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Evaluating the Effects of Performance-Focused Swimming Training on People with Cerebral Palsy Who Have High Support Needs – A Study Protocol Using Single-Case Experimental Design

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Evaluating the Effects of Performance-Focused Swimming Training on People with Cerebral Palsy Who Have High Support Needs – A Study Protocol Using Single-Case Experimental Design

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Background:

People with cerebral palsy (CP) are less physically active than the general population and, consequently, are at increased risk of preventable disease. Evidence indicates that low-moderate doses of physical activity can reduce disease risk and improve fitness and function in people with CP. Para athletes with CP typically engage in 'performance-focused' sports training, which is undertaken for the sole purpose of enhancing sports performance. Anecdotally, many Para athletes report that participation in performance-focused sports training confers meaningful clinical benefits which exceed those reported in the literature; however, supporting scientific evidence is lacking. The aim of this paper is to describe the protocol for an 18-month study evaluating the clinical effects of a performance-focused swimming training programme for people with CP who have high support needs.

This study will use a concurrent multiple-baseline, single-case experimental design across three participants with CP who have high support needs. Each participant will complete a five-phase trial comprising: baseline (A1); training phase 1 (B1); maintenance phase 1 (A2); training phase 2 (B2); and maintenance phase 2 (A3). For each participant, measurement of swim velocity, health-related quality of life and gross motor functioning will be carried out a minimum of five times in each of the five phases.

Discussion:

The study described will produce Level II evidence regarding the effects of performance-focused swimming training on clinical outcomes in people with CP who have high support needs. Findings are expected to provide an indication of the potential for sport to augment outcomes in neurological rehabilitation.

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Evaluating the Effects of Performance-Focused Swimming Training on People with Cerebral Palsy Who Have High Support Needs - A Study Protocol Using Single-Case Experimental Design | Brain Impairment | Cambridge Core

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Evaluating the Effects of Performance-Focused Swimming Training on People with Cerebral Palsy Who Have High Support Needs - A Study Protocol Using Single-Case Experimental Design - Volume 21 Issue 2 - I. M. Dutia, M. J. Connick, E. M. Beckman, L. M. Johnston, P. J. Wilson, A. Macaro, S. M.

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SPORTS STARS: a practitioner-led, peer-group sports intervention for ambulant children with cerebral palsy. Activity and participation outcomes of a randomised controlled trial

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SPORTS STARS: a practitioner-led, peer-group sports intervention for ambulant children with cerebral palsy. Activity and participation outcomes of a randomised controlled trial

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Purpose: To investigate the effectiveness of a practitioner-led, peer-group sports intervention for children with CP at GMFCS Level I-II.

Method: Children with CP (GMFCS I-II; 6-12 years) were randomised to Sports Stars or waitlist-control groups. Sports Stars included eight-weeks (eight hours) of physiotherapist-led, sports-specific gross motor activity training, sports education, teamwork development and confidence building. Sports participation was measured using self-identified participation goals (modified Canadian Occupational Performance Measure (mCOPM)). Physical competence was measured with mCOPM activity goals and high-level gross motor batteries (Test of Gross Motor Development (TGMD-2); GMFM-Challenge) and walking (Timed-Up-and-Go), running (Muscle Power Sprint Test; 10x5m Sprint Test), jumping (Standing Broad Jump; Vertical Jump) and throwing (Seated Throw) items. General participation and quality of life were also measured. Outcomes were measured pre, post and 12-weeks post-intervention. Data were analysed using linear mixed models.

Results: Fifty-four children were randomised into Sports Stars ( n = 29; GMFCS I = 7, II = 22; male = 19; 8.9 ± 2 years) or waitlist-control groups ( n = 25; GMFCS I = 10, II = 15; male = 14; 8.6 ± 2 years). The Sports Stars group improved sports participation and activity goals (mCOPM F = 5.49-10.29, p < 0.001) and sports-specific physical competence (TGMD-2, F = 3.45-5.19, p  = 0.001-0.009) compared to the waitlist-control.

Conclusion: Sports Stars is effective for improving sports-specific participation and physical competence for children with CP.

1. Implications for rehabilitation

2. Sports Stars improves performance and satisfaction in sports-specific participation and activity goals for ambulant children with CP.

3. Sports Stars improves sports-specific physical activity competence in locomotor and object control skills.

4. Sport-specific interventions should incorporate sport-specific gross motor activity training as well as sports education, confidence building and teamwork.

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SPORTS STARS: a practitioner-led, peer-group sports intervention for ambulant children with cerebral palsy. Activity and participation outcomes of a randomised controlled trial

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Purpose: To investigate the effectiveness of a practitioner-led, peer-group sports intervention for children with CP at GMFCS Level I-II. Method: Children with CP (GMFCS I-II; 6-12 years) were randomised to Sports Stars or waitlist-control groups. Sports Stars included eight-weeks (eight hours) of physiotherapist-led, sports-specific gross motor activity training, sports education, teamwork development and confidence building.

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SPORTS STARS: a practitioner-led, peer-group sports intervention for ambulant, school-aged children with cerebral palsy. Parent and physiotherapist perspectives

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SPORTS STARS: a practitioner-led, peer-group sports intervention for ambulant, school-aged children with cerebral palsy. Parent and physiotherapist perspectives

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Session plan template available here

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Background

Sports participation is an important goal for children with cerebral palsy classified at GMFCS Level I or II, however there are no studies of parent or physiotherapist perspectives on effectiveness or overall acceptability of transition-to-sports interventions.

Methods

Parent and physiotherapist perspectives of Sports Stars: a novel, practitioner-led, peer-group sports intervention (Trial registration: ACTRN12617000313336) were collected from Sports Stars Session Reports (39 children, 6-12 years, GMFCS I = 11, II = 28, Female = 12), Fidelity Evaluations (28 children), and Perspectives Surveys (Parents = 29, female = 26; Physiotherapists = 8, female = 5). Outcomes were perceived impact on: (1) sports Participation ( Attendance, Involvement), (2) sports Activity Competence across Physical, Social, Cognitive and Psychological Physical Literacy domains and (3) overall acceptability.

Results

Over 84% of children Attended most sessions. Physiotherapists rated session Involvement as high (median = 3/4). In Session Reports, physiotherapists recorded quantitative improvements in Physical and Cognitive performance and described improvements across all domains. Parents reported improvements across all domains, with comments focusing on Social and Psychological performance. All physiotherapists (8/8) and most parents (26/29) reported a community-based peer-group was the intervention design of choice for sports-focused goals.

Conclusions

Parents and physiotherapists perceived Sports Stars, a practitioner-led, peer-group sports intervention, as effective and acceptable for children with cerebral palsy with sports-focussed goals.

IMPLICATIONS FOR REHABILITATION

Parents and physiotherapists agree that Sports Stars improved sports Participation and Physical, Social, Psychological and Cognitive Activity Competence for children with cerebral palsy.

Children with sports-focused goals should be offered practitioner-led, peer-group sports interventions in community environments.

Therapists should design sports interventions with Physical, Cognitive, Social and Psychological content and outcomes.

Additional information

Funding

CPL- Choice, Passion, Life, received funding from a Queensland Government Community Benefit Gambling Grant to provide the Sports Stars intervention for this study. The lead investigator, Georgina Clutterbuck was supported by an Australian Government Research Training Scholarship.

