ORIGINAL RESEARCH| Volume 103, ISSUE 9, P1777-1785, September 2022

Association Between Daily Physical Activity and Clinical Anthropomorphic Measures in Adults With Cerebral Palsy

Published:February 21, 2022DOI:



      To describe the relationship between activity level and cardiovascular risk measures as well as describe general activity patterns of adults with cerebral palsy.




      Academic outpatient rehabilitation clinic.


      Adults with cerebral palsy (N=47).


      Not applicable.

      Main Outcome Measures

      Gross Motor Functional Classification System (GMFCS) level was determined by validated self‐report questionnaire. Activity (daily step count, walk time, sitting time, standing time, and transitional movements) over 6 days recorded using an activPAL. Weight, body mass index (BMI), and waist-to-hip ratio were measured. Bivariate relationships between anthropomorphic and activity measures were assessed.


      Thirty-eight participants completed all measurements. Nine were excluded because of incomplete activPAL data. The median age was 28.50 years (interquartile range [IQR]=24.25-47.00), range 18-77 years. Participants’ GMFCS levels were I: 13%; II: 16%; III: 21%; IV: 34%; and V: 16%. Median steps/day for GMFCS I/II participants were 5258.3 (IQR=3606.8-6634.7), and median steps/day were 1681.3 (IQR=657.2-2751.8) and 30.0 (IQR=6.8-54.2) for GMFCS level III and IV/V participants, respectively. Significantly greater steps/day were found for GMFCS I/II or III participants compared to those GMFCS IV/V (P<.001 and P=.0074, respectively). In addition, 60.5% of the subjects had a BMI in the normal range, 10.5% were obese, 23.6% were overweight, and 5.3% were underweight. For subjects with GMFCS I/II, the Spearman's rank correlation coefficient for time standing and waist circumference was −0.73 (0.01). GMFCS III and GMFCS IV/V participants had respective correlations of −0.16 (0.71) and −0.01 (0.98). For subjects with GMFCS I/II, the Spearman's rank correlation coefficient for standing time and BMI was −0.55 (P=.08). For the GMFCS III and GMFCS IV/V groups the respective correlations were −0.19 (0.67) and 0.00 (1.00).


      Subjects with GMFCS level I or II who engaged in more activity tended to have more favorable anthropometric profiles. Subjects with GMFCS level III, IV, or V did not have a similar trend. Our findings suggest factors beyond activity patterns affect anthropometrics to a greater degree in those with higher GMFCS levels.


      List of abbreviations:

      CP (cerebral palsy), CV (cardiovascular), BMI (body mass index), GMFCS (Gross Motor Function Classification System), HC (hip circumference), ICD-9 (International Classification of Diseases, 9th edition), ICD-10 (International Classification of Diseases, 10th edition), IQR (interquartile range), WC (waist circumference)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bax M
        • Goldstein M
        • Rosenbaum P
        • et al.
        Proposed definition and classification of cerebral palsy, April 2005.
        Dev Med Child Neurol. 2005; 47: 571-576
      1. Centers for Disease Control. Data and statistics for cerebral palsy. Available at: Accessed July 1, 2021.

