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. 2020 Spring;72(2):195–204. doi: 10.3138/ptc-2018-0053

Pilot Evaluation of a School-Based Programme Focused on Activity, Fitness, and Function among Children with Cerebral Palsy at GMFCS Level IV: Single-Subject Research Design

Carol Daly *, Connie L Moore †, Suzanne Johannes †, Julie Middleton ‡, Lisa K Kenyon §
PMCID: PMC7238939  PMID: 32494103

Abstract

Purpose: Children with cerebral palsy (CP) who function at Gross Motor Function Classification System (GMFCS) Level IV have difficulty achieving sufficient levels of physical activity to promote fitness. The purpose of this pilot evaluation was to investigate the practicability and impact of a school-based supported physical activity programme, using adaptive bicycles, on cardiorespiratory fitness and gross motor function among children with CP at GMFCS Level IV. Method: We used a single-subject, A–B–A–B research design replicated across three participants aged 8–14 years with CP at GMFCS Level IV who attended three different schools. Cardiorespiratory fitness was assessed weekly during all study phases using the energy expenditure index (EEI). Gross motor function was assessed using the Gross Motor Function Measure–66 (GMFM–66) and goal attainment scaling (GAS). During the intervention phases, an adaptive bicycle-riding programme was carried out daily at school for up to 30 minutes. Results: One participant demonstrated significant improvement on the EEI. All participants demonstrated improvement in gross motor function as determined by the GMFM–66 and GAS. Insights were garnered pertaining to the design for large-scale future studies. Conclusions: This pilot evaluation supports further investigation of school-based adaptive bicycle-riding programmes for children who have CP at GMFCS Level IV.

Key Words: sports for persons with disabilities, bicycling, cerebral palsy, school health services

Mots-clés : : cyclisme, paralysie cérébrale, paralysie cérébrale – GMFCS niveau IV, programmes d’activité physique en milieu scolaire, vélo adapté

Children and youth with cerebral palsy (CP) frequently have lower levels of physical activity and participation than their typically developing peers.1 These lower levels of physical activity may contribute to deconditioning and poor physical fitness, thereby creating a negative cycle in which a low level of physical fitness leads to an even lower level of physical activity.2,3 As children with severe CP age, impairments such as abnormal muscle tone, poor selective motor control, and elevated levels of energy expenditure may further limit a child’s physical activity and ability. Limitations in physical activity may lead to restricted participation in age-expected motor play and structured exercise.4 Because of the bidirectional interplay between impairments and physical activity, habitual low levels of physical activity contribute to the development of secondary conditions, including chronic pain, fatigue, and osteoporosis.4 Although there are no established standards for physical activity for people with CP, evidence-based guidelines suggest a minimum frequency of two to three times per week for a minimum of 20 minutes per session over a period of 8–16 weeks.5

Although much has been written about the importance of physical activity for all children,6 interest in the impact of sedentary behaviour on health is growing. Sedentary behaviour has been defined for typically developing children and adults as any waking behaviour that is characterized by an energy expenditure of 1.5 metabolic equivalents or fewer while sitting or reclining.7 For children with CP, impairments in body structure and function may increase their energy expenditure during activities such as sitting and standing, thereby making it difficult to apply the standard definition of sedentary behaviour to this population.7

Activity and participation-based approaches may be useful in decreasing sedentary behaviours,7 and they have been specifically used with school-aged children with CP who function at Gross Motor Function Classification System (GMFCS) Levels III–V.8,9 Although children classified at GMFCS Levels IV and V are unable to walk using hand-held assistive devices, ambulation in home and school settings as an activity and participation-based intervention using gait trainers has been reported in this population.10 Gait trainers, also referred to as support walkers, are lightweight wheeled walkers that provide additional trunk and pelvic support and may include a sling or seat that supports a portion of a child’s body weight.11

Gait trainers, partial weight-bearing treadmill training, and cycling on adaptive tricycles were among the interventions used in a programme to provide supported physical activity for children with complex motor and medical conditions (including CP at GMFCS Level IV).12 In this study, supported physical activity is operationally defined as any movement initiated by the skeletal muscles (made possible using human assistance, adaptive equipment, or assistive technology) that results in a minimal increase over resting energy expenditure. Using this definition, study participants demonstrated improvements in health-related quality-of-life scores as measured by the Caregiver Priorities and Child Health Index of Life with Disabilities.12