Acknowledgements

Thank you to our Sports Stars families and physiotherapists for their enthusiastic participation, and to CPL-Choice, Passion, Life and The University of Queensland for their considerable in-kind support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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SPORTS STARS: a practitioner-led, peer-group sports intervention for ambulant, school-aged children with cerebral palsy. Parent and physiotherapist perspectives

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Sports participation is an important goal for children with cerebral palsy classified at GMFCS Level I or II, however there are no studies of parent or physiotherapist perspectives on effectiveness or overall acceptability of transition-to-sports interventions.

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Tweets by CMCRC_tweets

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Systematic Review of Physical Literacy Terms

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Systematic Review of Physical Literacy Terms

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Edwards, L., Bryant, A., Keegan, R., Morgan, K., & Jones, A. (2016). Definitions, Foundations and Associations of Physical Literacy: A Systematic Review. Sports Medicine,

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This paper is the first to provide a systematic review of core attributes of the physical literacy construct, including the defining properties of physical literacy, the philosophical foundations and the theoretical associations of the construct.

An implication for theory development and research is the need for transparency and tolerance with different approaches to physical literacy.

Implications for applied practice include ensuring clarity of theoretical descriptions and phrases so that these can be translated clearly into a practical setting.

Introduction

The concept of physical literacy has gained prominence in recent years, in many different countries [ 1- 5], with scientific papers on the subject increasing from one in 1998 to 29 in 2014 [ 6]. Educational organizations and researchers around the world have argued that physical literacy should be given the same educational value as literacy and numeracy [ 1, 7, 8]. While there are many organizations, research groups and governments currently promoting physical literacy interventions around the world, the definitions adopted differ [ 4]. This chaotic situation may undermine the meaningful measurement of physical literacy, interpretation of findings, and prevents any meaningful accrual/agglomeration of research findings [ 6].

A Debated Definition

Physical literacy has been referred to, in a metaphorical sense, as developing literacy within a physical setting, synonymous to reading and writing, and specific to the culture in which individuals live [ 1]. Other definitions of physical literacy focus solely on developing physical competencies such as fundamental movement skills (FMS), motor development, running speed and 'exergames' [ 18, 25- 35]. Additionally, there exists a range of overlapping terms, such as movement literacy [ 36], aesthetic literacy [ 37], health literacy [ 10] and games literacy [ 38]. Not only are there different ways of defining and operationalizing physical literacy, there are also a range of competing constructs that may occupy very similar conceptual space. In this respect, the concept of physical literacy may be in danger of becoming diluted, redundant or meaningless.

In order for a coherent research tradition to develop, it is necessary to reach a level of clarity and transparency in relation to core constructs and, indeed, a level of consensus between researchers [ 39]. When a study claims to have measured or promoted physical literacy, and supported or refuted the associated theoretical claims, it is important to know exactly what was measured and what claims were tested. A further reason that research paradigms can degenerate is when there is no clarity regarding the underlying philosophy, or assumptions regarding the nature of the phenomena being studied [ 39]. Whitehead has proposed relatively detailed philosophical groundings for physical literacy, drawing from phenomenology, existentialism and monism [ 40]. It is possible that some researchers consider these philosophies as idealistic and complex [ 41]. However, if researchers are unable to articulate the hypothetical mechanisms explaining how concepts influence one another, then it is possible that no scientific theory is being tested by research, only relatively arbitrary/baseless and unscientific predictions. Hence, as well as understanding the defining properties of physical literacy and the underpinning philosophy, the final step in articulating a coherent 'paradigm' is to detail the theoretical associations and predictions offered by the theory. Such predictions could then be operationalized and tested, and these tests would be instructive as to whether the underpinning theory, assumptions and definitions are valid.

It is evident from the above discussion that there are a number of inconsistencies surrounding physical literacy; however, these contrasting arguments have not yet been evaluated systematically. To remedy this situation, the current paper adopted the systematic review methodology with a view to summarizing, appraising and communicating relevant research [ 42]. Systematic reviews utilize explicit, rigorous and transparent methods in order to minimize bias and offer a complete, coherent overview of contemporary knowledge on a topic [ 43].

Aims and Research Questions

The purpose of this systematic review was to collate, analyze and evaluate the core attributes of the physical literacy construct, as reflected in contemporary research literature (up to March 2016). This paper will explore and critically discuss the following three research questions: What are the (a) defining attributes; (b) philosophical underpinnings; and (c) theoretical associations of physical literacy in peer reviewed, published papers that attempt to define the concept?

Methods

Search Strategy

An electronic search strategy was employed using the following databases: (i) SPORTDiscus; (ii) MEDLINE (via PubMed); (iii) Scopus; (iv) ScienceDirect; and (v) Education Research Complete. No particular start date was adopted and the last search was conducted on 22 March 2016. These education, sport and health databases are suitable for the topic and increase the probability that all relevant studies have been located [ 44, 45]. The Boolean logic combinations search strategy was adopted within the electronic databases, including 'physical literacy', with physical education (PE), health literacy, movement literacy, fundamental movement skills, games literacy, gross motor skills, and kinesthetic literacy. Inverted commas were inserted around the term 'physical literacy' to ensure searches would find papers in relation to physical literacy as opposed to searches related to 'physical' and 'literacy'. 'English' and 'peer-reviewed' filter boxes were marked on all searches to ensure only these papers would appear in the results (see electronic supplementary material Appendix S1).

Eligibility Criteria

The criteria for inclusion in this systematic review were (i) papers with a peer reviewed, published status; and (ii) publications in the English language until the date last searched, i.e. 22 March 2016. To address the aims and research questions of the study, the following exclusion criteria were adopted: (i) papers not covering the definition, philosophy or associations of physical literacy; (ii) papers that used physical literacy in the title, keywords or abstract, but made no reference to physical literacy in the full body of text; (iii) book chapters, book reviews and book synopses; (iv) conference reports and readings; and (v) editorials and forewords. As a result of adopting the inclusion and exclusion criteria, only papers from 2000 onwards met the eligibility criteria.

The authors followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, an evidence-based checklist (see electronic supplementary material Appendix S2) for authors to use when reporting systematic reviews and meta-analyses [ 46]. In accordance with the PRISMA procedures, all duplicate papers, i.e. the same paper from different search engines, were removed. After 145 duplicates were removed, non-duplicated papers were read thoroughly and were considered either suitable or unsuitable following the inclusion and exclusion criteria (records were kept of this process). To minimize the risk of bias in individual studies, the authors followed the following two steps. First, data were extracted and analyzed in an inductive manner only if they pertained to the definition, core philosophy, or conceptual association of physical literacy. Second, to reduce reviewer selection bias and thus increase the reliability of selection, two reviewers independently examined and selected the applicable papers for the review, and a mutual agreement was made between reviewers as to whether or not they met basic inclusion criteria [ 47]. This process was documented and any discrepancies between reviewers were resolved by consensus and/or discussion with the third investigator. Records were kept of this process, with a 92 % agreement prior to discussion and 100 % post discussion. During the data analyzing process, the research team performed the following roles: the main analyst (LE), one coanalyst (AB), two consensus validators (KM and AJ) and one external critical colleague (RK). After this thorough process, and consistent with the exclusion criteria, a total of 50 papers were included in the review (see Fig. 1), including 36 different unique first authors.

