Barriers and Facilitators to Physical Activity in Individuals with Cerebral Palsy

Original Editor - Eki Tunjungsari Top Contributors - Eki Tunjungsari and Kim Jackson  

Introduction

Cerebral Palsy is the most common childhood physical disability that results from an injury in a developing fetal or infant brain[1]. Its presentation varies between individuals; ranging from musculoskeletal, cognitive, communication, and/or behavioural problems[2]. With the increasing survival rate of children with CP, the number of adults with CP increases. However, adult morbidity and mortality rates due to cardiovascular, cerebrovascular, and cancer diseases are higher in the CP population than in general population. Although the reason for that remains unclear, there is a possibility that reduced physical activity levels in the CP population is partly responsible for the higher mortality and morbidity rates[3]. The evidence of benefits of regular physical activity (PA) in preventing the abovementioned diseases as well as in improving physical and mental health status are well-established[4].

There have been many studies examining barriers and facilitators to physical activity participation in the general population and in individuals with disabilities. For more information about physical activity in individuals with disability, please click here. For more information about physical activity, sport, and recreation for young people with disability, please click here.

This page summarizes several studies that examined the barriers and facilitators to physical activity participation in individuals with Cerebral Palsy across different age groups. Two studies included children and adolescents with CP as their participants[5][6]; two studies included children and adolescents with CP and their parents[7][8]; one study included adults with CP[9]; while one study included adults with CP and their caregivers[10]. The individuals with CP included in those studies have varying degrees of severity; from score I to V of Gross Motor Function Classification Scale (GMFCS), from none until profound intelectual disability, with or without communication difficulty, and with varying levels of mobility.

From all of the reported factors affecting PA participation, the barriers and facilitators of PA can be categorized into physiological, psychological, and environmental factors. The followings are factors that affect PA participation of children, adolescents, and adults with CP.  

Factors Affecting PA Participation in Children, Adolescents, and Adults with Cerebral Palsy

Physiological Factors

Barrier: Pain as a result of physical activity or other treatment (such as assistive devices or surgery procedures)[5][6][8][9]. Post-surgery recovery time has also been reported to cause strength and skill loss that make it difficult to start PA again.

Facilitator: Positive physical effects of exercise/physical activity such as improved strength, agility, endurance, body shape, and body mass can promote sustained participation in physical activity[6][9].

Psychological Factors

Barriers:

1.      Poor understanding of benefits and importance of physical activity. Some individuals reported that they associate physical activity with pain, discomfort, and monotony[5][9]. Other individuals reported that they doubt the importance of PA and uncertain about the effects of PA[9].

2.      Negative self-conscious thoughts. Individuals may feel embarrased at appearing physically incapable in front of other people[5][6] and uncomfortable if the physical activity highlights their body as dysfunctional[9]. Individuals also reported feeling guilty towards their caregivers when they need to ask for help during a physical activity[7].

Facilitators:

1.      Good understanding of benefits and importance of physical activity. Many studies highlighted that awareness and belief of the importance and benefits of PA can override the pain from PA and other treatments and thus enable participation in PA[5][6][7][9].

2.      Enjoyment from physical activity and positive feelings as the result of exercise. Both children and adults reported that enjoyment enables and sustains their participation in PA. Children are more likely to take part in leisure PA. Meanwhile, adults reported that integration of PA with leisure activities enables their participation.

3.      Physical activity that improves self-efficacy, Self-efficacy that can be demonstrated in a physical activity becomes a motivation for an individual to sustain their participation. Some individuals prefer PA programs that focus on the activity rather than on the improvement of their body impairments[9]. Some individuals prefer PA programs that meet their interests and are something they are good at[5][8][9]. Both children and adults reported that PA can also be an opportunity to experience their bodies as competent and able.

Environmental Factors

Barriers:

1.      Caregiver’s lack of awareness of the importance of physical activity. If the caregiver perceives PA as unimportant and will not change the condition of the individual with CP, the individual will be less likely to participate in PA[7][10].

2.      Caregiver’s overprotection. When caregivers believe that the individual is vulnerable and PA will make their condition worse, the individual will be less likely to participate in PA[5][7][8].