Children with bilateral spastic CP (GMFCS Levels I–III) demonstrated improvements in cardiovascular fitness, endurance, gross motor function, and strength after participating in a clinic-based stationary cycling programme.13 However, these same children may have difficulty engaging in over-ground cycling activities because of poorly coordinated, arrhythmic cycling patterns; as a result, they may need additional time to switch from the downstroke to the upstroke when pedalling.14 Using an adaptive bicycle with a fixed-gear drive chain may give children who have difficulty coordinating their cycling patterns the opportunity to participate in over-ground cycling activities. A fixed-gear drive chain uses the inertia of the bicycle to minimize the time spent in the “dead spot” between the downstroke and the upstroke when pedalling. Such adaptive bicycles may provide children with CP with a means to increase their physical activity, physical fitness, and overall gross motor function.

This pilot evaluation investigated the practicability and impact of a school-based supported physical activity programme, using adaptive bicycles, on cardiorespiratory fitness and gross motor function among children with CP at GMFCS Level IV. We hypothesized that an adaptive bicycle-riding programme conducted in a school setting would have a positive impact on measures of cardiorespiratory fitness and gross motor function among these children. The institutional review board at the University of Michigan–Flint approved this study. Parental or guardian permission was obtained for all participants, and the children’s assent was obtained as appropriate.

Methods

Given the limited research in this area, this pilot evaluation used an A–B–A–B single-subject research design (SSRD) replicated across three participants who attended three different schools. SSRDs are recommended for studying heterogeneous conditions (such as CP at GMFCS Level IV) or when individual variation occurs from day to day.15,16 A pilot evaluation allows researchers to test the workability, reliability, and validity of their research methods on a smaller scale with the goal of informing a future large-scale study.17

Every effort was made to conduct the study in a manner that was consistent with the school environment. For this reason, the duration of each phase was planned a priori to accommodate the school calendar and was as follows: baseline (A1) phase, 4 weeks; first intervention (B1) phase, 8 weeks; second baseline (A2) phase, 7 weeks; and second intervention (B2) phase, 8 weeks, for a total study duration of 27 weeks. Although the A2 phase lasted 7 weeks, fewer than seven data points were obtained because of the school holidays in December and January.

Participants

A sample of convenience was recruited from two school districts in Iowa. Both school districts were moderate in size (5,000–13,000 students) and included schools in rural as well as suburban and urban settings. Inclusion criteria for the participants were that they be aged 6–18 years and have been diagnosed with CP classified as GMFCS Level IV (assessed by the school physical therapist [PT]). Participants demonstrated their ability to step using a gait trainer without adult assistance in the school environment to support the collection of energy expenditure index (EEI) data. Exclusion criteria included having undergone a musculoskeletal or neurological surgical procedure within the previous 6 months. All participants continued their regular school-based physical therapy services and were not restricted from being involved in other therapies or outpatient physical therapy services.

Outcome measures and schedule of testing

The outcome measures and the schedule of testing are detailed in Figure 1. The target behaviour in this study was cardiorespiratory fitness. During all phases of the study, cardiorespiratory fitness was assessed weekly using the EEI,18 an indirect measure of cardiorespiratory fitness that uses a submaximal heart rate (HR) response to calculate energy cost during ambulation. The EEI is calculated using the following formula: exercise HR – resting HR (beats per minute) ÷ walking speed (metres per minute). A low EEI score represents increased walking efficiency.18

Figure 1.

Outcome measures and schedule of testing.

Figure 1.

GMFM–66 = Gross Motor Function Measure–66; GAS = Goal Attainment Scaling; EEI = energy expenditure index.

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Although the EEI’s reliability in use with children with CP has been reported, its reliability and validity with children functioning at GMFCS Level IV has not specifically been explored.19 Ballaz and colleagues reported successfully using the EEI to measure the outcome of an aquatic therapy programme for children with CP, including one child described as being at GMFCS Level IV.20 Another study comparing the impact of two aquatic intervention programmes on walking described the use of the EEI with children classified at GMFCS Levels III, IV, and V.21

All the participants in this study used a gait trainer while the EEI was being administered. Although a 55-metre walk is commonly used to calculate walking speed,18 the EEI has been found to be reliable at distances of 55 metres or less.19,22 If the study participants were unable to use their gait trainers for 55 metres, their walking speed was calculated using the specific distance travelled. In administering the EEI, HR was obtained by auscultation, and distances were measured using a surveyor’s wheel.

