Validation and Responsiveness of activity limitation testing in framerunning for children and young people with CP. (Dr Sarah Reedman and Samantha King)

0:00Welcome to the ResearchWorks podcast, broadcasting live from the Oceana Academy of Civil Palsy and other childhood on-set disabilities conference 2026, the beautiful city of Hope Art Australia. Join Dr. Danipool and the ResearchWorks team as we bring you an exclusive series of interviews with visionary keynote speakers and leading presenters. Captured right here can meet the groundbreaking discussions and innovations, shaping the future of disability research and care. Well hello everyone, we are back for our conference series this time with Oceana Academy in Hope Art Australia. And to kick us off, we're gonna have a really good chat with two really incredible people about a paper that takes great interest for me. The title of this paper is Validation and Responsiveness of Activity Limitation Testing in Frame Running for Children and Young People with cerebral palsy. That was a mouthful, but all the titles are. So welcome to the pod for this conference series, Dr. Sarah Readman from the University of

1:02Queensland. Welcome Sarah. Hi Dana, hi Sam, so good to see you. Really good to see you and yes we also have Samantha King here from Healthy Strides Foundation and part of Curtin University for your Honours project. Welcome. Thank you very much, it's such an honour to be here. What a feeling to beat the mic, how's that feeling for you right now Sam? I'm quite nervous, but that's that's okay, that's right, you've got Sarah and myself here. We're just having a chat about what was your Honours project. But this is part of a larger study and Sarah, can you tell us a bit more about where this all came from and and the why I guess behind this particular study? Yeah, so we ran a large trial called Run for Health CP and it was across six Australian sites including Healthy Strides Foundation for West Australia. And the aim of that trial was to look at the impact of frame running across different health outcomes for children and young people with CP and similar disabilities. But we really wanted to also unpack a

2:10few other things including the frame running classification process. You know we might get into a little bit later and use the data that we collected in that larger trial and which is a randomized controlled trial. So there's lots and lots and lots of lots of data. But you so use some of that and repurpose it for, yeah, this look at how can we support the classification process and how can we do something called activity limitation testing, which I know Sam will talk about, to really improve that. I love that. Can we, I'd love to go into the classifications and why we need to do that. But just go back a little bit into your randomized controlled trial because I know we went through that really quickly and there was no small thing to run a trial across so many sites in Australia. And yes, we were lucky enough to be part of that as well. What was the, why did you choose frame running? Why is frame running something that you were interested in even looking at in the first place?

3:11Do you mind walking us through that a bit Sarah? Yeah, so frame running is a parabolic discipline kind of like running, you know, 100-metre sprint ambulance. So just using your legs or a wheelchair track racing. Frame running is just another discipline of par athletics. And frame running comes from back in, you know, I think it was the late 1980s or early 1990s Connie Hanson, who's a par athlete and occupational therapist and her friend, Mansor Siddiqui, basically created frame running because the only way that athletes with higher mobility support needs who didn't use a wheelchair because they didn't have good upper limb mobility, they actually wanted to rely on the legs. They had to do buck with wheelchair racing, filling with their feet. And Connie and Mansor thought there must be a better way of doing this so they created the first running frame of spare bicycle parts. So running frame has three wheels. So it kind of looks a little bit like a

4:15tricycle, except it doesn't have pedals. So you sit on a saddle, there's a chest support to support your upper body. And you propel the frame forward using feet and steer with handlebars that look a little bit like bike handlebars, of course. But today's running frame is a lot more refined than the original one from spare parts. So that's kind of the basic history of it. And really why we wanted to look into it is because it has the potential to have some really great health impacts for people with cerebral palsy and similar disabilities with high support needs and mobility because we know that it can be really hard for those young people to do an accessible, like an easily accessible sport or physical activity that gets the heart rate up. Yes. Because of course, there are lots of activities that those people can do, like, you know, body weight support and travel training, great example. But many of those examples actually use high cost assistive technology, things that can that are sort of stuck in one place, like, you know,

5:20body weight support, travel training is in a clinic. That's right. You know, or even even aquatic based exercise, you need to get to a pool and the pool is stuck. Yeah. That's right. Yeah. So frame running is great. You can transport the frame wherever you can use it wherever you run. So it's a really accessible form of high moderate to high intensity exercise. So we really wanted to have a look at how can that benefit health? I love that. And it's so important when you think about, you know, the culture that we live in, we, you know, we want to be able to run and how many goals do you have when you speak with kids that their goal is to run and they want to be able to move fast and they want to be able to participate. There is a, a real important piece here in terms of participation in addition to all of these really great physical benefits as well. And what about from a classification standpoint, coming in more to this study now and looking at these activity limitation tests, what is it about these tests that align with classification for parallel pixel sports? Yeah. So currently the classification process

