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Considerable attention was given to identifying and evaluating individual goals for each child. Goals were set in close collaboration with the parents, the child (as much as possible),
the childs preschool assistant, and staff from the habilitation
team (i.e. physical therapist, special needs teacher). Seven
specific and measurable goals were set for each child. Goal
attainment was graded as complete (100%), partial (50%), or
no improvement (<50%). An example of a set goal might be
for the child to get up from a prone position to a sitting position. Goal attainment would be graded as partial, for example,
if the children rolled over on their side, placed weight on the
elbow, and was able to stretch the arm to sit up, but was
unable to sit up completely.
Change in gross motor function was assessed using the
Gross Motor Function Measure (GMFM-66; Russell et al. 2002).
Achievement in daily life activities of self-care, mobility, and
social function was monitored with the Pediatric Evaluation
of Disability Inventory (PEDI; Haley et al. 1992) using a Swedish
version of the functional skills and caregiver assistance scales
(Nordmark et al. 1999).
Parents and preschool assistants perception of services was
evaluated with a self-administrated questionnaire: the MPOC
(Swedish version, Bjerre et al. 1997). The MPOC was supplemented with four questions to cover areas of interest not covered by it (see Appendix I). To appraise the frequency of
training, diaries were written at home and at preschool for one
week during the 1st, 3rd, and 5th months of the intervention
(Fig. 1).
Three physical therapists, sometimes together with a special
needs teacher, performed all the assessments. They followed
the same children throughout the study. They also participated
in the training of the children. All physical therapists had extensive (1225y) rehabilitation experience and were familiar with
using the various assessments.
INTERVENTION
The intervention period started with a structured four-day livein course for the participating families and the preschool assistants, together with staff from a habilitation team. Intervention
took place at a foundation in the countryside owned by the
association of parents of children with CP. Staff included a medical doctor, physiotherapist, special needs teacher, psychologist, and a social worker. The course was theoretical and
practical. To understand and participate in the training, knowledge about the aetiology of CP and the consequences for
overall development, normal and abnormal motor development, motor learning, psychological aspects, and motivation
were considered essential. During the four days the children
started their training. This began the process of practical guidance for parents and preschool assistants.
During the following 5 months, goal-directed functional
therapy was mainly carried out in the childs normal settings at
home and at preschool. Throughout the intervention period,
continuous discussions were held with, and advice and support given to trainers during regular home and preschool visits. All children met once a week for three hours to attend
training at the local habilitation-centre, together with parents
and/or preschool assistants. Group sessions also focused on
guiding parents and preschool assistants in goal-directed
training with the opportunity to discuss and practice the techniques. Special attention was paid to making children active
participants in this process. Apart from individually tailored
guidance, in group sessions children could meet peers, play,
and have fun. After 5 months, group training was reduced to
one meeting per month; only occasional guidance was given
to parents and assistants.
Child F, a female of 5 years of age (GMFCS level III), will
serve as an example of the individually tailored intervention.
One of the seven goals that the parents, preschool assistant,
and this participant considered important was to be able to
A
B
C
D
E
F
G
H
I
J
K
L
M
N
Age at start
of study (y:m)
Diagnosis
GMFCS
Other impairments
Group
2:6
2:11
4:0
4:1
4:2
4:2
4:9
5:4
6:0
1:6
1:9
3:4
3:0
2:8
SpDi
SpDi
SpDi
SpDi
SpDi
SpDi
SpTet
SpDi
SpDi
SpDi
SpDi
SpTet
SpDi
SpDi
III
III
III
III
IV
III
V
IV
II
III
III
V
III
IV
No speech
No speech
No speech, visual
No speech
No speech
Visual, epilepsy
No speech
1
1
1
1
1
1
1
1
2
2
2
2
2
2
GMFCS, Gross Motor Function Classification System (Palisano et al. 1997). SpDi, spastic diplegia; SpTet, spastic
tetraplegia. Children were assigned to training group 1 or 2 for didactic reasons.
614
stand up from the toilet and walk to the bathroom sink. The
activity was analyzed with the physiotherapist and found to
contain several sub-skills that the participant needed to learn,
i.e. stand up, step down a stair, move one hand during the
stepping-down transfer, walk sideways, and turn when reaching the sink. The bathroom floor, which was often slippery,
added to the difficulties. Training was given in the goal-activity
and its sub-skills several times each day, at home and at
preschool. Sub-skills could be practised during other activities, i.e. climbing down stairs and pavements, moving along
holding on to furniture when playing with friends, and standing up from a chair.
Participants were encouraged to perform the different activities in a variety of ways; activities were discussed and suitable
solutions were tried out. The physiotherapists discussion with
helpers (i.e. parents and caregivers) focused on how much
assistance the participant needed to succeed while still doing
as much as possible independently. Another important aspect
of the consultations was to support the helpers ability to do
task-analyses, i.e. what parts does a task consist of, what are the
difficulties for this particular child, how can the situation be
used for training, and how can the motivation of the child be
encouraged? For child F, the main problem was muscular
weakness which contributed to her difficulties in standing up
and walking down stairs. Therefore, focus was on strengthening as an integrated part of the activities. Stronger leg-muscles
would allow her to perform the task with less assistance.
Ninety-eight goals were set for all 14 participants (Fig. 2). Three
goals were related to body function, i.e. increasing range of
motion. One goal was related to participation and aimed at
promoting the childs ability to play with peers. The remaining 94 goals were related to activities, e.g. being able to walk
from the toilet to the sink or rise from the floor into a walker.
Goals relating to eating and dressing were also common, e.g.
taking off a sweater, cutting soft food.