PRISMA flow diagram showing the process of study identification and selection [ 46]. PRISMA preferred reporting items for systematic reviews and meta-analyses

Data Extraction and Synthesis

Thematic coding was used to identify distinct categories from the papers in the analysis. Thematic coding is a method of identifying common themes within passages of texts with a purpose of data retrieval [ 48]. The coding process goes beyond only considering key words or phrases directly from the text, but concentrates on describing both implicit and explicit concepts within the data [ 49]. For the purpose of this study, a two-step process was performed: first using basic coding techniques to identify the general themes (see electronic supplementary material Appendix S3), followed by thorough and interpretative coding, which highlighted more specific trends in the data [ 50]. This coding procedure allowed replication and transparency of data synthesis [ 51].

Qualitative synthesis using thematic analysis was conducted on the 50 applicable papers as the systematic review was concerned with meanings and semantics and not quantitative data. Thematic analysis is used frequently as a form of analysis in qualitative research and includes analytical examination and recording themes within data [ 52]. It was essential that the analyst was familiar with the content of the data through repeating reading of each text [ 53]. Next, initial codes were generated inductively under the headings of (a) properties of physical literacy; (b) philosophical underpinning; and (c) proposed associations. Once organized into three general themes, or 'higher-order themes' (see Table 1), an in-depth coding process occurred to identify the core categories and subthemes related to the higher-order theme [ 52]. The in-depth process included reading through every paper several times and highlighting key words and phrases in relation to the three higher-order themes, as outlined above. Finally, core categories and subthemes were reviewed and clearly defined before producing the final framework. The analysis summarized in Table 1 demonstrates the hierarchical structure that was deployed, building from raw codes to core categories, subthemes and higher-order themes. The tabulated information permits readers and authors to clearly identify the progression to a higher-order theme as well as the frequency of appearance of each core category.

Table 1 Physical literacy hierarchical structure, including core categories, subthemes and higher-order themes

Results

Summary of Studies

The number of papers that were identified, screened, and considered for eligibility are summarized in Fig. 1 [ 46]. Table 1 provides an overview of the core categories, subthemes and higher-order themes used for the analysis on the 50 papers for this systematic review.

Qualitative Synthesis

The analysis identified a total of 694 codes, which were organized into 37 core categories and 13 subthemes; these were then organized into higher-order themes representing the three aspects of our research question. The following section will review these three higher-order themes from the analysis; namely, properties of physical literacy, the philosophical underpinnings, and the theoretical associations of physical literacy from the perspectives of the papers being discussed. Each subtheme is defined and explained, and the core categories that constitute the subthemes are discussed.

Properties of Physical Literacy

For this higher-order theme, 22 core categories were evidenced under the following seven subthemes: affective, cognitive, physical capabilities, progression/developmental pathway, target audience, holistic concept and related constructs.

Affective

The three core categories that were adopted under the 'affective' subtheme included confidence, motivation and self-esteem. The affective domain describes one's motivation and confidence in relation to physical activities [ 16]. Individuals who are lacking in confidence, motivation and self-esteem are more likely to have lower incentive to participate in physical activity [ 16]. As identified in Table 1, the analysis reveals that the affective element was adopted in the papers more frequently than the cognitive and physical elements; confidence was adopted in 26 papers and motivation was adopted in 23 papers, compared with knowledge and understanding of activities (16 papers), knowledge and understanding of healthy and active lifestyles (13 papers) and physical competence (evident in only 12 papers). Four papers suggested that developing along one's physical literacy journey can impact on attitudinal factors, including encouraging self-esteem in a physical environment [ 54- 57]. Consistent with the philosophical underpinnings of physical literacy, Whitehead proposes that an awareness of embodiment and interacting with the physical environment stimulates positive self-esteem and self-confidence [ 13, 54, 58]. The reasoning is that individuals with high self-esteem are prone to engage fully with physical activities, whereas individuals with low self-esteem are likely to avoid unnecessary physical activities as a method of evading potential embarrassment or disappointment [ 13].

Cognitive

The cognitive properties of physical literacy centered on knowledge and understanding, and were evident in 29 papers. In general terms, the basis of what constitutes a literate individual in any domain is an acquired knowledge and understanding in a variety of settings [ 3, 59, 60]. Three core categories were deployed in the cognitive subtheme; specifically, knowledge and understanding of activities, knowledge and understanding of healthy and active lifestyles and the 'value to take responsibility for physical activity'. A thorough knowledge and understanding of activities is characteristic of a literate sports person, particularly concerning the sports' rules, traditions, and values [ 61], while knowledge and understanding of health and active lifestyle is a means to cognitively create a sound underpinning and awareness to value participating in a physically active lifestyle [ 9, 40, 54]. Furthermore, a total of 38 of the 50 papers in the analysis referred to Whitehead's definition of physical literacy, which is inclusive of the phrase "value and take responsibility for maintaining purposeful physical pursuits/activities throughout the life-course" [ 13], which was perceived vital to the cognitive domain.

Physical Capabilities

Physical capabilities refers to the physical domain and was divided into five core categories; namely, movement capacities, motor skill competence, physical competence, FMS and purposeful physical pursuits.

Progression/Developmental Pathway

Target Audience

Holistic Concept

Related Constructs

The next subtheme evidenced was the related constructs of physical literacy. This subtheme describes constructs that were related to, but not synonymous with, physical literacy. Two core categories were evidenced: health literacy and aesthetic literacy. Four papers made reference to health literacy and aesthetic literacy. Health literacy goes beyond acknowledging and understanding factual health information, but uses the factual information to make an informed decision about one's health [ 10, 18, 56]. Alternatively, the concept of aesthetic literacy represented a holistic form of movement that can be perceived via the senses [ 37]. In this sense, aesthetic literacy resonates with the 'poise' aspect of physical literacy identified above and is based on very similar philosophical considerations [ 37]. However, the discussion surrounding the aesthetic literacy concept focuses primarily on dance and dance education as opposed to all physical pursuits.

Philosophical Underpinning for Physical Literacy

Whitehead's paper [ 90] on meaningful existence, embodiment and PE has been identified as the philosophical basis for the development of the physical literacy concept. Consequently, a main theme deployed from the papers was the philosophical roots of physical literacy-an interweaving of phenomenology, existentialism and monism. However, one-third of papers (33 %) in the synthesis did not declare or discuss any philosophical considerations. Under the philosophical underpinning higher-order theme, nine core categories were adopted under the following three subthemes: ontological assumptions, epistemological assumptions and pedagogical implications. The structure of the philosophical underpinnings higher-order theme is as follows: (i) ontological assumptions (what is physical literacy from an ontological perspective); (ii) epistemological assumptions (how can physical literacy be studied from an epistemological perspective); and (iii) pedagogical implications (how appropriate pedagogy can influence and help develop physical literacy).