In addition to measuring the target behaviour, gross motor function was assessed at the start of the study and at the end of each intervention (B) phase using both the Gross Motor Function Measure–66 (GMFM–66) and goal attainment scaling (GAS).23,24 The GMFM–66 is a valid and reliable measure developed for use with children who have CP. GAS involves measuring the progress toward individualized goals using a five-level interval scale (ranging from –2 to +2): baseline performance at the initial administration of the GAS is assigned a value of –2, progress toward the expected outcome is assigned a value of –1, and the expected performance after intervention is assigned a value of 0. Values of +1 and +2 indicate performance that exceeds expected performance.

The validity and interrater reliability of GAS have been established, and it has also been shown to be sensitive to detecting change in school-based, individualized goals for children with CP across all GMFCS levels.25,26 To replicate standard practice in school-based physical therapy, the school-based PT and the participant’s school team developed one GAS measure for each participant in the study.25 These GAS data were collected throughout the study; participants were scored at the beginning of the study and at the end of intervention phases B1 and B2. Refer to online Appendix 1 for the detailed GAS goals for each participant.

All outcome measures were administered by each participant’s school-based PT (CLM or SJ). Both PTs had more than 14 years of experience and established competency to perform the standardized measures used in this study using annual competency assessments. Procedural fidelity during data collection activities was ensured by using checklists detailing each step in the data collection process. The GAS goals were scored by a co-investigator (JM), who was not involved in providing the intervention or other services to the participants.

Intervention

Freedom Concepts’ Discovery Series or Adventurer Series adaptive bicycles (Freedom Concepts, Inc., Winnipeg, MB), such as those shown in Figure 2, were selected to meet the needs of each participant. All adaptations were standard or selected from a list of available features. The adaptive bicycle-riding programme was conducted, as part of the participants’ regular school activities, by the paraprofessional educators who were familiar with the participants. Before the study began, paraprofessional educators received training from the primary investigator (CD) in human subjects research and aspects of the adaptive bicycle-riding programme, including its parameters (noted next), transfers, and safety.

Figure 2.

Figure 2.

Figure 2.

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Examples of adaptive bicycles, designed with hoop handlebars, headrest, backrest, wide seat belt, chest harness, attendant rear steering, and braking control.

During the intervention phases of the study, participants were given the opportunity to ride their adaptive bicycle either inside or outside for up to 30 minutes per day,12 5 days per week (within the confines of the school calendar). Each participant’s assent was obtained before starting each bicycle-riding session, and sessions were terminated if a participant indicated “all done” or stopped pedalling for 1 minute despite verbal encouragement. The total cycling time for each participant was measured using a stopwatch, and distance was measured using a wireless bicycle computer (Sigma Sport BC8.12, Sigma Sport USA, St. Charles, IL), which was installed by the bicycle manufacturer. Intervention data were collected using weekly log sheets.

The bicycle-riding programme was supervised each week by each participant’s school PT. Procedural fidelity was ensured by using checklists that detailed each step in the intervention process. To reflect the school environment, the programme was not conducted if it conflicted with other school activities, such as assemblies, field trips, early-dismissal days, vacation days, teacher in-service days, or weather-related school closures.

Data analysis

To supplement our visual analysis of the data, we used the 2-SD band method to determine significance for the EEI data. This method uses the first baseline phase (A1) mean score to create a ±2-SD band, which is then used to evaluate the data points for the remainder of the study.16 Two consecutive data points that fall outside the ±2-SD band are considered statistically significant.16 The GMFM–66 scores for each participant were interpreted using CIs to detect clinically meaningful change.16 To interpret changes in GAS scores, raw scores were transformed to T-scores with a mean of 50 (SD 10). A T-score of 40 or more (raw score ≥ −1) reflects progress toward attaining goals and changes in performance.24

Results

The characteristics of the three participants are presented in Table 1. Programme adherence rates were 99% for Participant 1, 75% for Participant 2, and 83% for Participant 3; details are presented in online Appendix 2. No procedural changes were made during the course of the study, and no adverse events occurred. GMFM–66 and GAS scores are given in Table 2, and GAS scores for each participant at various points in the study are provided in online Appendix 1. The results for each participant are detailed in the following sections.

Table 1.