After three months of training, 46 out of 98 goals were fulfilled completely and 25 were partially completed. After five
months, 76 goals were fulfilled completely and 19 were partially completed (Fig. 2). At eight months follow-up goal attainment was sustained.
DATA ANALYSIS
GMFM
GMFM scores did not change significantly during the baseline period. Two children, however, had an unstable baseline. One child exhibited a change of 1, and the other, the
youngest child in the group, a change of 2.42 between the
first and the second assessment. However, the amount of
change displayed during baseline measures was not significantly related to age (rs=0.49). An obvious change in gross
motor function took place over the 5-month training period
(Friedman p<0.001, median change score 3.13, range
1.476.79; Fig. 3). The improvement was most pronounced
Baseline
I
Baseline
II
1mo
Training
diary
PEDI
MPOC
Additional questionnaire
2mo
3mo
4mo
Training
diary
Goal attainment
5mo
PostPostintervention intervention
I
III
Postintervention
III
Training
diary
PEDI
MPOC
Additional questionnaire
Goal attainment
Goal
attainment
Figure 1: Timing of assessments before, during, and after intervention. Each interval indicates one month. Arrows indicate
timing. Gross Motor Function Measure-66 assessments (Russell et al. 2002) were made by three physical therapists (PTs)
following same child through indicated time-period. Pediatric Evaluation of Disability Inventory (PEDI; Haley et al. 1992)
assessments were made by same three PTs and a special needs teacher. Goal assessment was made by parents in
collaboration with PTs and a special needs teacher; MPOC, Measure of Processes of Care (King et al. 1995).
Functional Therapy in Children with Cerebral Palsy Lena Ekstrm Ahl et al. 615
PEDI
QUESTIONNAIRE
60
55
50
GMFM-66 score
45
40
35
Participants
30
Intervention
20
BL
BL I
II
1m
o
2m
o
3m
o
4m
o
5m
o
Po
st
Po I
st
Po II
st
III
Assessment times
(mo)
25
8
5
3
Assessments
0
20
40
60
80
98
Number of goals
Figure 2: Goal attainment. Black bar, seven goals set for each
child (n=98). Striped bars, goals fully achieved at 3, 5, and 8
months follow-up. White bars, goals partially achieved.
616
A
B
C
D
E
F
G
H
I
J
K
L
M
N
75
b
80
Caregiver assistance
65
Functional scales
55
45
35
25
15
5
a
60
40
20
Self-care
Mobility
Self-care
Social function
Mobility
Social function
Functional Therapy in Children with Cerebral Palsy Lena Ekstrm Ahl et al. 617
7
6
5
4
3
2
1
0
EP
PGI
PSI
CCC
RSC
618
Book Review
The Brains Sense of Movement
By Alain Berthoz
Cambridge, USA: Harvard University Press, 2000
pp 352, 16.95, US$24.95
ISBN 0 674 00980 0 (Paperback)
When I began my doctoral studies in sensorimotor control,
I was intrigued by seemingly unexplainable phenomena
associated with both perceptual illusions and altered perceptual experiences following unique brain lesions. How
could vibrations applied to biceps while the fingertip is on
the nose lead to the perception that the nose is growing
(Pinocchio illusion)? How could two objects of identical
weight but different size be perceived to have different
weights (sizeweight illusion)? How could patients with
parietal area lesions not recognize one half of their body or
visual field (unilateral neglect)? What underlies amputees
perception that their amputated limb still exists or hurts
(phantom limbs)? To me, answers to these questions
appeared to be the key to understanding sensorimotor
interactions in the brain. In The Brains Sense of Movement
(translated from French) the author, Alain Berthoz, uses
these or similar examples of perceptual disconnects as a
guide to describing the relationship between perception
and action. As stated by the author, the book is a reflection
on how the brain works proactively, with perception being
much more than an interpretation of sensory messages.
Perception is proposed to be inseparable from action, and it
is suggested that perceptual illusions are solutions to problems of sen-sory conflict or ambiguity.
What is truly unique is that the book frequently highlights these perceptual disconnects as well as practical
examples and exercises that show how we control movements, such as gaze control, posture and limb movement,
space orientation, and gait, to guide the reader to an understanding of sensorimotor control. Furthermore, it often
draws upon philosophy and presents historical perspectives on the interaction between perception and action.
The book is nicely divided into 14 important chapters
with sexy subheadings, such as The Art of Breaking and
What If Newton Had Wanted to Catch the Apple, that cover
many bases of perception and action, from control of balance, limb movement, and visual gaze. The central tenant is
that the brain uses sensory information proactively. The
brain is, above all, a biological machine for moving quickly
with anticipation. Berthoz, a highly regarded neurophysiologist, boldly asserts that the brain uses configurations of
receptors to work out a perception and action. As the
author acknowledges, science moves quickly. But despite
having been published almost five years ago, the work was
ahead of its time and this has been reinforced by subsequent
experimental work. However, one exception is the authors
rejection of the term internal representation. While he correctly asserts that it is too easy to hide our ignorance behind
such a generic term, considerable evidence for representations of manipulated objects and their use in proactive control has been published since this book was published.
However, as the author embraces the term internal model,
I suspect the objection largely involves the terms overuse
and that, therefore, Berthozs concern merely involves
syntax.
Overall, The Brains Sense of Movement is a detailed and
refreshing review of sensorimotor control. The book is
filled with wonderful examples which make the presentation of material practical, fascinating, and a delight to read.
The relation of basic material to interesting clinical pathologies makes it all the more interesting to clinicians. This book
contains information that should inspire research in clinical
motor control for decades to come.
DOI: 10.1017/S0012162205001283
Andrew M Gordon
Functional Therapy in Children with Cerebral Palsy Lena Ekstrm Ahl et al. 619