Ontological Assumptions

Epistemological Assumptions

This category refers to the epistemological assumptions in relation to the concept of physical literacy, including phenomenology and existentialism. Phenomenology has been described as the way in which an individual perceives the world from their unique point of view, whereas existentialism posits that individuals' unique perspective arises due to experiences of interacting with the world around us [ 40, 54, 58]. Eight papers referred to phenomenology and seven papers referred to existentialism [ 14, 37, 40, 54, 58, 69, 71, 80]. Phenomenology and existentialism are deemed central to the philosophical foundations that formed the physical literacy concept. Specifically, these phenomenological and existential philosophical foundations of physical literacy are fundamental to the interactions between individuals and the environment [ 75].

Pedagogical Implications

The pedagogical implications subtheme contained ten papers and three core categories. Five papers regarded meaningful experiences as a valuable attribute in relation to pedagogical implications [ 11, 58, 71, 84, 89]. The term 'meaningful experiences' encompasses motivating experiences that learners find rewarding and enjoyable, as well as influence their affective domain in developing self-confidence and self-worth [ 11]. Three papers challenged the pragmatic realities of the philosophical underpinnings of physical literacy [ 41, 59, 87], while two papers stated that physical literacy is not to be referred to as a pedagogical model [ 13, 61]. However, it was evident that the ten papers under this subtheme lacked detail on how to practically apply appropriate pedagogy.

Associations and Relationship of Physical Literacy

This theme referred to the proposed relationships and causal associations that are claimed for physical literacy, noting that very few of these relationships have been empirically tested to date, although such trials are currently underway. The associations of physical literacy were divided into three subthemes: (i) behavioral characteristics (two core categories); (ii) psychological, social and attitudinal factors (three core categories); and (iii) particular 'contexts' where physical literacy can be developed (two core categories).

Behavioral Characteristics

This category captured the notion that physical literacy is purported to influence behaviors such as physical activity, health behaviors, sport participation, and an active lifestyle outside of competitive sport. In each case, there are arguments that physical literacy may support these desirable outcomes but also that these behaviors may themselves contribute to enhancing physical literacy. Physical activity was evident in 44 % of the papers and is described as central to the physical literacy concept [ 72]. Development of the elements of physical literacy (motivation, confidence, physical competence, knowledge and understanding) can lead an individual to participate in physical activity, but, also, to progress one's physical literacy it is arguably necessary to participate in physical activity. Specifically, the main objective of all physical activity experiences is to ensure individuals develop along their physical literacy journey, and thus have the motivation, confidence, physical competence, knowledge and understanding to value physical activity [ 11]. Furthermore, the value of physical activity is important in all stages of an individual's life, with proposed goals at each stage within ones journey [ 76]; namely, developing motor competence and self-confidence within physical activity was encouraged in the early and primary years, and attention to understanding the importance of physical activity, health and wellbeing throughout the life course was encouraged in secondary schools [ 13, 76].

Psychological, Social and Attitudinal Factors

This subtheme captured the notion that physical literacy is theoretically associated with psychological, social and attitudinal factors such as (a) engagement, enthusiasm and enjoyment during physical activity; (b) support from significant others, and (c) cognitive and academic performance (e.g. in school). In each case, there are arguments that physical literacy may support these desirable outcomes but also that these psychological and attitudinal factors may themselves enhance physical literacy. It was identified that social support from significant others may contribute significantly to the development of physical literacy but, equally, physical literacy may promote the forming of stronger relationships and social networks.

Four papers reflected the notion of cognitive and academic performance in terms of schooling [ 61, 65, 69, 87]. It was highlighted that PE in the school system has been regarded for decades as a curriculum subject that contains limited cognitive substance [ 61]. However, the findings from the analysis suggest that there is growing connection between academic performance and physical fitness [ 87]. This indicates that being physically active may impact positively on children's results in school as well as creating a foundation to developing healthy, lifelong habits and physical literacy [ 87].

Contextual Factors

Discussion

This systematic review has mapped the defining properties, underpinning philosophy and theoretical associations of physical literacy that are reflected in the existing published peer-reviewed literature. Seventy percent of the articles that referred to the term 'physical literacy' adopted a 'Whiteheadian' perspective. Accordingly, we recommend that researchers be explicit in their definition of physical literacy, the philosophy they adopt and the theoretical predictions they are testing for clarity and consistency. Under philosophy, papers that specified a clear philosophical standpoint focused on the 'Whiteheadian' combination of phenomenology, existentialism and monism. The following discussion considers whether this is the only philosophical approach to physical literacy, and the implications of adopting different philosophical assumptions. Regarding theoretical associations, several broad categories of associations are identified in the existing literature, although the directions of these relationships are rarely made clear in the papers sampled. The following discussion explores whether (a) this is an exhaustive and complete list of theoretical associations; and (b) how the predictions detailed in this analysis might be tested and evaluated appropriately.

Defining Properties

Overall, common themes from the data highlight that physical literacy is conceptualized as the interactive and simultaneous consideration of competence in physical skills, confidence, motivation towards physical pursuits, and the valuing of physical movement and/or interacting with the physical world (see, for example, Whitehead [ 40] and Taplin [ 62]). The concept is applicable across the lifespan, to individuals of all ability levels, and will be experienced differently by every person, resulting in an individual 'physical literacy journey'. Physical literacy differs from related constructs such as health literacy and aesthetic literacy. Within the analysis, there are tendencies towards two recognizable approaches, or traditions, to physical literacy: a 'Whiteheadian' approach [ 13], and the 'LTAD' approach [ 94], with the latter appearing to focus more on developing physical literacy through, and for, sport participation. Overall, reflecting the arguments of Whitehead (eight papers) and Almond (six papers), the analysis suggests that the Whiteheadian conceptualization of physical literacy covers a wider range of movement types/skills, and psychosocial attributes, as it extends beyond competitive sport participation as the main vehicle for 'purposeful physical movements'. On the other hand, in all of the papers discussing the LTAD paradigm, the LTAD focuses on developing the physical elements of physical literacy [ 3, 59, 63, 75, 86]. As such, it might be argued that the LTAD model can be accommodated within the Whitehead model, but not vice versa. However, more recent LTAD literature suggests that the LTAD is not just unique to sport participation, but is also relevant to PE, recreation, and free-play environments [ 94].

The analysis presented in this paper reflects a unique synthesis drawing from a wide range of sources, and also reflecting the consistency and prevalence of key themes in papers that directly relate to 'physical literacy'. Reflecting on the nature of the findings generated through the above approach, most of the papers that seek or achieve publication in peer-reviewed academic journals adopt a conceptualization based on the 'Whiteheadian' definition [ 13]. While our analysis reflects aspects of different approaches to physical literacy, 70 % of the papers in this study (35 papers) adopted the conceptualization put forward by Whitehead [ 13], of which eight papers were written by Whitehead herself. Our analysis highlights key differences between different standpoints; namely, inconsistencies between a holistic definition and a definition solely from the physical domain. A necessity to either resolve these differences or accept and embrace diverse approaches to promoting physical literacy is pertinent. For example, different cultures, governance structures, geographical locations and physical environments may necessitate different conceptualizations and pedagogies for physical literacy.

