Measuring Habitual Physical Activity in Neuromuscular Disorders: A Systematic Review

Background: Free-living or habitual physical activity (HPA) refers to someone’s performance in his or her free-living environment. Neuromuscular disorders (NMD) manifest through HPA, and the observation of HPA can be used to identify clinical risks and to quantify outcomes in research. This review summarizes and analyses previous studies reporting the assessment of HPA in NMD, and may serve as the basis for evidence-based decision-making when considering assessing HPA in this population. Methods: A systematic review was performed to identify all studies related to HPA in NMD, followed by a critical appraisal of the assessment methodology and a final review of the identified HPA tools. Results: A total of 22 studies were selected, reporting on eight different direct tools (or activity monitors) and ten structured patient-reported outcomes. Overall, HPA patterns in NMD differ from healthy control populations. There was a noticeable lack of validation studies for these tools and outcome measures in NMD. Very little information regarding feasibility and barriers for the application of these tools in this population have been published. Conclusions: The variety and heterogeneity of tools and methods in the published literature makes the comparison across different studies difficult, and methodological guidelines are warranted. We propose a checklist of considerations for the assessment and reporting of HPA in NMD.

[1]  C. Victora,et al.  Reliability and validity of the International Physical Activity Questionnaire (IPAQ). , 2004, Medicine and science in sports and exercise.

[2]  Roslyn N Boyd,et al.  Systematic review of the relationship between habitual physical activity and motor capacity in children with cerebral palsy. , 2014, Research in developmental disabilities.

[3]  William R Leonard,et al.  Measuring human energy expenditure: What have we learned from the flex‐heart rate method? , 2003, American journal of human biology : the official journal of the Human Biology Council.

[4]  C. M. Wiles,et al.  Falls and stumbles in myotonic dystrophy , 2005, Journal of Neurology, Neurosurgery & Psychiatry.

[5]  J. Bussmann,et al.  Exercise training in adults with Pompe disease: the effects on pain, fatigue, and functioning. , 2015, Archives of physical medicine and rehabilitation.

[6]  Y. Anziska,et al.  Exercise in Neuromuscular Disease , 2014, Seminars in Neurology.

[7]  K R Westerterp,et al.  Heart rate monitoring to assess energy expenditure in children with reduced physical activity. , 1996, Medicine and science in sports and exercise.

[8]  C. Ottenheijm,et al.  Determining the role of sarcomeric proteins in facioscapulohumeral muscular dystrophy: a study protocol , 2013, BMC Neurology.

[9]  P. Portero,et al.  Exercise tolerance and daily life in McArdle's disease , 2005, Muscle & nerve.

[10]  Terry D Ellis,et al.  Capturing Ambulatory Activity Decline in Parkinson's Disease , 2012, Journal of neurologic physical therapy : JNPT.

[11]  C. Bouchard,et al.  A method to assess energy expenditure in children and adults. , 1983, The American journal of clinical nutrition.

[12]  M. Emtner,et al.  Exploratory study of physical activity in persons with Charcot-Marie-Tooth disease. , 2015, Archives of physical medicine and rehabilitation.

[13]  W P James,et al.  Calorimetric validation of the doubly-labelled water method for determination of energy expenditure in man. , 1984, Human nutrition. Clinical nutrition.

[14]  R. Ware,et al.  A Systematic Review of the Clinimetric Properties of Habitual Physical Activity Measures in Young Children with a Motor Disability , 2012, International journal of pediatrics.

[15]  C. Mazzà,et al.  Free‐living monitoring of Parkinson's disease: Lessons from the field , 2016, Movement disorders : official journal of the Movement Disorder Society.

[16]  P. Duncan,et al.  Adherence to Accelerometry Measurement of Community Ambulation Poststroke , 2013, Physical Therapy.

[17]  M. McCrory,et al.  Energy expenditure, physical activity, and body composition of ambulatory adults with hereditary neuromuscular disease. , 1998, The American journal of clinical nutrition.

[18]  A. Wintzen,et al.  Does modafinil enhance activity of patients with myotonic dystrophy? , 2007, Journal of Neurology.

[19]  J. Becher,et al.  Ambulatory activity of children with cerebral palsy: which characteristics are important? , 2012, Developmental medicine and child neurology.

[20]  A. Geurts,et al.  Effectiveness and cost-effectiveness of a self-management group program to improve social participation in patients with neuromuscular disease and chronic fatigue: protocol of the Energetic study , 2015, BMC Neurology.