        • Ryan JM
        • Cassidy EE
        • Noorduyn SG
        • O'Connell NE
        Exercise interventions for cerebral palsy.
        Cochrane Database Syst Rev. 2017; 6CD011660
        • Klawonn MA
        • Klamar K
        • Turk MA.
        Trends in publications about cerebral palsy 1990 to 2020.
        J Pediatr Rehabil Med. 2020; 13: 107-117
        • Brooks JC
        • Strauss DJ
        • Shavelle RM
        • Tran LM
        • Rosenbloom L
        • Wu YW.
        Recent trends in cerebral palsy survival. Part I: period and cohort effects.
        Dev Med Child Neurol. 2014; 56: 1059-1064
        • Strauss D
        • Shavelle R
        • Reynolds R
        • Rosenbloom L
        • Day S.
        Survival in cerebral palsy in the last 20 years: signs of improvement?.
        Dev Med Child Neurol. 2007; 49: 86-92
        • Bhushan V
        • Paneth N
        • Kiely JL.
        Impact of improved survival of very low birth weight infants on recent secular trends in the prevalence of cerebral palsy.
        Pediatrics. 1993; 91: 1094-1100
        • Oskoui M
        • Coutinho F
        • Dykeman J
        • Jetté N
        • Pringsheim T.
        An update on the prevalence of cerebral palsy: a systematic review and meta-analysis.
        Dev Med Child Neurol. 2013; 55: 509-519
        • van Gorp M
        • Hilberink SR
        • Noten S
        • et al.
        Epidemiology of cerebral palsy in adulthood: a systematic review and meta-analysis of the most frequently studied outcomes.
        Arch Phys Med Rehabil. 2020; 101: 1041-1052
        • Young NL.
        The transition to adulthood for children with cerebral palsy: what do we know about their health care needs?.
        J Pediatr Orthop. 2007; 27: 476-479
        • Hurvitz EA
        • Gross PH
        • Gannotti ME
        • Bailes AF
        • Horn SD.
        Registry-based research in cerebral palsy: the Cerebral Palsy Research Network.
        Phys Med Rehabil Clin N Am. 2020; 31: 185-194
        • Brown DR
        • Yore MM
        • Ham SA
        • Macera CA.
        Physical activity among adults >or=50 yr with and without disabilities, BRFSS 2001.
        Med Sci Sports Exerc. 2005; 37: 620-629
        • Yi YG
        • Jung SH
        • Bang MS.
        Emerging issues in cerebral palsy associated with aging: a physiatrist perspective.
        Ann Rehabil Med. 2019; 43: 241-249
        • Day SM
        • Wu YW
        • Strauss DJ
        • Shavelle RM
        • Reynolds RJ.
        Change in ambulatory ability of adolescents and young adults with cerebral palsy.
        Dev Med Child Neurol. 2007; 49: 647-653
        • Shortland A.
        Muscle deficits in cerebral palsy and early loss of mobility: can we learn something from our elders?.
        Dev Med Child Neurol. 2009; 51: 59-63
        • Haak P
        • Lenski M
        • Hidecker MJ
        • Li M
        • Paneth N.
        Cerebral palsy and aging.
        Dev Med Child Neurol. 2009; 51: 16-23
        • Peterson MD
        • Gordon PM
        • Hurvitz EA.
        Chronic disease risk among adults with cerebral palsy: the role of premature sarcopoenia, obesity and sedentary behaviour.
        Obes Rev. 2013; 14: 171-182
        • Hill JO
        • Wyatt HR.
        Role of physical activity in preventing and treating obesity.
        J Appl Physiol (1985). 2005; 99: 765-770
        • Singh R
        • Pattisapu A
        • Emery MS.
        US physical activity guidelines: current state, impact and future directions.
        Trends Cardiovasc Med. 2020; 30: 407-412
        • Ryan JM
        • Hensey O
        • McLoughlin B
        • Lyons A
        • Gormley J.
        Associations of sedentary behaviour, physical activity, blood pressure and anthropometric measures with cardiorespiratory fitness in children with cerebral palsy.
        PLoS One. 2015; 10e0123267
        • Nooijen CF
        • Slaman J
        • Stam HJ
        • Roebroeck ME
        • van den Berg-Emons RJ
        • Learn2Move Research Group
        Inactive and sedentary lifestyles amongst ambulatory adolescents and young adults with cerebral palsy.
        J Neuroeng Rehabil. 2014; 11: 49
        • Ryan JM
        • Crowley VE
        • Hensey O
        • Broderick JM
        • McGahey A
        • Gormley J.
        Habitual physical activity and cardiometabolic risk factors in adults with cerebral palsy.
        Res Dev Disabil. 2014; 35: 1995-2002
        • Nieuwenhuijsen C
        • van der Slot WM
        • Beelen A
        • et al.
        Inactive lifestyle in adults with bilateral spastic cerebral palsy.
        J Rehabil Med. 2009; 41: 375-381
        • Lai B
        • Lee E
        • Kim Y
        • et al.
        Leisure-time physical activity interventions for children and adults with cerebral palsy: a scoping review.
        Dev Med Child Neurol. 2021; 63: 162-171
        • Flanigan M
        • Gaebler-Spira D
        • Kocherginsky M
        • Garrett A
        • Marciniak C.
        Spasticity and pain in adults with cerebral palsy.
        Dev Med Child Neurol. 2020; 62: 379-385
        • Brown MC
        • Marciniak CM
        • Garrett AM
        • Gaebler-Spira DJ.
        Diet quality in adults with cerebral palsy: a modifiable risk factor for cardiovascular disease prevention.
        Dev Med Child Neurol. 2021; 63: 1221-1228
      2. Medicode (Firm). ICD-9-CM: International classification of diseases, 9th revision, clinical modification. Salt Lake City: Medicod; 1996.