6:25uses some tests that are well familiar to us, for example, testing the spasticity of the legs. So that sort of overactive stretch reflex. And if you are the different things to establish, I guess, the degree of what we call impairment. So an athlete with a disability has some impairments that are kind of inherent to their disability like spasticity and uses those along with a, you know, a comprehensive physical assessment, looking at the athlete in competition and using the frame to basically put the athlete into classes. And we have classes in non-parasport that people forget about, like, for example, men and women compete separately, those are classes. So in frame running, the T71 and T72 classes, basically the purpose of classification in all sport is to make the competition more fair or as fair as is possible. So we're basically grouping athletes with similar impairments together. And then the difference in their performance then,

7:28when they get on the racetrack and they run, should be truly about or more closely about how well prepared they are and their performance. So how well they train their performance on their day, not how much spasticity they have. Because you've got to remember they grouped in athletes with similar levels of impairment. So that's a good thing. The gap in frame running at the moment, though, is that classification process is lacking what we call activity limitation tests. So we have the impairment testing, but we don't have tests that show the impact of those impairments on the activity that the athlete needs to use in sport. And in the case of frame running, that's things like power and propulsion and also step efficiency. And so we want to see how well can athletes do those skills. They're basically skills is what the activity is. And then

8:33be able to then also see the translation of that into performance. So it's kind of like three levels. You've got impairment activity and performance. We're kind of missing the activity part. So we thought this is a great opportunity to develop some activity limitation tests and validate them through this process because we've got a large enough sample. And they have to repeat it a number of times. Yeah, that's great. What a wonderful opportunity. And look, before we get into that, Sam, Sarah and I had a chat about this. I think we were at, reminds me, we were at Rouge EACD conference where we were chatting about this, I think, of like what we could offer in terms of an honours project. And it's so great to be part of these bigger projects when you're doing research. And what a great learning opportunity for you. So when you embarked on this as an occupational therapy student and wanted to do your honours with Sarah, what was it that draw you to this particular study? For me, it was really about the participation side of things.

9:36Working at Healthy Strides, I got to see the run for health CP study in motion as well. So I got to see some of our kids that come here participate and I got to see the other flow and effect of seeing kids then use the frame runner to participate. And like running festivals or running along the foreshore and that side of it, I really loved as well as getting to come down and see the kids participate in the frame running training as well. That's really cool. And that's just a bit of a shout out to, you know, finding opportunities to be involved in research doesn't mean no matter which stage you're in. Yeah. You can be part of these bigger research projects and you can get so much out of it. And this data is really meaningful. So over to you, Sam, talk to us about the activity limitation test that you looked at for this particular study. Yeah. So activity limitation tests in general, they've been used in other parabolic classification processes for other power sports as well. But for the main paradigm is that all athletes compete the same movement, but the method varies

10:37comparing compared to the different sports. So for this specific study, the two activity limitation tests we searched were, sorry, for the two activity limitation tests that we looked at were one called the four bounds for distance, which is how far a child can propel in their frame runner in four bounds or eight reciprocal steps. And the second one was the number of steps in 20 meters, which kind of speaks for itself in that. It's how many steps a child took in their frame runner when covering a 20 meter distance. And these were both designed to measure the degree of impairment, to which a child's impairments impact on their ability to use and perform in their frame runner. Cool. So to really, and even as you describe that, their tests that you can do relatively easily, you don't need lots of equipment for it. And I love how the tests do you find a lot of our physio tests are great. Like we name them based on like what you actually have to do. Yes. It is fantastic. I love it. I love it. So if you ever get confused, that's what it is.

11:40Tell me a little bit about the population. So you did have a great sample here that you were able to look at. Didn't you, Sam? Yes. So the population we tested this in was children with cerebral palsy from GMFCS levels two to five. The inclusion criteria was the same as the run for health CP inclusion criteria, which I'm sure Sarah can speak a bit more on. But with the additional inclusion criteria of having one valid outcome measure or enough of the outcome measure recorded to facilitate an analysis. Yeah, sure. Okay. So any other main features, Sarah in terms of inclusion criteria into this study is probably worthwhile just to elaborate on that a bit more from a population perspective. Yeah. So the athletes were between six to 21. So just really children and young people and in GMFCS levels. Yeah. Great. GMFCS levels two through to five. And really, they just had to be able to understand instructions for testing. So our sample did

