validity of the Melbourne Assessment 2 such as dimensionality and rating scale structure. We know it is inappropriate to use the total score for interpretation and scores derived from individual subscales are more robust. Understanding that the subscales are relatively discrete may assist in planning intervention. The solid basis for the Melbourne Assessment 2 is a launching platform for more research, which will aid our confidence in its use as a discriminative tool and outcome measure. Decisions as to whether to use the Melbourne Assessment 2 for clinical and research purposes depend on balancing the requirements of the assessment, knowledge of psychometric properties, and clinical utility. The Melbourne Assessment is clearly feasible to use, considering frequency of use in intervention research, despite the need to videotape the assessment and time taken for scoring. The Melbourne Assessment 2 has a solid foundation to its psychometric properties based on Rasch modelling and extrapolating evidence from the existing Melbourne Assessment. The Melbourne Assessment 2 is more useful in out-

come evaluation than treatment planning, although understanding that the four subscales are discrete highlights relative areas of strength and weakness to exploit during treatment planning. It is probably the assessment of choice when a measure of unilateral, as opposed to bimanual, upper limb capacity is required. The Melbourne Assessment 2 may be used to assess both upper limbs, but the assessment is then undertaken and scored for each upper limb separately. Evaluation of bimanual performance in naturalistic environments would complement information obtained from the Melbourne Assessment 2. One option is observation of spontaneous use of the affected hand in bimanual activities using the Assisting Hand Assessments (AHA)4 for children with unilateral disability. The AHA is suitable for children aged 18 months to 12 years. Another option is the parent-rated ABILHAND-Kids5 for older children aged 6–15 years and which is validated for use with unilateral or bilateral cerebral palsy.

REFERENCES 1. Hoare B, Imms C, Randall M, Carey L. Linking cere-

3. Spirtos M, O’Mahony P, Malone J. Interrater reliability

bral palsy upper limb measures to the International

of the Melbourne Assessment of Unilateral Upper Limb

Classification of Functioning, Disability and Health. J

Function for children with hemiplegic cerebral palsy.

Rehabil Med 2011; 43: 987–96.

Am J Occup Ther 2011; 65: 378–83.

2. Randall M, Imms C, Carey L, Pallant J. Rasch analysis

4. Krumlinde-Sundholm L, Holmefur M, Kottorp A,

of the Melbourne Assessment of Unilateral Upper Limb

Eliasson AC. The Assisting Hand Assessment: current

evidence of validity, reliability and responsiveness to change. Dev Med Child Neurol 2007; 49: 259–64. 5. Arnould C, Penta M, Renders A, Thonnard JL. ABILHAND-Kids: a measure of manual ability in children with cerebral palsy. Neurology 2004; 63: 1045–52.

Function. Dev Med Child Neurol 2014; 56: 665–72.

Sedentary behaviour in adolescents and young adults with cerebral palsy NICHOLAS F TAYLOR 1,2 1 Department of Physiotherapy, La Trobe University, Bundoora, Vic.; 2 Allied Health Clinical Research Office, Eastern Health, Box Hill, Vic., Australia. doi: 10.1111/dmcn.12424 This commentary is on the original article by Shkedy Rabani et al. on pages 673–680 of this issue.

Much focus in public health recommendations has been on achieving a sufficient amount of physical activity (of at least moderate intensity) for good health. For example, it is recommended that adolescents up to age 17 years should accumulate at least 60 min of moderate to vigorous activity daily, and that when possible adolescents with disabilities should meet these guidelines. However, it is now emerging in large population studies that the amount of sedentary behaviour, and not just the total amount of physical activ-

ity, is an important predictor of cardiovascular and metabolic risk.1 Sedentary behaviour can be defined as sitting and lying postures characterized by low energy expenditure. Increased sedentary time, especially the time spent in sedentary behaviour without a break, can have a negative effect on the metabolic and cardiovascular systems, independent of the amount of time spent exercising at moderate to vigorous intensity.1 Therefore, it is possible for a person who is sufficiently physically active according to guidelines, to be to be at risk of developing heart disease and diabetes if they spend prolonged periods sitting and lying. It is also well recognized that people with cerebral palsy (CP) are a group that is particularly vulnerable to the negative health consequences of low levels of physical activity and increased amounts of sedentary behaviour. The physical impairments that characterize CP can result in a cycle of Commentaries


