Clinical Corner – Reducing sedentary behaviour and increasing activity levels in children who require postural care

Clinical Corner – Reducing sedentary behaviour and increasing activity levels in children who require postural care 

Written by Kieran Murphy, Clinical Partnerships Manager

What is sedentary behaviour? 

Sedentary behaviour (SB) is defined as “any waking behaviour characterized by an energy expenditure lower than 1.5 metabolic equivalents (METs)” [1]. Typically, when a person is sitting or lying down, they are engaging in SB.  

How does sedentary behaviour affect health? 

SB is associated with a raft of negative health issues, including increased risk of cardiovascular disease, metabolic disorders, poorer mental health, and increased mortality risk [2,3,4]. 

Sedentary behaviour in children with disabilities 

Disabled children are typically more sedentary than their typically developing peers [4]. More severe motor impairment and increasing age are associated with increased levels of SB [5]. Evidence has previously suggested that children with Cerebral Palsy who require 24-hour postural care approaches spend between 98-99% of their waking hours being sedentary [6]. It is paramount that children with disabilities are supported to be more physically active and counteract the negative effects associated with SB. 

Physical activity 

Physical activity (PA), in the opposite manner to SB, is associated with a raft of positive health benefits [7]. There are numerous guidelines worldwide promoting an increase in PA levels, including specialised guidelines for children with disabilities, such as the UK CMO guidelines from 2022 [7]. However, exercise guidelines often place a large focus on partaking in ‘moderate (3-6 METs) to vigorous (6-9 METs)’ intensity exercise, which can be difficult to both measure and achieve in children with more complex disabilities.

It has also been noted that individuals who meet physical activity guidelines but still engage in excessive SB still experience increased negative health risks [5]. A focus, particularly for children with more complex disability, should be to reduce SB as much as possible. We should aim to support them to partake lots of PA that is more achievable, such as light PA (1.6-3 METs). 

Sleep 

There is a bi-directional relationship between exercise and sleep, in that increased exercise may improve sleep quality, but poorer sleep may contribute to lower PA levels [8]. Sleep difficulties are common in children with neurodisability [9]. Therefore, if supportive sleep strategies are not considered alongside reducing SB in these children, there is likely a key element being missed that could maximise their ability to partake in PA throughout the day. 

A 24-hour approach 

There has been a trend in more recent years to view healthier lifestyles from a 24-hour perspective, incorporating recommendations for increased PA (of all levels), reducing SB and improving sleep quality [10]. There have even been 24-hour movement guidelines produced specifically for children with disabilities [11,12]. 

This is a welcome shift in thinking, and it is one that compliments 24-hour postural care approaches. 24-hour postural care is not simply about maintaining postural symmetry and preventing body deformity. Postural care should be utilised to encourage PA and reduce SB, facilitate socialising, skill practice, participation, and improved sleep. It should encapsulate all the aspects of the ICF framework and F-Words in Childhood Disability [13,14]. 

How might 24-hour postural care look with a 24-hour movement viewpoint? 

Here are some simple strategies to think about when using adaptive equipment in postural care. 

Make sitting active 

Sitting does not need to be a sedentary activity. Activity seats such as the Rifton Activity Chair have great features such as hi-lo bases, tilt-in-space and tool-free adjustments to supports that can support targeted training . These features can improve access to the child’s environment, encourage more stimulated and active sitting, and can make sitting a little more physically challenging. Finger painting or using building blocks are great examples of light physical activities that can be done while sitting.  

Standing is exercise 

Some studies have suggested that just the task of supported standing is not passive for non-ambulant children [15,16, 17]. Regular access to a standing frame is a great way to reduce SB. Standing can be made more active by incorporating it into fun and practical activities that a child enjoys and is motivated to do. A mobile stander is also a great option for active standing and independent mobility.

Break down barriers and facilitate more ‘leisure’ activities 

Children with physical disability have significant barriers placed against them by society. Lack of access and funding to equipment that can be vital for being more physically active is a huge problem. Adaptive tricycles are a great way to increase PA, and should not be viewed as simply a ‘leisure’ activity. Let’s facilitate more opportunities to experience cycling – such as the adaptive tricycle days Jiraffe have been conducting throughout the UK. Here’s Bertie cycling round his local park, he also cycles to and from school. 

Encourage more independence in self-care 

For example, an adaptive shower or toileting chair can be hugely impactful to practice task-specific skills such as sit-to-stand and step transfers, hair washing, or going for a wee or poo on the toilet. Weight-bearing or flip-away footplates may aid transfers, trunk supports may aid upper limb use, encouraging a squatting position may aid more effective bowel voiding and energy conservation for practicing self-hygiene afterwards. 

Sleep Systems must be used to encourage good sleep 

For children with limited mobility, their asymmetrical or ‘destructive’ lying postures quickly become associated with their ability to fall asleep [18]. We cannot assume that a more symmetrical posture is one that is conducive to a good night’s sleep – how symmetrical is your sleeping posture? Sleep system supports should be introduced sensitively and gradually, taking into account the child’s routine. Professionals need to collaborate with the children, and their carers, to support good sleep for both.  

