Long hours of daily sitting and lack of Physical Activity (PA) are risk factors for morbidity and mortality.

People with movement disabilities, including adolescents with Cerebral Palsy (CP) tend to lead a sedentary life styl and have have poor physical fitness. Adolescents with CP where found to be inactive most of the day thus, they are in greater risk of disease than the general population. In addition, over the years, people with disabilities experience physical and functional deterioration. Reducing sedentary behavior and increasing daily activity can reduce health risk factors among the adolescents with CP, reduce secondary impairments and preserve function.

Interventions that included exercise alone has not resulted in physical activity and participating in a structured training did not continue after cessation intervention.

The objectives of this study are to establish effective programs aiming to promote an active life style among adolescents and young adults with CP and to evaluate there outcomes.

Specific objectives- Stage 1- Identifying barriers and facilitators for reducing sedentary behaviors and increasing physical activity among adolescents and young adults with CP. As well as, identifying mediators, needs and preferences for reducing sedentary behaviors and increasing physical activity among adolescents and young adults with CP.

Stage 2- Based on stage 1- Establishing an intervention for reducing sedentary behaviors and increasing physical activity among adolescents.

Stage 3- translating and developing questioners for the study.

• Translating the ASK-Performance and the ASK-Capability questionnaires to Hebrew and validating the Hebrew translation.
• Developing a self-efficacy perception questioner for increasing physical activity and reducing and sedentary behavior.
• Translating to Hebrew, adjusting and validating an activity diary.

Stage 4- evaluating the effectiveness of the proposed intervention program on reducing sedentary behaviors and increasing physical activity among adolescents and young adults with CP.

Stage 1 focus group- Identifying barriers and facilitators for reducing sedentary behaviors and increasing physical activity as well as, identifying mediators, needs and preferences for reducing sedentary behaviors and increasing physical activity.

Stage 2- Based on stage 1- Establishing an intervention for reducing sedentary behaviors and increasing physical activity among adolescents. The intervention group will receive behavior-modification in group. The control group will get physical exercises.Stage 3- translating and developing questioners for the study.

• Translating the ASK-Performance and the ASK-Capability questionnaires to Hebrew and validating the Hebrew translation.
• Developing a self-efficacy perception questioner for increasing physical activity and reducing and sedentary behavior.
• Translating to Hebrew, adjusting and validating an activity diary.

Stage 4- evaluating the effectiveness of the proposed intervention program on reducing sedentary behaviors and increasing physical activity among adolescents and young adults with CP. The outcome measures will measure change from base line after intervention and 4-6 months after intervention finished.

All partners of this project will obtain approval for experiments on human subjects from their local committees. Each subject (or parents/guardians for the participation of minor subjects) will be able to sign an informed voluntary consent form, consistent with the Helsinki Declaration, after reading a detailed explanation and having an oral Q/A session with the investigator.

Recruitment: Prospective focused direct mailing or personal contacts will be initiated with the parents/guardians of children with CP who are ambulatory, who had been seen by physiotherapists in social groups and schools.

Inclusion exclusion criteria for Focus Groups:

• 30 adolescents with Cerebral Palsy
• aged 14-25yrs
• mobility level GMFCS I, II & III and
• 20 Typically Developed individuals same age group
• with verbal ability suitable for discussion
• Cognitive level sufficient to comprehend and cooperate with measurements.
• Parent or the individual (if above 18) has agreed to participate in the study

Exclusion criteria:

• Unstable medical situation
• Progressive degenerative condition of the Central Nervous System (CNS) or musculoskeletal system.

Inclusion exclusion criteria for intervention groups:

• adolescents and young adults with bilateral spastic CP
• at GMFCS level I, II and III
• age 14-25 yrs
• can speak their native language fluently
• are able to follow verbal instructions
• are willing to train in a group.

The exclusion criteria:

adolescents and young adults who had orthopedic surgery or tone reduction interventions (e.g. botulinum toxin injections, history of baclofen pump or selective dorsal rhizotomy) within 6 months prior to this study

- have exercise induced asthma or cardiac problems.

Inclusion criteria for validation ASK & Self Efficiency Questionnaire study:

• 30 Children and adolescents with CP
• age 5-20yrs
• GMFCS I;II;III.
• Cognitive level sufficient to comprehend and cooperate with measurements.
• Parent or the subject (if above 18) has agreed to participate in the study

Exclusion criteria:

• Unstable medical situation
• Progressive degenerative condition of the CNS or musculoskeletal system

Outcome measurements:

1. Habitual Physical Activity (HPA).Physical activity is recorded using an "ActivPAL3™" (PAL Technologies, Glasgow, UK) tri-axial accelerometer-based activity monitor.
2. 6 min walk test (6minWT): This test measures the self-paced distance in meters walked in 6 minutes on a flat, firm surface.
3. 10 meter walk test (10MWT): This self-paced test measures gait speed, important for safe community mobility (e.g., crossing streets in response to signals).
4. Timed Up-and-Go (TUG): This test measures mobility for those able to walk on their own (assistive device permitted).
5. Functional Mobility Scale (FMS): The FMS uses three distances (5, 50 and 500m) which represent typical distances walked by children at home, at school, and in the wider community.
6. The Activities Scale for Kids (ASK) is a child self-report measure of physical disability. It is designed for children five to 15 years of age who are experiencing limitations in physical activity due to musculoskeletal disorders.
7. The Pediatric Evaluation of Disability Inventory™ Computer Adaptive Test (PEDI-CAT) measures abilities in the three functional domains of Daily Activities, Mobility and Social/Cognitive. The PEDI-CAT's Responsibility domain measures the extent to which the caregiver or child takes responsibility for managing complex, multi-step life tasks.
8. Self efficiency questionnaire: for evaluating perception of self efficiency for engaging in physical activity and reducing sedentary behavior.

Statistics:

Focus group: Coding text and theorizing: In grounded theory research. Identifying anchors that allow the key points of the data to be gathered. Collections of codes of similar content that allows the data to be grouped.

Repeated measures analysis of variance (ANOVA) will be used to determine the effects and compare the two groups methods.

A correlation test will take place between the ASK Capability and the PEDI-CAT. A correlation test will take place between the ASK PERFORMANCE and the results from the accelerometers.

One-way ANOVA test by separation the sample to severity groups, according to the GMFCS levels, using the age as a co-variant.

Inclusion Criteria:

Intervention group:

• children, adolescents and young adults age 14-25 yrs
• with bilateral spastic Cerebral Palsy
• at GMFCS level I, II and III
• can speak their native language fluently
• able to follow verbal instructions
• willing to train in a group.

For ASK: age 5-18yrs.

• children, adolescents and young adults age 5-18yrs
• with bilateral spastic Cerebral Palsy
• at GMFCS level I, II and III
• can speak their native language
• able to follow verbal instructions

The exclusion criteria:

• Individual who had orthopedic surgery or tone reduction interventions (e.g. botulinum toxin injections, or have a history of baclofen pump or selective dorsal rhizotomy within 6 months prior to this study
• have exercise induced asthma or cardiac problems.