make a change in culture that supports an active lifestyle for children at GMFCS Level IV.

Strengths of the School Environment

With its educational, daily structure, related services, and physical environmental strengths, the school setting has remarkable potential to advance active, skill-based opportunities for children with disabilities and to carry out and inform evidence-based research. The US Individuals with Disabilities Education Improvement Act of 2004 mandates a free and appropriate education for children with disabilities;¹² as such, the majority of children with disabilities attend school, where they spend a substantial part of their day and their childhood. Helping children to become more active and accomplish skills in the school setting will foster motor, cognitive, and social growth. By modeling successful growth and abilities for children with disabilities using physical activity, schools may inspire and cultivate carryover into the home and community settings. As with those portrayed in Daly and colleagues’ article,¹ researchers and school personnel would be wise to recognize the strengths of a school setting in research because it can provide rich, real-world research applications and environments that produce realistic translational evidence.

Costs

Implementing an adaptive cycling programme can be costly in terms of two areas: finances and space. Daly and colleagues plainly discussed the $3,500 price tag for an adaptive cycle.¹ Although these cycles are costly, they are safe and operationally reliable and were designed with children with disabilities in mind. In addition, one size usually fits a range of children’s body sizes, so they can be used by multiple users and encourage more efficient usage in settings, such as schools. Despite these advantages, purchasing adaptive cycles may be cost prohibitive for some schools. However, with today’s current computer technology, it may be possible to use 3-D printers to create and produce reasonably priced adaptive cycles much like Huang and colleagues¹³ did with ride-on cars and Go Baby Go projects.

In terms of space costs, schools are likely the best place for children to use these cycles. Schools are typically larger, more open, and more accessible than home and community settings; thus, they would better facilitate regular daily riding and offer storage space.

Setting Higher Expectations

Daly and colleagues used Goal Attainment Scaling (GAS) in their study, which highlighted individual improvements among all study participants.¹ This approach is to be applauded, but these GAS findings do speak to my experience and concern: rehabilitation and educational specialists often have low expectations of the abilities of children with more severe health conditions or disabilities. In the Daly and colleagues study, for example, the study participants all surpassed the expected GAS level by the study mid-point rather than the endpoint, reflecting how their abilities had been underestimated. It is imperative that rehabilitation and educational personnel focus on ability rather than disability while also raising the ability achievement bar.

The F-words Conclusion

Daly and colleagues are to be commended for their “F-words” programming. This pilot project fully embodied the F-words – fitness, function, friends, family, and fun – all of which will lead children with disabilities to have a brighter future.^1,14 The study demonstrated that engaging in light physical activity and reducing sedentary behavior is feasible for children with disabilities who are more motorically involved, and it showed that functional gains can occur. Daly and colleagues should be encouraged to further investigate their adaptive cycling programme in school settings and share those findings. Their work may serve as a catalyst to motivate other schools, communities, and rehabilitation organizations and their personnel to create and adopt physical activity programming for children with disabilities across all severity levels.