[21]  Ulf Ekelund,et al.  Guide to the assessment of physical activity: Clinical and research applications: a scientific statement from the American Heart Association. , 2013, Circulation.

[22]  Physical Activity Measurement In Older Adult Interventions: A Systematic Review And Meta-analysis , 2015 .

[23]  Diego Munguía-Izquierdo,et al.  Evaluation of a wearable body monitoring device during treadmill walking and jogging in patients with fibromyalgia syndrome. , 2012, Archives of physical medicine and rehabilitation.

[24]  David B Allison,et al.  Evaluation of a portable device to measure daily energy expenditure in free-living adults. , 2007, The American journal of clinical nutrition.

[25]  David A. Rowe,et al.  Measuring free-living physical activity in COPD patients: Deriving methodology standards for clinical trials through a review of research studies. , 2016, Contemporary clinical trials.

[26]  Tiffany J Dwyer,et al.  Evaluation of the SenseWear activity monitor during exercise in cystic fibrosis and in health. , 2009, Respiratory medicine.

[27]  A. Emery Population frequencies of inherited neuromuscular diseases—A world survey , 1991, Neuromuscular Disorders.

[28]  Validity of the Brazilian version of the Godin-Shephard Leisure-Time Physical Activity Questionnaire. , 2015, Cadernos de saude publica.

[29]  Richard R Rosenkranz,et al.  Validity of the Actical accelerometer step-count function in children. , 2010, Pediatric exercise science.

[30]  A. Jette,et al.  The Physical Activity Scale for the Elderly (PASE): development and evaluation. , 1993, Journal of clinical epidemiology.

[31]  D. A. Bailey,et al.  Physical Activity Questionnaire for Older Children , 2019 .

[32]  K R Westerterp,et al.  Doubly labelled water validation of three physical activity questionnaires. , 1999, International journal of sports medicine.

[33]  M. Tremblay,et al.  A comparison of direct versus self-report measures for assessing physical activity in adults: a systematic review , 2008, The international journal of behavioral nutrition and physical activity.

[34]  H. Dawes,et al.  Supported community exercise in people with long-term neurological conditions: a phase II randomized controlled trial , 2011, Clinical rehabilitation.

[35]  J F Sallis,et al.  Assessment of physical activity by self-report: status, limitations, and future directions. , 2000, Research quarterly for exercise and sport.

[36]  G. Hawker,et al.  Alendronate in the treatment of low bone mass in steroid-treated boys with Duchennes muscular dystrophy. , 2005, Archives of physical medicine and rehabilitation.

[37]  C. McDonald Physical activity, health impairments, and disability in neuromuscular disease. , 2002, American journal of physical medicine & rehabilitation.

[38]  Huong Q. Nguyen,et al.  Physical activity patterns of patients with cardiopulmonary illnesses. , 2012, Archives of physical medicine and rehabilitation.

[39]  D. Allen,et al.  Remote Physical Activity Monitoring in Neurological Disease: A Systematic Review , 2016, PloS one.

[40]  Regina L. Leckie,et al.  Measuring Physical Activity Using Accelerometry in a Community Sample with Dementia , 2013, Journal of the American Geriatrics Society.

[41]  A. Kornberg,et al.  Strong Correlation Between the 6-Minute Walk Test and Accelerometry Functional Outcomes in Boys With Duchenne Muscular Dystrophy , 2015, Journal of child neurology.

[42]  Catherine Sackley,et al.  Pedometer step counts in individuals with neurological conditions , 2009, Clinical rehabilitation.

[43]  M. Hagströmer,et al.  The International Physical Activity Questionnaire (IPAQ): a study of concurrent and construct validity , 2006, Public Health Nutrition.

[44]  L. Denehy,et al.  Comparison of Pedometer and Activity Diary for Measurement of Physical Activity in Chronic Obstructive Pulmonary Disease , 2009, Journal of cardiopulmonary rehabilitation and prevention.

[45]  Basia Belza,et al.  The Relationship of Physical Activity to Health Status and Quality of Life in Cerebral Palsy , 2008, Pediatric physical therapy : the official publication of the Section on Pediatrics of the American Physical Therapy Association.

[46]  P. Williamson,et al.  Using the Delphi Technique to Determine Which Outcomes to Measure in Clinical Trials: Recommendations for the Future Based on a Systematic Review of Existing Studies , 2011, PLoS medicine.