12:42include a large cross-section of young people, including young people, even with moderate intellectual disability, who AAC uses and people with also co-occurring payments, including visual, like severe visual impairments. Yeah. So really great, like representative sample of outstanding young people. And that's so fantastic because even as you describe that, the age range, you know, even going up to 21, incredibly unique, including children, GMFCS level four and five, incredibly unique. And the fact that even individuals with intellectual impairment could be involved with this too, you know, often these are the exclusion criteria. And it makes this population such an interesting one to study because it's just so representative of what we often see in clinical practice. I love that you did all of that, but that just speaks to the fact that you're a clinician as well, Sarah. So of course, you're going to think about things like this in a study. We're going to make sure it works. Okay. So let's go into some of the results in terms of what

13:45it is that you actually did because I did see when I look across your abstract, you included what 48 participants. Yes. That's pretty amazing. Average age of 11 years and 10 months, 35 male, and the GMFCS spread was pretty incredible. So you had nine GMFCS level two, 13 at GMFCS level three, 23 at GMFCS level four, which is amazing, and two at GMFCS level five. So tell us a little bit about the results and what you actually did for this study. Yeah. So we looked at the validity, more specifically, the convergent validity in the non-groups validity. So within the convergent validity, we looked at two non-frame running assessments, the six-minute frame running tests. So how far child can propel in their frame running in six minutes, similar to the six-minute walk test? And we also looked at the 100-metre sprint, which is currently the only parathletic assessment or event that frame running athletes can compete in. And we compared them to the activity limitation

14:49test outcomes. And before we get into the results of that, Sarah, you're always really good at describing what convergent validity is. I've heard you say it before. I'm going to get you to do it again on the spot. Sorry, but go. Okay, so when we're validating a new assessment, what we're really doing is trying to answer the question, does it measure what we think or say that it measures, right? So one way to do that is convergent validity, where we take another outcome that should be related to it. So if you think about six-minute frame running tests, how far can you run like your endurance? And also sprint tests. So basically, these are two performance measures. So basically, the better that you perform on the activity limitation tests, like the lower your activity limitations are, the better you should perform. So these should be highly correlated with one and other. And when, so if we look at that correlation, we're looking for a strong correlation

15:49in the expected direction as well. Beautifully described. And what was the result for that? Yeah, so we found very statistically significant results. We found that those should propelled further in four bounds for distance, propelled further in the six-minute frame running test. And those who took more steps in the step 20-meter assessment covered less distance in the six-minute frame running test, along with the 100-meter sprints, those who propelled further in four bounds for distance produced a faster 100-meter sprint time. And those who stepped had a higher step count in the number of steps in 20 meters had a slower 100-meter sprint time. So it's what you expected. Was there anything there that popped out as unusual? Or it was what you were hoping for? I mean, it was what I was hoping for. The other thing that popped out was that the correlation between the two activity limitation tests. So we found that those who propelled further in four bounds for distance tended to take less steps within the 20-meter distance as each step propelled them further. Good, good. So the known group's validity? We'll talk a little bit about

16:54that. Yes. So we had some statistically significant results in that. We had a trend for the median four bounds for distance to decrease as gmfcs levels increased. And the median step 20 meter to increase as the gmfcs levels increased as well. But we had no statistically significant results for the type of cerebral palsy and the activity limitation test outcomes. Okay, so over to Sarah, what do you think that means and maybe a quick snapshot about what known groups validity is as well? So known groups, I love how I'm just like I'm explaining these statistical tags. Did you say great? I've heard you just know how to get it in a great way. No group's validity is about, again, a type of construct validity where we're trying to establish whether the test is what it says on the box. And we can take known groups. So things that we already know distinguish between individuals really well. So gmfcs is a great example because we know

17:59and it's been shown time and time again that there are distinct groups of people according to their motor ability. And so what we can do is test whether the performance of these tests differ between those known groups, which means it distinguishes between people that should have different motor ability. And so to show that there is a known groups validity is a really positive sign because again, it demonstrates that this assessment can distinguish between athletes with different levels of motor ability. And the thing about also the not having those statistically significant results for the type of CP. And by type of CP, what Sarah was talking about is motor type, which is like whether an athlete has specificity or dyskinetic CP, like dystonia, choropotosis or ataxia, for example, so like the actual symptom, and the mergly symptom. And that, you know, there could be two or more reasons for that. One is