decreased physical activity, increased sedentary behaviour, and deteriorating muscle morphology leading to greater cardiovascular and metabolic risk and early mortality.2 The study of Shkedy Rabani et al.3 confirms previous reports that physical activity levels of young people with CP are low compared with their typically developing peers.4 However, in addition to reporting physical activity levels, Shkedy Rabani et al. also report new and more detailed information about the sedentary behaviour of this population. Adolescents and young adults with CP are sedentary for between 82% and 96% of the day. These results are similar to sedentary behaviour reported for other populations with mobility disability, and indicate that young people with CP demonstrate substantially greater amounts of sedentary behaviour than people without health conditions.5 Of particular interest, Shkedy Rabani et al. reported other markers of sedentary behaviour such as the number of daily transitions from sit to stand, and the median duration of bouts of sedentary behaviour. As well as being sedentary for the majority of each day, these data suggests that adolescents and young adults with CP are sedentary for prolonged periods with few transitions or periods of light activity. Therefore, young people with CP may be at long-term risk of developing health problems not only

because they are not physically active enough, but also because they spend too long in sedentary postures. The issue is what to do about this problem. Attempts to increase levels of moderate to vigorous levels of physical activity in young people with CP have proven difficult to achieve and maintain, with only modest benefits found in a small number of trials. Another approach that is now being proposed for people with motor disabilities, and which may be applicable to people with CP, is to trial interventions that reduce sedentary behaviour.5 What is appealing about this approach is that these interventions are less intensive and so may be more achievable than interventions designed to increase moderate intensity physical activity. For example, designing and integrating standing work stations in classrooms, allocating time for students to walk or self-propel their wheelchairs between classes, and having limits on sustained screen time are practical strategies that could be trialled in future research. If strategies to reduce sedentary behaviour are going to be trialled, sedentary behaviour first needs to be measured. The study of Shkedy Rabani et al. is important because it is one of the first to measure and report detailed baseline information about sedentary behaviour in young people with CP.

REFERENCES 1. Dunstan DW, Howard B, Healy GN, Owen N. Too

3. Shkedy Rabani A, Harries N, Namoora I, Al-Jarrah

much sitting – a health hazard. Diabetes Res Clin Pract

MD, Karniel A, Bar-Haim S. Duration and patterns of

a systematic review. Disabil Rehabil 2013; 35: 647–55.

2012; 97: 369–76.

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5. Manns PJ, Dunstan DW, Owen N, Healy GN. Address-

adults with cerebral palsy. Dev Med Child Neurol 2014;

ing the nonexercise part of the activity continuum: a

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more realistic and achievable approach to activity pro-

2. Peterson MD, Gordon PM, Hurvitz EA. Chronic disease risk among adults with cerebral palsy: the role of premature sarcopenia, obesity and sedentary behaviour. Obes Rev 2013; 14: 171–82.

4. Carlon SL, Taylor NF, Dodd KJ, Shields N. Differences in habitual physical activity levels of young people

with cerebral palsy and their typically developing peers:

gramming for adults with mobility disability? Phys Ther 2012; 92: 614–25.

Sleep: the other life of children with cerebral palsy CHRISTOPHER J NEWMAN Paediatric Neurology and Neurorehabilitation Unit, Department of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland. doi: 10.1111/dmcn.12441 This commentary is on the original article by Atmawidjaja et al. on pages 681–685 of this issue.

Sleep is an all important part of childhood, not only in terms of the cumulative years a child spends asleep, but mainly because of its essential role in general health, body growth, brain development, and learning. Considering this, there has only been a belated interest in the ‘sleep life’ of children with cerebral palsy (CP), which has thankfully increased over the last decade. Studies in children with CP 610 Developmental Medicine & Child Neurology 2014, 56: 605–611

show some variation in the prevalence of sleep disorders, due to differences in population characteristics and in the tools used to identify these disorders, as well as the inherent difficulty in defining the cut-off point between good, poor, and pathological sleepers. However, there is overwhelming evidence that children with CP have a severalfold increase (seven to twelve times) in the frequency of sleep disorders, notably disorders of initiation and maintenance of sleep, when compared with their peers.1 Sleep, as a biological phenomenon, could be expected to transcend cultures; however, culture has a strong bearing on where we sleep, with whom we sleep, when we sleep, as well as on judgements of what we consider good sleep.2 Atmawidjaja et al.’s study makes a significant contribution to the literature on sleep in CP, by exploring sleep quality

Sedentary behaviour in adolescents and young adults with cerebral palsy.

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