Click here to access Jiraffe’s FREE 24 Hour Movement Toolkit  

About the Author

Kieran qualified as a Physiotherpist in 2016 at the University of Salford and later attained an MSc at the same university in Advanced Physiotherapy. He completed his core rotations before becoming a senior paediatric physiotherapist for the NHS in Greater Manchester, UK.

Kieran’ s experience as a physiotherapist has seen him provide a wide range of holistic therapy to children with developmental delay, complex neurological and physical disabilities and musculoskeletal injuries. He continues to work alongside his role as Clinical Partnerships Manager for Jenx with a small caseload of private patients and as a locum therapist.

Kieran has a keen interest in supporting adolescents with cerebral palsy and the management of hip dysplasia.

References 

[1] Tremblay, M. S., Aubert, S., Barnes, J. D., Saunders, T. J., Carson, V., Latimer-Cheung, A. E., Chastin, S. F. M., Altenburg, T. M., Chinapaw, M. J. M., & SBRN Terminology Consensus Project Participants (2017). Sedentary Behavior Research Network (SBRN) – Terminology Consensus Project process and outcome. The international journal of behavioral nutrition and physical activity, 14(1), 75. https://doi.org/10.1186/s12966-017-0525-8 

[2] Zhang, J., Yang, S. X., Wang, L., Han, L. H., & Wu, X. Y. (2022). The influence of sedentary behaviour on mental health among children and adolescents: A systematic review and meta-analysis of longitudinal studies. Journal of affective disorders, 306, 90–114. https://doi.org/10.1016/j.jad.2022.03.018 

[3] Park, H.P. et al. Sedentary Lifestyle: Overview of Updated Evidence of Potential Health Risks. 

Korean J Fam Med. 2020; 41(6): 365-373 

[4]  Ganz, F., Hammam, N. & Pritchard L. Sedentary behavior and children with physical disabilities: a scoping review. Disabil Rehabil. 2021; 43(20): 2963-2975. 

[5] Bradbury, M. et al. Sedentary behaviour in non-ambulant children and young people with 

physical disabilities: a systematic search and review protocol. BMJ Open. 2021; 11: e053077. 

[6] Verschuren, O. et. al. Exercise and Physical Activity Recommendations for People with CerebralPalsy. Dev Med Child Neurol. 2016; 58(8): 798-808. 

 [7] Smith, B. et al. Physical activity for general health in disabled children and disabled young 

people: summary of a rapid evidence review for the UK Chief Medical Officers’ update of the 

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https://www.gov.uk/government/news/new-guidelines-to-support-disabled-children-to-be-more-active. 

[8] Kline C. E. (2014). The bidirectional relationship between exercise and sleep: Implications for exercise adherence and sleep improvement. American journal of lifestyle medicine, 8(6), 375–379. https://doi.org/10.1177/1559827614544437 

[9] McDonald, A. & Joseph, D. Paediatric neurodisability and sleep disorders: clinical pathways and management strategies. BMJ Paediatrics Open, 2019;3:bmjpo-2018-000290. 

[10] World Health Organization. 2019. WHO guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age. Available at: https://www.who.int/publications-detail/guidelines-on-physical-activity-sedentary-behaviour-and-sleep-for-children-under-5-years-of-age 

[11] Canadian Disability Participation Project (CDPP), Canadian Society for Exercise Physiology (CSEP), ParticipACTION & the Healthy Active Living and Obesity Research Group (HALO) at CHEO. (2019). The Ability Toolkit. https://cdpp2.ca/wp-content/uploads/2025/04/Ability-Toolkit-Final-ENG_FINAL-s.pdf 

[12] Verschuren, O., Hulst, R. Y., Voorman, J., Pillen, S., Luitwieler, N., Dudink, J., & Gorter, J. W. (2021). 24-hour activity for children with cerebral palsy: a clinical practice guide. Developmental medicine and child neurology, 63(1), 54–59. https://doi.org/10.1111/dmcn.14654 

[13] World Health Organization. (2001) International Classification of Functioning, Disability and Health (ICF). 

[14] Rosenbaum, P. & Gorter J. The ‘F-words’ in childhood disability: I swear this is how we should think! Child: care, health and development. 2011; 38(4): 457–46. 

[15] Verschuren, O. et al. Muscle activation and energy-requirements for varying postures in children and adolescents with cerebral palsy. J Pediatr. 2014; Nov; 165(5):1011-6. https://pubmed.ncbi.nlm.nih.gov/25151195/ 

[16] Israeli-Mendlovic H, Mendlovic J, Katz-Leurer M. Heart rate and heart rate variability parameters at rest, during activity and passive standing among children with cerebral palsy GMFCS IV-V. Dev Neurorehabil. 2014; 17(6): 398–402. https://doi.org/10.3109/17518423.2014.895439 

[17] McLean, L. J., Paleg, G. S., & Livingstone, R. W. Supported-standing interventions for children and young adults with non-ambulant cerebral palsy: A scoping review. Developmental medicine and child neurology, 2023; 65(6), 754–772. https://doi.org/10.1111/dmcn.15435 

[18] Baylis, M. 24 Hour postural care and use of sleep systems in cerebral palsy. Paediatrics and Child Health. 2020, 30(8): 296-302.