Philosophical Underpinnings

Our analysis sought to identify the philosophical underpinnings of physical literacy in terms of (a) the aims and purpose of physical literacy; (b) the ontology and epistemology of physical literacy; and (c) the pedagogy of promoting and supporting physical literacy. This assumption proposes that one's experience and interpretation of the world is heavily dependent on one's ability to perceive physical cues, and respond meaningfully in the physical realm. These aims are aligned to the ontological and epistemological assumptions that arise from attempting to combine phenomenology, existentialism and monism. Such a combination of assumption sets is challenging for practitioners and researchers to access, operationalize and put into practice. Therefore, these assumptions require further articulation or better communication in order to connect with both researchers and practitioners working in this area. Once these aims and underlying assumptions are accepted, then the resulting pedagogy must focus on the whole person, the individualized learning, ipsative evaluation that focuses on individual progression, and contextualized real-world experiences (i.e. not simulated, abstract training, such as drills) [ 16]. Notably, this was the only philosophy offered by the papers included in our analysis, with no alternative approaches to philosophical underpinnings available. It may become important to consider how physical literacy would be operationalized under different assumption sets, such as empiricism, post-positivism, and critical realism. For example, does physical literacy theory lend itself to objective testing of effectiveness?

Furthermore, in line with Whitehead's ipsative, individualized assessment [ 16], one potential problem is the interpretation of standards and assessment within physical literacy. In addition, given the relative paucity of philosophical consideration in many scientific papers, does physical literacy lend itself to being studied and tested by those unfamiliar with philosophical assumptions? Failing that, can we expect each researcher or teacher/practitioner to engage with detailed ontology and philosophy prior to engaging with this concept? While philosophy may be quite an unpopular and impenetrable topic, resolving some of the above issues may genuinely energize both the scientific study and practical delivery of physical literacy.

Nonetheless, the philosophical underpinnings and the properties of physical literacy seem to be ill-aligned in research to date, specifically the predominant philosophy of monism, meaning that mind and body are one indivisible whole [ 40]. However, the physical, psychological and behavioral properties in physical literacy are largely considered as separate entities, although clearly interlinking constructs. As such, the question of how to promote the relative importance of each factor is left unconsidered in the majority of physical literacy research to date.

Theoretical Associations and Relationships

Our analysis sought to identify the concepts and constructs that are frequently linked to physical literacy, as understanding the proposed determinants and outcomes of physical literacy allows for the development and testing of specific hypotheses. Furthermore, if supported, these relationships would form the core justification for practitioners choosing to adopt a physical literacy approach, or to choose physical literacy over other existing approaches. Our findings suggest that physical literacy is proposed to be associated with a wide array of behavioral, psychological, social and physical variables, as well as linked to specific contexts in which physical literacy can be developed. It is unlikely that the list generated in our analysis is exhaustive, as elsewhere physical literacy has been linked to outcomes such as cardiovascular fitness, strength, motor skill, and obesity/overweight status [ 17]. Hence, our analysis may simply reflect the most accepted and salient associations made with physical literacy. Additionally, however, it was extremely rare for papers to specify the direction of the relationship between physical literacy and its associated construct, and bidirectional causation was plausible in many cases. As such, there is an emerging need to both test which variables contribute to the development of physical literacy and test those that are enhanced by the development of physical literacy. As noted above, the nature of the experiments and tests used should, ideally, be aligned to a specific philosophical approach, and in many ways the approach offered by combining phenomenology, existentialism and monism does not submit as readily to traditional empirical testing, such as randomized controlled trials. In this case, the research community will need to debate and agree what would count as sufficient evidence to claim efficacy within specific philosophical assumption sets.

Limitations

The limitations of this systematic review include (i) only papers in the English language were considered, thus the papers were primarily derived from the UK and Canada; and (ii) no empirical data or measurement attempts for physical literacy were considered for this systematic review as the authors' aim and research questions were to discuss the properties of physical literacy, philosophical underpinnings and its associations. Nevertheless, a review of empirical data and attempts to measure physical literacy needs to be addressed in future research papers. Furthermore, this systematic review does not answer the question of which definition and philosophy is correct, which may be viewed as a limitation. However, the review recorded and discussed the various definitions and philosophies, which was the most appropriate course of action.

Conclusions

This paper is the first to provide a systematic review of core attributes of the physical literacy construct, including the defining properties of physical literacy, the philosophical foundations and the theoretical associations of the construct. As identified, there have been many references to the physical literacy theory and its implications to practice. Five databases were searched using the PRISMA guidelines for systematic reviews. Inclusion criteria were English language, peer reviewed, published by March 2016, and seeking to conceptualize physical literacy. A total of 50 published articles met the inclusion criteria and were analyzed qualitatively using inductive thematic analysis. Three higher-order themes were adopted from the thematic analysis on the 50 papers selected following the rigorous PRISMA guidelines; namely, qualities of physical literacy, philosophical underpinning for physical literacy, and the connection between physical literacy and PE. This paper has illustrated the importance of adopting a pragmatic perspective to physical literacy but acknowledges that physical literacy represents more than solely a physical concept.

An implication for theory development and research is the need for transparency and tolerance with different approaches to physical literacy. The authors acknowledge the philosophical perspective but recognize a more pragmatic perspective reflecting the evidence-based society that is lived within to track whether individuals are making progress along their physical literacy journey. This approach would enable researchers to operationalize the construct of physical literacy and establish meaningful, measureable differences. Implications for applied practice include ensuring clarity of theoretical descriptions and phrases so that these can be translated clearly into a practical setting. For example, 'reading the environment' can be misinterpreted in many ways, thus making it difficult for practitioners to understand what this concept looks like in practice. Additionally, it is pertinent for practitioners to consider that there are other factors that disengage individuals from taking part in physical activity throughout the life course, such as the fear of being discriminated against by others [ 41]. It has been established that physical literacy and FMS are not synonyms; FMS focuses on progressing physical skills only, whereas physical literacy also considers the affective and cognitive elements [ 91]. One implication of this is that FMS may play a role in a broader program of physical literacy as a way of developing the physical competence element of physical literacy. This implication indicates that if the locomotor, stability and manipulative strands of FMS are completed in an applied setting, this could be one method, alongside others, to help develop the physical competence aspect of physical literacy.

Recommendations for future research include not only the need for transparency and clarity but also tolerance of different approaches, providing researchers are transparent and clear in what they did/assumed. Consequently, this would lead to a pluralism where different ideas can compete and be evaluated over time, without which it would be impossible to decipher whether physical literacy is being tested, supported or refuted. Ultimately, researchers need to operationalize physical literacy and generate meaningful, measurable differences that will eventually be the arbiter of what physical literacy is and how it works.

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Affiliations

1. Cardiff School of Sport, Cardiff Metropolitan University, Cyncoed Campus, Cardiff, CF23 6XD, UK

Lowri C. Edwards, Anna S. Bryant, Kevin Morgan & Anwen M. Jones

2. Faculty of Health, Research Institute for Sport and Exercise, University of Canberra, Bruce, ACT, Australia

Richard J. Keegan

Corresponding author

Correspondence to Lowri C. Edwards.

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No sources of funding were used to assist in the preparation of this article.

Conflict of interest

Lowri C. Edwards, Anna S. Bryant, Richard J. Keegan, Kevin Morgan and Anwen M. Jones declare that they have no conflicts of interest that are relevant to the content of this review.

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# data[].attributes.attachment_link.title
Definitions, Foundations and Associations of Physical Literacy: A Systematic Review

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The concept of physical literacy has stimulated increased research attention in recent years-being deployed in physical education, sport participation, and the promotion of physical activity. Independent research groups currently operationalize the construct differently. The purpose of this systematic review was to conduct a systematic review of the physical literacy construct, as reflected in contemporary research literature.