[47]  G. Bleijenberg,et al.  Dimensional assessment of chronic fatigue syndrome. , 1994, Journal of psychosomatic research.

[48]  Basia Belza,et al.  Ambulatory Physical Activity Performance in Youth With Cerebral Palsy and Youth Who Are Developing Typically , 2007, Physical Therapy.

[49]  M. Sjöström,et al.  Comparison of the ActiGraph accelerometer and Bouchard diary to estimate energy expenditure in Spanish adolescents. , 2009, Nutricion hospitalaria.

[50]  D. Gill,et al.  Physical Activity and Quality of Life , 2013, Journal of preventive medicine and public health = Yebang Uihakhoe chi.

[51]  D. Turnbull,et al.  Habitual Physical Activity in Mitochondrial Disease , 2011, PloS one.

[52]  G. Mawston,et al.  Exploring actical accelerometers as an objective measure of physical activity in people with multiple sclerosis. , 2009, Archives of physical medicine and rehabilitation.

[53]  K. Tsintzas,et al.  An exploratory study of physical activity and perceived barriers to exercise in ambulant people with neuromuscular disease compared with unaffected controls , 2009, Clinical rehabilitation.

[54]  C. McDonald,et al.  Prevention and management of limb contractures in neuromuscular diseases. , 2012, Physical medicine and rehabilitation clinics of North America.

[55]  R A Washburn,et al.  Physical Activity Scale for the Elderly (PASE): the relationship with activity measured by a portable accelerometer. , 1999, The Journal of sports medicine and physical fitness.

[56]  D. Bassett Validity and reliability issues in objective monitoring of physical activity. , 2000, Research quarterly for exercise and sport.

[57]  H. Dawes,et al.  Wearable accelerometry-based technology capable of assessing functional activities in neurological populations in community settings: a systematic review , 2014, Journal of NeuroEngineering and Rehabilitation.

[58]  R. Motl,et al.  Self-reported depression and physical activity in adults with mobility impairments. , 2013, Archives of physical medicine and rehabilitation.

[59]  R. Abresch,et al.  M.P.3.04 Assessment of StepWatch™ activity monitoring in phase 2b study of ataluren (PTC124™) in nmDMD/BMD , 2009, Neuromuscular Disorders.

[60]  I. Norman,et al.  Physical activity in older people: a systematic review , 2013, BMC Public Health.

[61]  C. Caspersen,et al.  Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. , 1985, Public health reports.

[62]  M. Decramer,et al.  Daily physical activity in subjects with newly diagnosed COPD , 2013, Thorax.

[63]  S. Coote,et al.  Comparative validity of accelerometer-based measures of physical activity for people with multiple sclerosis. , 2012, Archives of physical medicine and rehabilitation.

[64]  Kamiar Aminian,et al.  Ambulatory system for human motion analysis using a kinematic sensor: monitoring of daily physical activity in the elderly , 2003, IEEE Transactions on Biomedical Engineering.

[65]  David R Bassett,et al.  Validity of Physical Activity Monitors for Estimating Energy Expenditure During Wheelchair Propulsion. , 2015, Journal of physical activity & health.

[66]  H. Kemper,et al.  Validity and repeatability of a modified Baecke questionnaire on physical activity. , 1995, International journal of epidemiology.

[67]  Marten Munneke,et al.  Exercise therapy and other types of physical therapy for patients with neuromuscular diseases: a systematic review. , 2007, Archives of physical medicine and rehabilitation.

[68]  L. Andersen,et al.  Low validity of the Sensewear Pro3 activity monitor compared to indirect calorimetry during simulated free living in patients with osteoarthritis of the hip , 2014, BMC Musculoskeletal Disorders.

[69]  T. Olds,et al.  Measuring activity and participation in children and adolescents with disabilities: a literature review of available instruments. , 2013, Australian occupational therapy journal.

[70]  Ines Becker,et al.  Measuring free-living physical activity in adults with and without neurologic dysfunction with a triaxial accelerometer. , 2008, Archives of physical medicine and rehabilitation.

[71]  J. Lacour,et al.  Simultaneous Validation of Ten Physical Activity Questionnaires in Older Men: A Doubly Labeled Water Study , 2001, Journal of the American Geriatrics Society.

[72]  R. Shephard Limits to the measurement of habitual physical activity by questionnaires , 2003, British journal of sports medicine.