Participants’ Characteristics at Beginning of Study

Participant Age, y Type of CP GMFCS7 level MACS27 level CFCS28 level EDACS29 level Vision status Type of gait trainer used during EEI18
1 14 Spastic quadriplegia IV IV III V Low vision KidWalk
2   8 Spastic quadriplegia IV V IV IV Cerebral visual impairment KidWalk
3 10 Spastic quadriplegia IV IV III IV No known visual issues Rifton Pacer with chest and hip prompts
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CP = cerebral palsy; GMFCS = Gross Motor Function Classification System; MACS = Manual Ability Classification System; CFCS = Communication Function Classification System; EDACS = Eating and Drinking Ability Classification System; EEI = energy expenditure index.

Table 2.

Participants’ Outcomes on GMFM–6623 and GAS24

Participant GMFM–6623 GAS24
Before study began End of first intervention (B1) End of second intervention (B2) Clinically meaningful change? Before study began End of first intervention (B1) End of second intervention (B2) Clinically meaningful change?
Score, mean (SD) 95% CI Score, mean (SD) 95% CI Score, mean (SD) 95% CI Raw score T-score Raw score T-score Raw score T-score
1 28.0 (2.0) 24.1, 31.9 30.0 (1.9) 26.2, 33.8 32.9 (1.8) 29.3, 36.4 Yes, between start of study and end of B2 −2 30 2 70 2 70 Yes, between start of study and end of both B1 and B2
Goal: XXX will require touch cues to hold his head upright no more than 6–8 times while engaged in the bicycle-riding programme over a 30-min time frame
2 36.4 (1.5) 33.6, 39.3 42.4 (1.1) 40.3, 44.6 42.4 (1.1) 40.3, 44.6 Yes, between start of study and end of both B1 and B2 −2 30 2 70 1 60 Yes, between start of study and end of both B1 and B2
Goal: XXX will be able to ride his adaptive bicycle 1 km on 2 out of 5 d
3 35.7 (1.6) 32.6, 38.8 41.6 (1.1) 39.4, 43.8 42.8 (1.1) 40.7, 45.0 Yes, between start of study and end of both B1 and B2 −2 30 0 50 2 Goals Yes, between start of study and end of both B1 and B2
Goal: XXX will complete 90% of the 30-min bicycle-riding programme on 2 out of 5 d
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GMFM–66 = Gross Motor Function Measure–66; GAS = goal attainment scaling; B1 = first intervention phase; B2 = second intervention phase.

The results of the EEI for each participant can be found in Figures 3a–c, respectively. Because of school holidays, we obtained fewer than seven data points during the 7-week second baseline (A2) phase.

Figure 3.

Energy expenditure index results for (a) Participant 1, (b) Participant 2, and (c) Participant 3.

Figure 3.

Figure 3.

Figure 3.

Solid lines = mean; dotted lines = ±1 SD; dashed lines = ±2 SDs.

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Participant 1

As shown in Figure 3a, the EEI scores were variable during the first baseline (A1) but became more consistent and trended downward during the first intervention (B1), second baseline (A2), and second intervention (B2) phases. Multiple EEI data points dropped below the 1-SD band line, but improvements in the EEI scores did not reach the level of significance (i.e., none of the data points fell below the 2-SD band line). Clinically meaningful change was demonstrated between the GMFM–66 score obtained before the study began and the score obtained at the end of B2. Improvement was noted in the GAS goal “XXX will require touch cues to hold his head upright no more than 6–8 times while engaged in the bicycle-riding programme over a 30-minute time frame” in that performance greatly exceeded expectations (raw score +2, T = 70) after B1. This improved performance was maintained at the same level through B2. In addition, school personnel reported that Participant 1 had progressed to using his gait trainer to ambulate as part of his daily school activities during the study.

Participant 2

Variability in the EEI scores was noted through the first baseline (A1) phase and first intervention (B1) phase. Greater consistency in the EEI scores was observed during the second baseline (A2) phase and the second intervention (B2) phase, during which time multiple EEI data points (i.e., two or more consecutive data points) dropped below the 2-SD band, indicating significant improvement. Clinically meaningful change was demonstrated between the GMFM–66 score obtained before the study began and the score obtained at both the end of B1 and the end of B2. Improvement was noted in the GAS goal “XXX will be able to ride his adaptive bicycle 1 kilometre on 2 out of 5 days” in that performance exceeded expectations (raw score +2, T = 70) after the first intervention (B1) phase. This improved performance was maintained although at a slightly lower level (raw score +1, T = 60) at the end of the second intervention (B2) phase.