      3. PAL Technologies. PAL Technologies Ltd. Available at: Accessed July 1, 2021.

        • Palisano R
        • Rosenbaum P
        • Walter S
        • Russell D
        • Wood E
        • Galuppi B.
        Development and reliability of a system to classify gross motor function in children with cerebral palsy.
        Dev Med Child Neurol. 1997; 39: 214-223
        • McCormick A
        • Brien M
        • Plourde J
        • Wood E
        • Rosenbaum P
        • McLean J.
        Stability of the Gross Motor Function Classification System in adults with cerebral palsy.
        Dev Med Child Neurol. 2007; 49: 265-269
        • Sandström K
        • Alinder J
        • Oberg B.
        Descriptions of functioning and health and relations to a gross motor classification in adults with cerebral palsy.
        Disabil Rehabil. 2004; 26: 1023-1031
        • Jahnsen R
        • Aamodt G
        • Rosenbaum P.
        Gross Motor Function Classification System used in adults with cerebral palsy: agreement of self-reported versus professional rating.
        Dev Med Child Neurol. 2006; 48: 734-738
      4. Bartlett D, Gorter JW. GMFCS Family Report Questionnaire. Available at: Accessed July 1, 2021.

        • Hogan SE.
        Knee height as a predictor of recumbent length for individuals with mobility-impaired cerebral palsy.
        J Am Coll Nutr. 1999; 18: 201-205
        • Sellers C
        • Dall P
        • Grant M
        • Stansfield B.
        Validity and reliability of the activPAL3 for measuring posture and stepping in adults and young people.
        Gait Posture. 2016; 43: 42-47
        • Bania T.
        Measuring physical activity in young people with cerebral palsy: validity and reliability of the ActivPAL™ monitor.
        Physiother Res Int. 2014; 19: 186-192
        • Hurvitz EA
        • Green LB
        • Hornyak JE
        • Khurana SR
        • Koch LG.
        Body mass index measures in children with cerebral palsy related to gross motor function classification: a clinic-based study.
        Am J Phys Med Rehabil. 2008; 87: 395-403
      5. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report [erratum in: Obes Res 1998;6:464]. National Institutes of Health.
        Obes Res. 1998; 6: 51S-209S
        • Flint AJ
        • Rexrode KM
        • Hu FB
        • et al.
        Body mass index, waist circumference, and risk of coronary heart disease: a prospective study among men and women.
        Obes Res Clin Pract. 2010; 4: e171-e181
        • Ross R
        • Neeland IJ
        • Yamashita S
        • et al.
        Waist circumference as a vital sign in clinical practice: a consensus statement from the IAS and ICCR Working Group on Visceral Obesity.
        Nat Rev Endocrinol. 2020; 16: 177-189
        • de Koning L
        • Merchant AT
        • Pogue J
        • Anand SS.
        Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: meta-regression analysis of prospective studies.
        Eur Heart J. 2007; 28: 850-856
        • Owen N
        • Sparling PB
        • Healy GN
        • Dunstan DW
        • Matthews CE.
        Sedentary behavior: emerging evidence for a new health risk.
        Mayo Clin Proc. 2010; 85: 1138-1141
        • Lee IM
        • Shiroma EJ
        • Lobelo F
        • et al.
        Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.
        Lancet. 2012; 380: 219-229
        • Matthews CE
        • Moore SC
        • Sampson J
        • et al.
        Mortality benefits for replacing sitting time with different physical activities.
        Med Sci Sports Exerc. 2015; 47: 1833-1840