[73]  B E Ainsworth,et al.  Comparison of three methods for measuring the time spent in physical activity. , 2000, Medicine and science in sports and exercise.

[74]  J. Speight,et al.  FDA guidance on patient reported outcomes , 2010, BMJ : British Medical Journal.

[75]  D. Christakis,et al.  Relation of stride activity and participation in mobility-based life habits among children with cerebral palsy. , 2014, Archives of physical medicine and rehabilitation.

[76]  K R Westerterp,et al.  Comparison of two questionnaires with a tri-axial accelerometer to assess physical activity patterns. , 2001, International journal of sports medicine.

[77]  P. S. Davies,et al.  Accuracy of Parent-Reported Energy Intake and Physical Activity Levels in Boys With Duchenne Muscular Dystrophy. , 2015, Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition.

[78]  J. Brach,et al.  Using activity monitors to measure physical activity in free-living conditions. , 2006, Physical therapy.

[79]  Kelly M. Clanchy,et al.  Measurement of habitual physical activity performance in adolescents with cerebral palsy: a systematic review , 2011, Developmental medicine and child neurology.

[80]  Ulf Ekelund,et al.  Assessment of physical activity – a review of methodologies with reference to epidemiological research: a report of the exercise physiology section of the European Association of Cardiovascular Prevention and Rehabilitation , 2010, European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology.

[81]  Kamiar Aminian,et al.  Continuous monitoring and quantification of multiple parameters of daily physical activity in ambulatory Duchenne muscular dystrophy patients. , 2011, European journal of paediatric neurology : EJPN : official journal of the European Paediatric Neurology Society.

[82]  Nuala M. Byrne,et al.  Assessment of Physical Activity and Energy Expenditure: An Overview of Objective Measures , 2014, Front. Nutr..

[83]  D. Kilmer,et al.  Impact of a home-based activity and dietary intervention in people with slowly progressive neuromuscular diseases. , 2005, Archives of physical medicine and rehabilitation.

[84]  Thierry Troosters,et al.  Validity of activity monitors in health and chronic disease: a systematic review , 2012, International Journal of Behavioral Nutrition and Physical Activity.

[85]  G. Kolt,et al.  The Physical Activity and Disability Survey (PADS): reliability, validity and acceptability in people with multiple sclerosis , 2007, Clinical rehabilitation.

[86]  D R Bassett,et al.  Validity and Reliability issues in Objective Monitoring of Physical Activity , 2015 .

[87]  Ilse de Bourdeaudhuij,et al.  How many steps/day are enough? For older adults and special populations , 2011, The international journal of behavioral nutrition and physical activity.

[88]  M. Pierrynowski,et al.  Habitual Physical Activity Levels Are Associated with Biomechanical Walking Economy in Children with Cerebral Palsy , 2005, American journal of physical medicine & rehabilitation.

[89]  Tracy L. Washington,et al.  Assigning metabolic equivalent values to the 2002 census occupational classification system. , 2011, Journal of physical activity & health.

[90]  G. Bleijenberg,et al.  Relationship Between Objectively Assessed Physical Activity and Fatigue in Patients With Rheumatoid Arthritis: Inverse Correlation of Activity and Fatigue , 2014, Arthritis care & research.

[91]  Luc J. Hébert,et al.  Relationship between muscle impairments, postural stability, and gait parameters assessed with lower-trunk accelerometry in myotonic dystrophy type 1 , 2016, Neuromuscular Disorders.

[92]  G. Bleijenberg,et al.  The measurement of fatigue in patients with multiple sclerosis. A multidimensional comparison with patients with chronic fatigue syndrome and healthy subjects. , 1996, Archives of neurology.

[93]  Thomas Voit,et al.  A Movement Monitor Based on Magneto-Inertial Sensors for Non-Ambulant Patients with Duchenne Muscular Dystrophy: A Pilot Study in Controlled Environment , 2016, PloS one.

[94]  A. Carr,et al.  Primary total hip replacement surgery: a systematic review of outcomes and modelling of cost-effectiveness associated with different prostheses. , 1998, Health technology assessment.

[95]  Robert W Motl,et al.  Validity of physical activity measures in ambulatory individuals with multiple sclerosis , 2006, Disability and rehabilitation.

[96]  E. Slevin,et al.  A pilot survey of physical activity in men with an intellectual disability , 2013, Journal of intellectual disabilities : JOID.

[97]  C. Zampieri,et al.  A randomized controlled trial of exercise in spinal and bulbar muscular atrophy , 2015, Annals of clinical and translational neurology.