Participant 3

The EEI scores for Participant 3 were variable throughout the first three phases of the study. Greater consistency and lower scores were noted in the second intervention (B2) phase, in which multiple EEI data points were at or below the 1-SD band, but improvements in the EEI scores did not reach the level of significance (i.e., none of the data points fell below the 2-SD band line). Clinically meaningful change was demonstrated between the GMFM–66 score obtained before the study began and the score obtained at the end of intervention phases B1 and B2. Improvement was noted in the GAS goal “XXX will complete 90% of the 30-minute bicycle-riding programme on 2 out of 5 days” in that performance improvement was as expected (raw score 0, T = 50) after the first intervention (B1) phase. Improvements in performance continued: performance exceeded expectations (raw score +2, T = 70) after the second intervention (B2) phase. School personnel reported that Participant 3 was able to ambulate faster using his gait trainer by the end of the bicycle-riding programme.

Pilot evaluation assessment

Because this was a pilot evaluation, it is important to consider the study factors related to process, resources, management, and method that may affect or facilitate a future study.17 The mechanics of the adaptive bicycle-riding programme appear to have been successfully carried out in these three school-based settings. The staff at each school informally reported that they had enjoyed carrying out the programme because of the positive reaction of both the participants and their respective school communities. Formally assessing the social validity of the programme in future studies to determine whether it was acceptable, socially relevant, and useful from the perspective of the school staff would be beneficial. This pilot evaluation also provided specific insights into research methods that should be considered in future studies.

Given that cardiorespiratory fitness was only significantly improved for one participant, changing the target behaviour to exercise capacity and endurance as measured using the 1-minute walk test (1MWT) may be better suited for future studies with children who have CP at GMFCS Level IV.30–32 Specifically establishing the reliability, validity, and responsiveness of the 1MWT in children with CP at GMFCS Level IV who use gait trainers would be an additional step in improving methodological rigor and would increase confidence in the findings of future studies.33 Using accelerometers to measure physical activity during the baseline and intervention phases might also help to determine whether partaking in a bicycle-riding programme would significantly affect the overall level of physical activity among this population. Future studies could also explore using a bicycle-riding programme to promote leisure activity and decrease sedentary behaviours among this population.

Although none of the participants achieved a steady state for EEI during the initial baseline (A1) phase, extending the baseline period to achieve stability in the target behaviour may have resulted in a training effect because of the characteristics of the test itself. To help avoid such issues in future studies and raise the level of evidence provided, either a concurrent, multiple-baseline A–B SSRD with randomized assignment to baselines of various durations or a within-subjects cohort design should be considered for a future study. Such designs would also simultaneously provide a possible opportunity to increase the number of intervention weeks that could be included in a school calendar and would eliminate the need to return to baseline, thereby further increasing the number of intervention weeks. Adding qualitative interviews with various stakeholders (teachers, parents, other school personnel, and participants, if able) might also help in better understanding the benefits and challenges of implementing a school-based bicycle-riding programme. Finally, the cost of the adaptive bicycles ($3,500) is a factor that would need to be addressed in future studies.

Discussion

This pilot evaluation explored the impact of a school-based adaptive bicycle-riding programme on cardiorespiratory fitness and gross motor function of children with CP at GMFCS Level IV. The study was designed to be consistent with school-based physical therapy practice, the school environment, the school calendar, and the rhythm of the school day. The programme was well tolerated by the participants, no adverse events occurred, and school personnel in all three school settings appeared to accept and enjoy being involved in the programme. All three participants demonstrated clinically meaningful change on measures of gross motor function and goal achievement. One participant demonstrated significant improvement in cardiorespiratory fitness.

Children with CP often reach their gross motor capacity when they are aged 7 years, and they typically experience a decline in gross motor skills and ambulatory function as they age into late childhood and adolescence.34,35 Yet the participants in this study demonstrated stable or improved GMFM–66 scores across the 27-week duration of the study. Given recent research on the need for and benefits of physical activity for children with CP,5 regular, ongoing participation in activities such as a school-based bicycle-riding programme may help to slow the expected decrease in gross motor skills. Future research should investigate whether the increased physical activity provided by such programmes could curtail the development of secondary impairments, which contribute to declining motor function with age in individuals who have CP at GMFCS Level IV.