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Active exercise interventions improve gross motor function of ambulant children with cerebral palsy: A systematic review

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Active exercise interventions improve gross motor function of ambulant children with cerebral palsy: A systematic review

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Published in Disability and Rehabilitaiton

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PURPOSE:

Evaluate effectiveness of active exercise interventions for improving gross motor activity/participation of school-aged, ambulant/semi-ambulant children with cerebral palsy (CP).

METHOD:

A systematic review was conducted following PRISMA guidelines. Five databases were searched for papers including school-aged children with CP, participating in active, exercise interventions with gross motor outcomes measured at the Activity/Participation level. Interventions with previous systematic reviews were excluded (e.g. hippotherapy). Evidence Level and conduct were examined by two raters.

RESULTS:

Seven interventions (34 studies) met criteria. All studies reported on gross motor function, however, a limited number investigated participation outcomes. Strong positive evidence was available for Gross Motor Activity Training (n= 6, Evidence Level II-IV), and Gross Motor Activity Training with progressive resistance exercise plus additional physiotherapy (n = 3, all Evidence Level II). Moderate positive evidence exists for Gross Motor Activity Training plus additional physiotherapy (n = 2, all Evidence Level II) and Physical Fitness Training (n = 4, Evidence Level II-V). Weak positive evidence was available for Modified Sport (n = 3, Evidence Level IV-V) and Non-Immersive Virtual Reality (n = 12, Evidence Level II-V). There was strong evidence against Gross Motor Activity Training plus progressive resistance exercise without additional physiotherapy (n = 4, all Evidence Level II).

INTERPRETATION:

Active, performance-focused exercise with variable practice opportunities improves gross motor function in ambulant/semi-ambulant children with CP. Implications for rehabilitation Active exercise interventions improve gross motor function of ambulant/semi-ambulant children with cerebral palsy. Gross Motor Activity Training is the most common and effective intervention. Practice variability is essential to improve gross motor function. Participation was rarely measured and requires further research, particularly in interventions that embed real-world participation opportunities like Modified Sport.

# data[].attributes.attachment_link.title
Active exercise interventions improve gross motor function of ambulant/semi-ambulant children with cerebral palsy: a systematic review.

# data[].attributes.attachment_link.description
PURPOSE: Evaluate effectiveness of active exercise interventions for improving gross motor activity/participation of school-aged, ambulant/semi-ambulant children with cerebral palsy (CP). METHOD: A systematic review was conducted following PRISMA guidelines. Five databases were searched for papers including school-aged children with CP, participating in active, exercise interventions with gross motor outcomes measured at the Activity/Participation level.

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SPORTS STARS study protocol: a randomised, controlled trial of the effectiveness of a physiotherapist-led modified sport intervention for ambulant school-aged children with cerebral palsy" 

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SPORTS STARS study protocol: a randomised, controlled trial of the effectiveness of a physiotherapist-led modified sport intervention for ambulant school-aged children with cerebral palsy" 

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Sports Stars session plan available here.

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Study aims

The proposed study is a randomised, waitlist controlled, assessor blinded, superiority trial with two parallel groups. This study will aim to compare the effectiveness of a group-based, sports oriented physiotherapy intervention, Sports Stars, for ambulant school-aged children with CP, to standard care across all ICF domains. This study will also aim to gain feedback from treating physiotherapists and caregivers involved in the study to determine the acceptability of the intervention. The specific hypotheses to be tested are:

Primary hypothesis

H1: Compared to children in the standard care group, children in the Sports Stars group will demonstrate greater improvement in their individually-selected, sports activity and participation related goals measured by the Canadian Occupational Performance Measure (COPM).

Secondary hypotheses

H2: Body function and structure: Compared to children in the standard care group, children in the Sports Stars group will demonstrate greater improvements in lower limb and upper limb strength, balance, agility and their aerobic and anaerobic fitness.

H3: Activity: Compared to children in the standard care group, children in the Sports Stars group will demonstrate greater improvements in gross motor capacity, including locomotor ability and object control skills.

H4: Participation: Compared to children in the standard care group, children in the Sports Stars group will demonstrate increased participation in physical activities including recreational or formal sporting activities.

H5: Quality of life: Compared to children in the standard care group, children in the Sports Stars group will demonstrate greater improvements in quality of life as measured by parent report.

Study sample and recruitment

Inclusion criteria

This study will include children who:

1. 1.
Are aged 6-12 years at study entry;

2. 2.
Have a confirmed diagnosis of CP;

3. 3.
Are ambulant without aids (classified as GMFCS- E&R Level I or II);

4. 4.
Can commit to eight, one-hour weekly group physiotherapy sessions and three, two-hour assessment appointments over a period of 6 months.

Exclusion criteria

Children will be excluded from the study if they:

1. 1.
Are unable to complete baseline assessments;

2. 2.
Have had orthopaedic or neurological surgery within 6 months prior to the immediate intervention start date;

3. 3.
Have had Botulinum Toxin injections within 3 months prior to the immediate intervention start date;

4. 4.
Have intellectual or behavioural difficulties which would limit their ability to participate in the assessment or therapy protocols;

5. 5.
Have medical co-morbidities which prevent them from exercising safely (e.g. cardiac or respiratory instability, uncontrolled seizures).

Criteria for withdrawal

Participants will be excluded from the study if they fail to attend either their baseline assessment or withdraw prior to the commencement of the immediate Sports Stars group. Primary analysis will use the intention to treat principle, using the last observation carried forward for participants who withdraw after commencement of intervention in the immediate Sports Stars group.

Recruitment

Sample size

According to CONSORT guidelines, sample size calculations are based on adequate power for comparison between the effects of the Sports Stars program compared to standard care using the COPM immediately post intervention (T2). Data from a previous study investigating the effects of an exercise group aiming to improve physical activity, balance and strength in ambulant children with CP (6-14 years) showed a standard deviation of 1.87/2.88 (intervention/control) [ 32]. This standard deviation and a mean change of 2 points for performance on the COPM (clinically meaningful difference) were used to calculate sample size. Based on significance (alpha) of 0.05 and 80% power, a minimum sample of 25 participants in each group (50 participants total) will be required. Therefore, 60 participants (30 in each group) will be recruited to allow for 20% attrition.

Recruitment process

Eligible children will be prospectively recruited through the client database of a state-wide community rehabilitation service. As geographical location and participant availability are critical to forming groups of sufficient participant numbers for this study, participants will be recruited in blocks according to their geographical location. Once at least four, and a maximum of six, children are identified that can attend an eight-week group on a specified day in a specific geographical location, these children will be assigned as group one. When a second group of four to six children are identified for a geographical location, they will be assigned as group two. When two groups of four to six participants each are identified, they will proceed to randomisation.

Randomisation

A random sequence will be generated via coin flip by an independent, off-site co-investigator (MA) who will not be involved with assessment or treatment (as per process used in previous studies [ 17]). The outcome (heads: group 1 = immediate Sports Stars intervention, group 2 = waitlist Sports Stars intervention. Tails: group 1 = waitlist Sports Stars intervention, group 2 = immediate Sports Stars intervention) will be written on a piece of paper and concealed inside a sequentially numbered, opaque envelope and stored securely off-site.