[98]  Roslyn N. Boyd,et al.  Validity of accelerometry in ambulatory children and adolescents with cerebral palsy , 2011, European Journal of Applied Physiology.

[99]  R. Abresch,et al.  Utility of a step activity monitor for the measurement of daily ambulatory activity in children. , 2005, Archives of physical medicine and rehabilitation.

[100]  Alison Rushton,et al.  Systematic review of the measurement properties of self-report physical activity questionnaires in healthy adult populations , 2015, BMJ Open.

[101]  Frank C Sciurba,et al.  Activity Monitoring and Energy Expenditure in COPD Patients: A Validation Study , 2007, COPD.

[102]  C. Matthews,et al.  Best practices for using physical activity monitors in population-based research. , 2012, Medicine and science in sports and exercise.

[103]  Washburn Ra,et al.  Physical Activity Scale for the Elderly (PASE) : the relationship with activity measured by a portable accelerometer , 1999 .

[104]  B. Engelen,et al.  Cognitive behaviour therapy plus aerobic exercise training to increase activity in patients with myotonic dystrophy type 1 (DM1) compared to usual care (OPTIMISTIC): study protocol for randomised controlled trial , 2015 .

[105]  M J Buxton,et al.  Evaluating patient-based outcome measures for use in clinical trials. , 1998, Health technology assessment.

[106]  Sandra A Walsh,et al.  Use of step activity monitoring for continuous physical activity assessment in boys with Duchenne muscular dystrophy. , 2005, Archives of physical medicine and rehabilitation.

[107]  D. Morgan,et al.  Influence of age on step activity patterns in children with cerebral palsy and typically developing children. , 2010, Archives of physical medicine and rehabilitation.

[108]  A. Prentice,et al.  Energy expenditure from minute-by-minute heart-rate recording: comparison with indirect calorimetry. , 1988, The American journal of clinical nutrition.

[109]  N. Day,et al.  Validity and repeatability of the EPIC-Norfolk Physical Activity Questionnaire. , 2002, International journal of epidemiology.

[110]  P. Jones,et al.  Evaluation of a movement detector to measure daily activity in patients with chronic lung disease. , 1997, The European respiratory journal.

[111]  D. Bassett,et al.  Use of pedometers and accelerometers in clinical populations: validity and reliability issues , 2010 .

[112]  Daniel Arvidsson,et al.  Energy cost of physical activities in children: validation of SenseWear Armband. , 2007, Medicine and science in sports and exercise.

[113]  Baziel G M van Engelen,et al.  The development of a model of fatigue in neuromuscular disorders: a longitudinal study. , 2007, Journal of psychosomatic research.

[114]  M. McCrory,et al.  Metabolic syndrome in neuromuscular disease. , 2005, Archives of physical medicine and rehabilitation.

[115]  Shirley Bryan,et al.  Validity of the Actical accelerometer step-count function. , 2007, Medicine and science in sports and exercise.

[116]  K. Westerterp,et al.  Comparison of heart rate monitoring combined with indirect calorimetry and the doubly labelled water (2H218O) method for the measurement of energy expenditure in children , 2004, European Journal of Applied Physiology and Occupational Physiology.

[117]  R. Abresch,et al.  Assessment of pain and health-related quality of life in slowly progressive neuromuscular disease , 2002, The American journal of hospice & palliative care.

[118]  Angie S Page,et al.  Contribution of the school journey to daily physical activity in children aged 11-12 years. , 2012, American Journal of Preventive Medicine.

[119]  M. Zwarts,et al.  Experienced fatigue in facioscapulohumeral dystrophy, myotonic dystrophy, and HMSN-I , 2005, Journal of Neurology, Neurosurgery & Psychiatry.

[120]  C. M. Wiles,et al.  Quantified measurement of activity provides insight into motor function and recovery in neurological disease , 2004, Journal of Neurology, Neurosurgery & Psychiatry.

[121]  Heather K. Neilson,et al.  Estimating activity energy expenditure: how valid are physical activity questionnaires? , 2008, The American journal of clinical nutrition.

[122]  Stewart G. Trost,et al.  State of the Art Reviews: Measurement of Physical Activity in Children and Adolescents , 2007 .

[123]  A. Rowlands,et al.  Psychometric properties of the 7-Day Physical Activity Recall questionnaire in individuals with severe mental illness. , 2007, Archives of psychiatric nursing.