3.      General ignorance of the specific needs of the CP population. Lack of information regarding PA opportunities in the community and suitable PA for CP population were seen as barriers to participation. Moreover, the lack of competent coaches/professionals with sufficient knowledge about CP, good communication skills, and positive attitudes are also reported as challenges to PA participation[5][6][7][8][9][10].

4.      Lack of adaptive resources. Lack of availability, time-constraint, poor equipment quality, and proximity of available resources were reported as barriers to PA participation[5][6][7][8][9][10]

Facilitators:

1.      Caregiver’s awareness of the importance of physical activity. Parents' awareness and belief of the importance of PA[7]; parents, teachers, and therapists' encouragement[5]; and parents' lifestyle and perseverance in relation to PA[7] were reported to facilitate individuals' participation in PA.

2.      Caregiver’s support and involvement in physical activity facilitates individual's participation[5][6].

3.      Social acceptance and inclusion of the CP population. PA was seen as an opportunity to gain a sense of belonging to a group[6]. Therefore, information about and access to adaptive PA opportunities at schools and communities were reported as facilitators to PA participation[5][7][9][10].

4.      Availability of adaptive resource and competent service providers with regards to sufficient knowledge about CP and disability[5][6][7][8][9][10]

Children in a study reported that they found it challenging to keep up physically with their peers as they grow up[8]. Meanwhile, adults reported that they experienced a gap in PA participation during adolescence period[9]. This shows that the transitional period between childhood and adulthood poses a great challenge for individuals with CP to maintain their participation in physical activity. It may be due to lack of PA opportunities outside of school environment, lack of follow-up after leaving pediatric care, and personal factors such as changing priorities, peer influence, and higher concern of social acceptance[11].

Resources

Physical Fitness and Exercise for Adults with Cerebral Palsy FACT SHEET

Exercise and Physical Activity Recommendations for People with Cerebral Palsy

References

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  2. Proposed definition and classification of cerebral palsy, april 2005. Developmental Medicine & Child Neurology 2005;47(8):571-.
  3. Strauss D, Cable W, Shavelle R. Causes of excess mortality in cerebral palsy. Developmental Medicine & Child Neurology 1999;41(9):580-5.
  4. Warburton D, Nicol CW, Bredin S. Health benefits of physical activity: The evidence. Cmaj 2006;174(14):801-809.
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 Lauruschkus K, Nordmark E, Hallström I. 'It's fun, but ...' children with cerebral palsy and their experiences of participation in physical activities. Disabil Rehabil 2015 02/15;37(4):283-9.
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Conchar L, Bantjes J, Swartz L, Derman W. Barriers and facilitators to participation in physical activity: The experiences of a group of south african adolescents with cerebral palsy. J Health Psychol 2016 02;21(2):152-63.
  7. 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 Verschuren O, Wiart L, Hermans D, Ketelaar M. Identification of facilitators and barriers to physical activity in children and adolescents with cerebral palsy. J Pediatr 2012 09;161(3):488-94.
  8. 8.0 8.1 8.2 8.3 8.4 8.5 8.6 8.7 Shimmell LJ, Gorter JW, Jackson D, Wright M, Galuppi B. 'It's the participation that motivates him': Physical activity experiences of youth with cerebral palsy and their parents. Phys Occup Ther Pediatr 2013 11;33(4):405-20.
  9. 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 9.12 9.13 Sandström K, Samuelsson K, Öberg B. Prerequisites for carrying out physiotherapy and physical activity - experiences from adults with cerebral palsy. Disabil Rehabil 2009 02;31(3):161-9.
  10. 10.0 10.1 10.2 10.3 10.4 10.5 Heller T, Ying G, Rimmer J, Marks BA. Determinants of exercise in adults with cerebral palsy. Public Health Nursing 2002;19(3):223-31.
  11. Martins J, Marques A, Sarmento H, da Costa FC. Adolescents’ perspectives on the barriers and facilitators of physical activity: A systematic review of qualitative studies. Health Education Research 2015;30(5):742–755.