19:06we didn't have a large enough sample because some of, you know, we had a very large number of people with spastic CP, a small and a with dyskinetic and very, very small number with ataxic and hypotonic CP. So perhaps the groups of individuals is just that large enough because there's a lot of variability within the group. Or it's basically that actually this test, it doesn't really matter what type of CP you have. What's really important is it distinguishes between your general gross motor ability. That's right. Rather than what is actually causing that limitation, like what symptom is caused by spasticity, caused by the impairment, which is probably a good thing. So I think it's actually better that it doesn't discriminate between different motor types. That's right. I love that. So what does this all mean? I mean, these results are really fantastic, and I imagine for an honest project, it was very exciting to get these kind of results. What does this all mean, Sam? For going forward, I hope that this can contribute to the classification

20:09process for frame running, it proves that we have something to add to the battery of tests that are currently being used in frame running classification. Yeah, I think it's really exciting. And something that you can do quite easily as well. This adds to the, I loved in your abstract, you wrote about how this can support this sort of the notion of intentional misrepresentation. Can you talk about what that actually is and what that means, Sarah, because I have heard this before within classifications? Yeah, so intentional misrepresentation. That's what we have to remember, is really rare, like most athletes in the classification process are not going to do this, but intentional misrepresentation is when an athlete deliberately tries to make their impairments seem more significant than they are. So it's kind of a form of cheating. And again, it's something that's very unusual and very rare, but because it has such a big impact on competition fairness, we want to detect it, like we want to be able to detect it really

21:12well. So having these tests and adding them to the battery of the assessments that are already used, and also the properties of these tests that we discovered. So for example, one thing that Sam identified is that they have opposing directions of correlation. So for the six minute frame running test, like one test kind of has a positive correlation. So as one gets bigger, the other gets bigger. One has a negative direction of correlation, as one gets bigger, the other gets smaller. Yes. And having to test that have opposing directions of correlation, if you're an athlete, if you're performing truthfully, that's exactly what should happen. If you're trying to cheat intentionally, you might not account for that, or you might not understand what is supposed to happen. So it could be easier for a classifier to detect intentional misrepresentation. So I think that's a really good feature of both of these assessments. That's wonderful. And like you said, it's not, I imagine most of you don't go into it with that intention, but if there is that,

22:13you want to make sure that the competition is fair, and people do put a lot of work and effort. We all know what it might be like to do some training, but at this level, there's so much more that you'll be putting on the line, the sacrifices, and these tests play an important part of that. So in terms of these tests being available, people can can use these tests. They're described in your protocol paper, I believe, Sarah. So people can take a look at that as well. Is there anything that you want to say with regards to the future steps of this Sarah and the activity limitation tests and where you'd like it to go? Yeah. So one of the things I guess Sam didn't mention is that we also looked at something called responsiveness, and probably that could take a really long time. So the tests basically how they respond to training. And so these tests in this population, this population were novice athletes. So they hadn't done frame running before, or just even only a small amount of frame running before. Basically, they were totally new to the discipline.

23:15And so in this sample, we actually showed that the tests were responsive to training. So their performance on these tests actually got better after they did the 12-week frame running training program. And that's why Kate, active in limitation tests, we're not necessarily expecting that they're stable over time, like impairments. But a future direction is we really should repeat this in elite athletes and highly trained athletes. Because what we would expect is that perhaps they're less responsive to training so they don't have as a dramatic increase in their performance, of course. And that would be a really good thing for the classification. I think also just testing them in the real world. So I'd love to have a discussion with the paraclassifiers, be able to demonstrate these tests, and see if we can get them tested in real classification processes, and get the opinions of the paraclassifiers to understand, you know, are these really adding to the picture? Are they useful? Are they fast?

24:16And is it helping you to distinguish between sport classes for frame running athletes? That's a fantastic feature for the area, for the industry. So it's such a meaningful project and honours research that you're involved with, Sam, you must be so proud, congratulations. Thank you very much. But this is me, there's a future direction for you in research. Potentially. It's great to get a sample of what it is like, isn't it? And this was a really lovely experience for you. And your message be to people who are thinking about getting involved in research. I honestly really enjoyed the process. I feel like a bit of a nerd, but I actually really loved the writing. I loved looking at the data I went to, I understood what I was looking at. And yeah, kind of extrapolating it and having a look at what that actually means for the children that we see in the clinic. Yeah, there's a direct translation there isn't there. So yeah, this is the value of this kind of research is doing it within this clinical setting. And and that's also the value of why, you know, just developing research projects that are really

25:17practical and really thinking about the end result of where it could be implemented is the, is really the future direction. And this is a great example. So thank you to both of you for joining our conference series of Oceana Academy in Hobart. Thank you very much for having me. Lovely to have you. Thank you, Sarah. Thank you, Sam. All of our listeners hope you enjoyed that. Are there so much more to come, of course, in this conference series? We'll talk to you all again really soon. Goodbye.