This concept is reinforced by the findings of a longitudinal study of 92 children with CP, aged 9–16 years, at GMFCS Levels I–V, which explored changes in motor capacity (defined as motor ability in a standardized environment) and activity performance (defined as what is actually done in daily life).36 This study found that over a 1.2-year time frame, only youth at GMFCS Level I demonstrated a significant increase in activity performance. Motor capacity was statistically unchanged among participants who functioned at GMFCS Levels I–III, and it significantly declined in participants with GMFCS Levels IV and V. For youth at these levels, measures of activity performance at the beginning of the study were more strongly positively correlated with their later motor capacity than was seen among study participants at Levels I–III. For youth with CP at GMFCS Levels IV, this study finding provides evidence in support of activity- or participation-based interventions across the life span to slow age-related declines in motor capacity.35,36

Children with CP at GMFCS Level IV are likely to have additional conditions, such as difficulties with communication, feeding, digestion, and so forth, that may affect their health, and their daily lives are more likely to be curtailed by these additional health conditions.37,38 It is therefore not surprising that each of the children in the study missed biking days as a result of school absences (see online Appendix 1). Participant 2 missed the greatest number of biking days because of school absences (16 out of 80, or 20%). Had he been able to bike a greater number of days, he might have experienced greater improvements. Future research involving children with CP at GMFCS Level IV should not only consider the potential impact of additional health conditions on programme adherence but also explore the possibility of incorporating the adaptive bicycle-riding programme into a comprehensive health and wellness programme across the school, home, and community environments to more fully address the needs of children with limited motor abilities.

Future research in school and non-school settings is warranted to more fully explore the impact of an adaptive bicycle-riding programme on children and youth with CP. Participating in adaptive bicycle-riding programmes could be a beneficial lifelong leisure activity for individuals with CP at GMFCS Level IV, one that could help to decrease the sedentary behaviours often observed in this population. Research into participants’ function in areas such as manual ability, communication, and eating and drinking, which interact with gross motor function, could provide insight into the prognosis for a child’s success with an adaptive-bicycle riding programme. In addition, a study exploring how the use of available bicycle adaptations may assist or hinder individual performance could help therapists to better tailor bicycle-riding programmes to meet the needs of specific children.

This study had several limitations. The first was its small sample size and the corresponding lack of generalizability of the results. Second, the use of a replicated SSRD, designed to reflect the realities of a school-based programme, resulted in inherent limitations in internal validity and restricted the number of data collection opportunities in its various phases. Internal validity would have been strengthened by establishing intrarater and interrater reliability at the start of each phase of the study. In addition, given that the EEI has not been fully explored for use with children with CP who function at GMFCS Level IV, its use may also have affected internal validity. We also did not gather information on other forms of physical activity that the participants may have been involved in during the study. Finally, this study focused solely on children with CP at GMFCS Level IV and consequently cannot be generalized to children who do not have CP at GMFCS Level IV.

Conclusion

This pilot evaluation demonstrated that the mechanics of an adaptive bicycle-riding programme for children with CP GMFCS Level IV could be successfully carried out in three different school-based settings. Many insights to help plan and conduct future studies were gleaned from the study. Although this was a pilot evaluation, the participants demonstrated improvements in motor function that were perhaps unexpected given their age. Given the paucity of evidence for physical therapy interventions for individuals with CP at GMFCS Level IV, this pilot evaluation also appears to support continued investigation of school-based adaptive bicycle-riding programmes with children who have CP at GMFCS Level IV.

Key Messages

What is already known on this topic

Secondary to multiple impairments, children with cerebral palsy (CP) who function at Gross Motor Function Classification System (GMFCS) Level IV have difficulty achieving sufficient levels of physical activity to promote fitness. As such, their levels of fitness are diminished. Low levels of physical activity may contribute to secondary conditions such as chronic pain, fatigue, and osteoporosis.

What this study adds

This pilot evaluation demonstrated that the mechanics of an adaptive bicycle-riding programme for children with CP at GMFCS Level IV could be successfully carried out in three different school-based settings. This pilot evaluation supports further exploration of a school-based physical activity programme using adaptive bicycles with children and youth who have CP at GMFCS Level IV. Future studies should consider a target behaviour related to exercise capacity and endurance and using accelerometers to measure physical activity during the baseline and intervention phases. To build on the findings of this study and help raise the level of evidence provided, future studies should consider a multiple-baseline single-subject research design with randomized assignment to baselines of various durations.

Supplementary Material

Appendix 1
Click here for additional data file. (14.8KB, pdf)
Appendix 2
Click here for additional data file. (16.9KB, pdf)

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