[124]  Paul W. Franks,et al.  Estimation of Free-Living Energy Expenditure by Heart Rate and Movement Sensing: A Doubly-Labelled Water Study , 2015, PloS one.

[125]  Jennifer L. Keating,et al.  How is physical activity monitored in people following stroke? , 2015, Disability and rehabilitation.

[126]  Elena M. Umland,et al.  A Common Language for Interprofessional Education: The World Health Organization's International Classification of Functioning, Disability and Health (ICF) , 2013 .

[127]  A. Cooper,et al.  Independent mobility, perceptions of the built environment and children's participation in play, active travel and structured exercise and sport: the PEACH Project , 2010, The international journal of behavioral nutrition and physical activity.

[128]  Roberta Cunha Matheus,et al.  Adaptação cultural da versão brasileira do Godin-Shephard Leisure-Time Physical Activity Questionnaire Cultural adaptation of the Brazilian version of the Godin-Shephard Leisure-Time Physical Activity Questionnaire , 2013 .

[129]  D. Brooks,et al.  Measurement properties of the SenseWear armband in adults with chronic obstructive pulmonary disease , 2010, Thorax.

[130]  S. Trost,et al.  Clinical use of objective measures of physical activity , 2013, British Journal of Sports Medicine.

[131]  Caroline B. Terwee,et al.  The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and how to select an outcome measurement instrument , 2016, Brazilian journal of physical therapy.

[132]  S. Berntsen,et al.  Physical Activity and Motor Function in Children and Adolescents With Neuromuscular Disorders , 2013, Pediatric physical therapy : the official publication of the Section on Pediatrics of the American Physical Therapy Association.

[133]  Michael W. Beets,et al.  Measurement of physical activity in older adult interventions: a systematic review , 2015, British Journal of Sports Medicine.

[134]  Issa Zakeri,et al.  Prediction of activity energy expenditure using accelerometers in children. , 2004, Medicine and science in sports and exercise.

[135]  P. Crocker,et al.  Validation of the Physical Activity Questionnaire for Older Children , 1997 .

[136]  E. McAuley,et al.  The physical activity scale for individuals with physical disabilities: development and evaluation. , 2002, Archives of physical medicine and rehabilitation.

[137]  A. Prentice,et al.  The use of heart rate monitoring in the estimation of energy expenditure: a validation study using indirect whole-body calorimetry , 1989, British Journal of Nutrition.

[138]  Kamiar Aminian,et al.  Ambulatory Monitoring of Physical Activities in Patients With Parkinson's Disease , 2007, IEEE Transactions on Biomedical Engineering.

[139]  David Andre,et al.  Recent Advances in Free-Living Physical Activity Monitoring: A Review , 2007, Journal of diabetes science and technology.

[140]  A. Geurts,et al.  Both aerobic exercise and cognitive-behavioral therapy reduce chronic fatigue in FSHD , 2014, Neurology.

[141]  D. Heil Predicting Activity Energy Expenditure Using the Actical® Activity Monitor , 2006, Research quarterly for exercise and sport.

[142]  Clemens Drenowatz,et al.  Validation of the SenseWear Armband at high intensity exercise , 2011, European Journal of Applied Physiology.

[143]  A. Cooper,et al.  International Journal of Behavioral Nutrition and Physical Activity Independent Mobility in Relation to Weekday and Weekend Physical Activity in Children Aged 10–11 Years: the Peach Project , 2022 .

[144]  M. Pierrynowski,et al.  Physical activity level is associated with the O2 cost of walking in cerebral palsy. , 2005, Medicine and science in sports and exercise.

[145]  J. Bussmann,et al.  Validation of the Physical Activity Scale for individuals with physical disabilities. , 2011, Archives of physical medicine and rehabilitation.

[146]  Brian W. Timmons,et al.  Accelerometry: A Feasible Method to Quantify Physical Activity in Ambulatory and Nonambulatory Adolescents with Cerebral Palsy , 2012, International journal of pediatrics.

[147]  M. Tremblay,et al.  Actical accelerometer sedentary activity thresholds for adults. , 2011, Journal of physical activity & health.

[148]  J. Ziviani,et al.  A systematic review of the clinimetric properties of measures of habitual physical activity in primary school aged children with cerebral palsy. , 2013, Research in developmental disabilities.

[149]  G. Bleijenberg,et al.  Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment. , 2000, Journal of psychosomatic research.