When two groups are identified, they will be randomly assigned to either the immediate intervention group or the waitlist control group with a 1:1 block allocation via drawing of one of the opaque envelopes. Randomisation will be completed offsite by the same independent co-investigator (MA). This process will continue until 60 participants complete baseline assessments and proceed to the Sports Stars group.

Therapy protocols and delivery

Refer to Fig. 2 for the study flow diagram according to CONSORT guidelines.

Sports Stars flow chart according to CONSORT guidelines

Sports Stars intervention

Each group will contain between four and six participants with one lead Physiotherapist. The immediate Sports Stars group will receive eight, one-hour, weekly sessions (8 hours) of group-based, sports specific fundamental movement skills training, detailed in Fig. 3. These groups will introduce children to four popular Australian sports and support the development of core motor skills for transition to recreational mainstream and modified sports opportunities including Junior Entry Point sports programs, NetSetGo (netball), In2Cricket, MiniRoos (soccer) or T-Ball (softball/baseball). To achieve this, Sports Stars will focus on developing key Body Functions (aerobic and anaerobic fitness, muscle strength, balance and agility, and locomotor and object control) and sport-specific Activity skills to facilitate participation in modified sport games of soccer, netball, T-ball and cricket.

Sports Stars session content summary

Location

Sports Stars will be conducted at local parks in the community in association with Queensland's largest state-wide community physiotherapy service provider for children with CP. Groups will be provided in urban/regional Queensland, Australia, capturing the breadth of cultural and socioeconomic diversity. Each group will include back-up undercover areas to be used in the event of wet weather.

Participants of the Sports Stars group will not be permitted to receive other physiotherapy during their 8 week Sports Stars group. Throughout the duration of the study, all participants will be permitted to access standard care from other allied health (e.g. occupational therapy, speech and language pathology) and/or other adjunct therapies. Parents/guardians will be requested to record the frequency, duration and content of any standard care received including any home exercise performed.

Standard care comparison

Participants in the Sports Stars Waitlist group will receive standard care. This describes the typical intervention that a six to 12-year-old child with a diagnosis of CP would receive from their normal therapists in community, private or hospital contexts. Therapists who provided standard care will have varying degrees of experience working with children with CP. Standard care may include neurodevelopmental therapy, context-focussed therapy, strength or fitness training, or functional training. At this age, children are typically seen for 1:1 therapy, however some group therapy may also be offered. Ambulant children of this age (classified as GMFCS- E&R I-II) with CP would typically receive only 1-2 physiotherapy sessions per quarter. This may include a home program and is expected to vary between participants, however most children would receive no more than two sessions during the comparative 8 weeks of a Sports Stars program. Details of frequency, duration and content of any therapy session, particularly physiotherapy, will be collected via a parent log book throughout the project.

Treatment fidelity

Intervention therapists will be masked to baseline outcome assessments. All intervention therapists providing the Sports Stars intervention will be qualified physiotherapists with experience working with children with CP in a community setting. At therapist training, the detailed Sports Stars protocol and a sports equipment pack will be provided to all therapists to ensure that participants in all groups received consistent delivery. This includes a written week by week program of sports focussed exercises and progressions (Additional file 1) with detailed instructions and video resources that therapists can use to select predetermined difficulty levels to suit each child's age, goals and preferences. Therapists will receive individual, face to face training in the Sports Stars protocol by the first author prior to the commencement of the group. Treating therapists will engage in further consultation as required with the study coordinator either by phone or in person to review the Sports Stars package and to discuss program content and structure prior to providing the group to participants. Each child will have features of their participation in each group session recorded by the treating therapist, including exercise type, level of difficulty and therapist observed engagement. At week three and six of the study, each therapist will undergo fidelity review and receive guidance via email through an independent, offsite co-investigator (MA) who will not be involved with assessment or treatment regarding intervention format, content, progression and data recording. Independent content analysis will determine compliance with the provided protocol. Parents of both the immediate and waitlist groups will be provided with training journals to record any therapy, including home exercises, and sport that they undertake during the study period.

Outcome measures and procedures

All outcomes will be collected pre-intervention, immediately post intervention and at 12 weeks post intervention by the blinded chief investigator (GC).

Participants will be classified based on their severity and age to compare groups at baseline. They will be classified according to:

The Gross Motor Function Classification System is an internationally recognized classification system for children and youth with CP. Participants will be classified as either classified as GMFCS- E&R I (able to walk independently at home, school, outdoors and in the community with limitations in speed, balance or coordination) or II (able to walk in most settings, however may have difficulty with distances or more challenging environments and gross motor skills like running and jumping) using the descriptors for between the child's 6th and 12th birthday [ 33].

Participants will be classified by motor type (spasticity, dyskinesia, ataxia or unclassifiable) and distribution (unilateral or bilateral) [ 34, 35].

Participants will be classified by their ability to walk five, 50 and 500 m, correlating to their ability at home, school and community. Scores range from N (does not apply), to 6 (independent on all surfaces without aids) [ 36].

2.
Outcomes: Measured for all participants at four time points and compared to baseline and each other:

Time one (T1): zero months- Baseline

Time two (T2): 2 months- Immediately after immediate intervention

Time three (T3): 5 months- 12 weeks after immediate intervention

For children participating in the waitlist group, an optional fourth assessment will occur:

Body function and structure outcomes

Aerobic capacity & agility: 10 × 5 Meter Sprint Test [37]

The 10 × 5 Meter Sprint Test is designed to measure aerobic capacity and agility in children with CP of GMFCS- E&R level I or II. Children must continuously sprint the five-meter course 10 times, making turns at the cones marking the end of the five meters. The 10 × 5 Meter Sprint Test has excellent inter-observer (ICC > 0.97) and test-retest reliability ( r = 1). It has reported good construct validity. The 10 × 5-m sprint test is sensitive to change for children at GMFCS- E&R levels I and II and therapists report a high clinical feasibility. A decrease in exercise time of 3.2 s would be considered real change [ 37].

Anaerobic Capacity Muscle Power Sprint Test (MPST) [37]

The MPST measures anaerobic capacity by asking the participant to sprint 15 m (marked by lines and cones) at their maximum pace, 6 times, with 10 s recovery between each sprint. The MPST has a high inter-observer and test-retest reliability ( r = 0.97-0.99). It has good construct validity with GMFCS- E&R [ 37] and the Wingate Anaerobic Test (Peak Power: r = 0.731, Mean Power: r = 0.903) [ 38]. It is sensitive to change in children GMFCS- E&R level I and II and has high clinical feasibility. Standard errors of measurement were reported at 13.9 (peak power) and 9 (mean power) Watts [ 37].

Functional Lower Limb Strength: Standing Broad Jump [39]

The standing broad jump measures lower limb strength in the context of sports participation. Standing with toes up to a line, children are asked to jump forward as far as they can, landing with both feet. The distance between the start line and the most distal part of their toes of their back foot will be measured for three jumps, with the average recorded to the nearest centimetre. The standing broad jump has excellent test-retest reliability in typically developing children (ICC- 0.88 [ 40]) and in children with down syndrome (ICC- 0.89 [ 41]). It has excellent concurrent validity with measures of physical fitness ( r = 0.84) [ 40], Paralympic throwing ( r = 0.77-0.86) [ 42] and sprinting ( r = 0.82) [ 43] for children with disabilities. It has been reported to be sensitive to change as part of a test battery and is a feasible clinical test [ 40].