        • Saint-Maurice PF
        • Troiano RP
        • Bassett DR
        • et al.
        Association of daily step count and step intensity with mortality among US adults.
        JAMA. 2020; 323: 1151-1160
        • Claridge EA
        • McPhee PG
        • Timmons BW
        • Martin Ginis KA
        • Macdonald MJ
        • Gorter JW
        Quantification of physical activity and sedentary time in adults with cerebral palsy.
        Med Sci Sports Exerc. 2015; 47: 1719-1726
        • Kuperminc MN
        • Stevenson RD.
        Growth and nutrition disorders in children with cerebral palsy.
        Dev Disabil Res Rev. 2008; 14: 137-146
        • Marciniak C
        • Gabet J
        • Lee J
        • Ma M
        • Brander K
        • Wysocki N.
        Osteoporosis in adults with cerebral palsy: feasibility of DXA screening and risk factors for low bone density.
        Osteoporos Int. 2016; 27: 1477-1484
        • Lundberg A.
        Oxygen consumption in relation to work load in students with cerebral palsy.
        J Appl Physiol. 1976; 40: 873-875
        • Lundberg A.
        Maximal aerobic capacity of young people with spastic cerebral palsy.
        Dev Med Child Neurol. 1978; 20: 205-210
        • McCoy AA
        • Fox MA
        • Schaubel DE
        • Ayyangar RN.
        Weight gain in children with hypertonia of cerebral origin receiving intrathecal baclofen therapy.
        Arch Phys Med Rehabil. 2006; 87: 1503-1508
        • Bandini LG
        • Schoeller DA
        • Fukagawa NK
        • Wykes LJ
        • Dietz WH.
        Body composition and energy expenditure in adolescents with cerebral palsy or myelodysplasia.
        Pediatr Res. 1991; 29: 70-77
        • Stallings VA
        • Zemel BS
        • Davies JC
        • Cronk CE
        • Charney EB.
        Energy expenditure of children and adolescents with severe disabilities: a cerebral palsy model.
        Am J Clin Nutr. 1996; 64: 627-634
        • Verschuren O
        • Peterson MD
        • Balemans AC
        • Hurvitz EA.
        Exercise and physical activity recommendations for people with cerebral palsy.
        Dev Med Child Neurol. 2016; 58: 798-808
        • Rogozinski BM
        • Davids JR
        • Davis RB
        • et al.
        Prevalence of obesity in ambulatory children with cerebral palsy.
        J Bone Joint Surg Am. 2007; 89: 2421-2426
        • Peterson MD
        • Haapala HJ
        • Hurvitz EA.
        Predictors of cardiometabolic risk among adults with cerebral palsy.
        Arch Phys Med Rehabil. 2012; 93: 816-821
        • Ryan JM
        • Crowley VE
        • Hensey O
        • McGahey A
        • Gormley J.
        Waist circumference provides an indication of numerous cardiometabolic risk factors in adults with cerebral palsy.
        Arch Phys Med Rehabil. 2014; 95: 1540-1546
        • Cremer N
        • Hurvitz EA
        • Peterson MD.
        Multimorbidity in middle-aged adults with cerebral palsy.
        Am J Med. 2017; 130 (744.e9-744.e15)
        • National Center on Health, Physical Activity and Disability
        Building healthy inclusive communities through the National Center on Health.
        Physical Activity and Disability (NCHPAD), 2021 (Available at) (Accessed May 25)
        • Hiremath SV
        • Ding D.
        Evaluation of activity monitors in manual wheelchair users with paraplegia.
        J Spinal Cord Med. 2011; 34: 110-117
        • Warms CA
        • Belza BL.
        Actigraphy as a measure of physical activity for wheelchair users with spinal cord injury.
        Nurs Res. 2004; 53: 136-143