Functional Lower Limb Strength: Vertical Jump [39]

The vertical jump measures lower limb strength. Standing next to a wall, children raise their arm. The most distal point of their fingers is marked. They are instructed to jump as high as they can, a second mark being made at the height of their jump. The vertical distance of three jumps will be measured and averaged to obtain the jump height to the nearest centimetre. The vertical jump has been used to represent the core functional output of children's strength in previous literature [ 44]. It is also utilised readily in mainstream sport and physical education and is included in Australia's national talent identification and development program [ 39].

Functional Upper Limb Strength: Seated throw [39]

The seated throw measures functional upper limb strength. Children are seated comfortably with their back against a wall. Using a chest pass, they are asked to throw a basketball as far as possible while keeping their back against the wall. The distance between the wall and the first point of contact of the ball will be measured to the nearest centimetre for three throws and the average calculated. Similar to the vertical jump, the seated throw has been used to represent the core functional output of children's strength in previous literature [ 44, 45], is common and clinically feasible in mainstream sport and physical education and is included in Australia's national talent identification and development program [ 39].

Activity and Participation outcomes

Individual activity and participation based goals: Canadian Occupational Performance Measure (COPM) [46]

The COPM is the most frequently used measure of individual client centred outcomes in paediatric rehabilitation [ 47]. It measures individual, client-centred outcomes by focussing on the goals and priorities of the child and family [ 48]. The child-adapted model of the COPM will be administered via semi-structured interview with the parent/caregiver and child. Three sports related goals (at least one activity and one participation focussed) will be identified by caregivers. Ratings scale of their child's performance and their satisfaction with this performance will be made on a 1-10 ordinal scale. The COPM has high re-test reliability (ICC 0.76-0.89). It demonstrates concurrent validity with the Functional Independence Measure and Klein-Bell [ 49] in addition to construct and criterion validity [ 50]. It has good sensitivity to change [ 49]. On the ordinal scale (1-10) a change of two or more points is considered clinically meaningful [ 51].

Functional Mobility and Balance: Timed up and go (TUG) [52]

The TUG is a simple measure of balance, anticipatory postural control and functional mobility. The modified procedure for children described by Williams et al. [ 52] requires participants to stand up from a chair with a backrest but no arms, walk three meters to touch a target before turning and returning to a seated position. They are timed from their bottom rising from the seat to touching back down on the seat and are given encouragement throughout the procedure. The TUG has a high within-session and test-retest reliability (ICC 0.99) [ 53]. It is reported to be an ecologically valid tool. The TUG is responsive to change over time in children with physical disabilities [ 52]. Minimal detectable changes of 1.4 s (GMFCS- E&R I) and 2.87 s (GMFCS- E&R II) have been calculated [ 54].

Gross Motor Capacity (CP Specific): Gross Motor Function Measure Challenge Module (GMFM Challenge) [55]

The GMFM Challenge was developed as an extension of the GMFM which is used internationally to quantify gross motor performance in children with CP. The GMFM can have a ceiling effect, especially for children of GMFCS- E&R I classification over the age of 5 years. The GMFM Challenge is an observational measure of high-level skills, speed and quality of performance in children with ambulatory CP. It has been found to have excellent inter-rater (ICC = 0.97) and test-retest reliability (ICC = 0.96) [ 56]. The content validity of the GMFM Challenge was enhanced by using existing, feasible and relevant observational gross motor measures, working with experienced clinicians and performing participant based content validity checking with children with CP. Rasch analysis has been completed but not yet published [ 57]. Preliminary minimal detectable change values have been reported at 7.17-8.44 [ 56].

Gross Motor Capacity (Sport Specific): Test of Gross Motor Development-2 (TGMD-2) [58]

The TGMD-2 is an observational measure of gross motor skill performance relating to sports. It assesses skills in two categories, locomotor and object control, each with six items. In doing this, the TGMD-2 focusses on specific sports skills and is often used for children in mainstream education or sporting contexts and has been reported to be the gold standard for gross motor skill for pre-schoolers [ 59]. It is reported to have high inter-rater, test-retest, internal and composite reliability [ 58, 60, 61, 62]. Ulrich [ 58] reports excellent validity and clinical feasibility in the TGMD-2 manual and studies have demonstrated construct validity [ 61] and concurrent validity with the GMFCS- E&R [ 62], Pre-schooler Gross Motor Quality Scale [ 59] and measures of physical fitness [ 63].

Participation Frequency and Enjoyment: Children's Assessment of Participation and Enjoyment (CAPE) and Preferences of Activities for Children (PAC) [64]

The CAPE and PAC are questionnaires that measure participation of children in a range of activities outside of school. The CAPE-PAC measures who a child is participating with, enjoyment of an activity and the diversity and intensity of participation in formal (organised sport, other skill-based activities, and clubs, groups and organisations) and informal activities (recreational, active-physical, social, skill-based, and self-improvement). It has adequate test-retest reliability (ICC = 0.67-0.86) [ 65]. There is evidence for construct and face validity and clinical utility [ 65, 66].

Contextual

Quality of Life: Cerebral Palsy Quality of Life- children's version (CP QOL-Child) [67]

The CP QOL-Child is a quality of life questionnaire that assesses wellbeing in seven domains. It was specifically designed for children with CP aged 4-12 years. Parent proxy reports will be used in this study due to the age of most children anticipated in the Sports Stars group. The CP QOL-Child demonstrates high internal consistency (ICC 0.74-0.92) and test-retest reliability (ICC 0.76-0.89) for the parent proxy report. It demonstrates adequate construct validity relative construct validity with the Child Health Questionnaire, KIDSCREEN and GMFCS- E&R [ 67].

Caregiver satisfaction

Post intervention (T2) a custom-designed questionnaire will be used to measure satisfaction with the Sports Stars program. Questions will relate to group design, group content, and satisfaction with sport readiness. Outcomes will be measured on a Sports Stars specific eleven point Likert Scales with an additional open-ended question in each category. Answers will be reviewed by the primary investigator (GC) to determine consistent themes.

Child's motivation and engagement within the Sports Stars group

To evaluate if there is a relationship between study outcomes and participant engagement, treating physiotherapists will be asked to record participants' engagement in each component of the group intervention (warm-up, locomotor skills, object control skills, game participation and cool-down), in each therapy session using Sports Stars specific five point Likert Scales. Thematic analysis will be performed by to determine overarching themes.

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SPORTS STARS study protocol: a randomised, controlled trial of the effectiveness of a physiotherapist-led modified sport intervention for ambulant school-aged children with cerebral palsy

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Modified sport interventions run by physiotherapists have shown potential as cost-effective, engaging, and effective interventions to improve gross motor skills and support transition to real-world sports participation for children with cerebral palsy. At present, this population demonstrates decreased participation in physical activities and sport compared to peers due to barriers ranging from body function to accessibility challenges.

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Sport Australia is determined to have more Australians participating and excelling in sport, from grass-roots right up to the pinnacle of elite competition.