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ISSN: 1751-8423 (print), 1751-8431 (electronic)

Dev Neurorehabil, 2014; 17(6): 426432

! 2014 Informa UK Ltd. DOI: 10.3109/17518423.2014.923057

ORIGINAL ARTICLE

Continuous vs. blocks of physiotherapy for motor development

in children with cerebral palsy and similar syndromes:
A prospective randomized study
Anne-Louise Brunner1, Erich Rutz2, Stephanie Juenemann3, & Reinald Brunner2
1
Physiotherapie Erik Goossens, Oberwilerstrasse, Binningen, Switzerland, 2Department of Neuroorthopaedics, Pediatric Orthopaedic Unit,
University Childrens Hospital Basel, Basel, Switzerland, and 3Department of Neuropaediatriccs, Pediatric Unit, Childrens Hospital,
Kantonsspital, Luzern, Switzerland

Abstract Keywords
Objective: To determine whether physiotherapy is more effective when applied in blocks or Cerebral palsy, en bloc, motor development,
continuously in children with cerebral palsy (CP). Methods: A prospective randomized cross-over physiotherapy, randomized clinical trial,
design study compared the effect of regular physiotherapy (baseline) with blocks of regular
physiotherapy alternating with no physiotherapy over one year. Thirty-nine institutionalized
children with CP and clinically similar syndromes (616 years old, Gross Motor Function History
Classification Scale IIIV) were included. During the first scholastic year, group A received
regular physiotherapy, group B blocks of physiotherapy and vice versa in the second year. The Received 26 January 2014
Gross Motor Function Measure 66 (GMFM-66) was the outcome measure. Results: Thirteen Revised 7 May 2014
children in each group completed the study. GMFM-66 improved (p50.05) over the study Accepted 7 May 2014
period in both groups in total; changes (p50.05) were seen only in dimension D (group B) and Published online 22 May 2014
E (both groups) during regular therapy. Conclusion: Physiotherapy may be more effective when
provided regularly rather than in blocks.

Introduction children received more physiotherapy than usual (12 times

per week) concentrated in blocks, and that blocks of
Physiotherapy is standard in the management of children with
physiotherapy (34 sessions/week) and breaks without
cerebral palsy (CP) [1, 2]. It aims at maintaining muscle
physiotherapy were well tolerated. The assessments in these
length, muscle strength and tone reduction as well as
studies [35] were performed immediately before and after
improvement of motor skills. In Switzerland, usually one or
the physiotherapy blocks, and these studies did not give
two sessions weekly are given over many years on a
information on the carry-over effects of physiotherapy on
neurophysiological basis (neurodevelopmental treatment
function. Other studies [7, 8], however, reported the opposite.
(NDT), Bobath and Voijta), but patients may receive more
None of these studies [35, 7, 8] ran for more than 18 months.
after an intervention. The provision of physiotherapy is based
Current evidence, hence, is not sufficiently robust to deter-
mostly on clinical experience. There is concern that habitu-
mine the optimal physiotherapy regimen for children with CP.
ation with this approach by the therapist and the child over
A recent study on a very small cohort of infants indicated that,
such a long period and the reduced number of weekly sessions
for targeted problems, blocks of therapy could possibly be
may compromise the efficacy of this regular therapy. Blocks
superior [6] (Table I).
of intensive physiotherapy, in contrast, are carried out for a
The aim of this study was to compare the effects of blocks
limited period, but have an increased number of weekly
of physiotherapy vs. regular physiotherapy on motor skills in
sessions. This may offer opportunities to concentrate on more
children with CP. The study ran for 24 months, and the
specific functional problems and perhaps result in a higher
children were tested after the block or regular therapy
functional impact, although the block of therapy is followed
regimens ended. We hypothesized that blocks of physiother-
by a period without or with reduced therapy.
apy would offer a more intensive regimen and consequently
There are few well-designed studies that consider different
be superior in promoting motor skills than regular
protocols of physiotherapy provision for children with CP.
physiotherapy.
Some studies [36] showed improved motor skills when
Methods
Correspondence: Reinald Brunner, Prof. Dr. med, Head of Design
Neuroorthopaedics, Pediatric Orthopaedic Unit, University Childrens
Hospital Basel, Spitalstrasse 33, CH-4005 Basel, Switzerland. In Switzerland, all children with CP and similar syndromes
Tel: +41 79 958 2303. E-mail: reinald.brunner@ukbb.ch receive physiotherapy aiming at improving motor
DOI: 10.3109/17518423.2014.923057 Continuous vs. blocks of physiotherapy 427
Table I. Overview of studies from the literature.

Authors Years Participants Age GMFCS Duration Intervention (PT sessions) Tests Results
Trahan and 2002 5 children Mean 45 6 months No groups four sessions/ After four and eight Improvement
Malouin 22.6 months week for four weeks weeks (GMFM 66)
eight weeks without
therapy
Tsorlakis et al. 2004 34 children 314 years 13 16 weeks Group A: basic two Before and after the Improvement
sessions/week Group B: intervention (GMFM
intervention five 66)
sessions/week
Shamir et al. 2012 10 children 1224 months 20 weeks Groups A and B Both At four weeks intervals Improvement
groups: four weeks (GMFM 66 and 88)
baseline one session/
week Group A: eight
weeks intensive four
sessions/week Cross
over for eight more
weeks
Mayo NE 1991 29 children 02 years 6 months 17 children one session/ After intervention (no Improvement
week one hour GMFM/other motor
(intensive) 12 children development tests)
one session/month one
hour (basic) Both groups
got a home program
Bower et al. 2001 56 children 312 years 35 18 months Six months baseline 12 At three-month intervals Equal
sessions/week Six (GMG 66)
months treatment five
sessions/week Six
months follow-up 12
sessions/week
Christiansen 2008 25 children 18 years 15 30 weeks Intermittent four sessions/ Before and after Equal
and Lange week for fuor weeks and intervention
six weeks without ther-
apy Continuous 12
sessions/week

development and avoiding contractures. It was deemed
unethical to leave such children untreated. Thus, it was not
possible to design a study that had an untreated group of
children with CP, and so only treatment modalities could be
compared. Motor skills may improve with growth and
increasing age, but it was impossible to identify sufficient
pairs of children with similar severity of CP for a matched
pair study design. For these reasons, a crossover design was
chosen. Each child acted as his/her own control.
A double-blinded study was not possible, because the
children, parents and treating physiotherapists would be aware
of their physiotherapy schedule. The study, however, was
single-blinded since the physiotherapists who assessed the
children were blinded to the physiotherapy regimen. As all
children already had regular physiotherapy (NDT, Bobath,
Peto, Vojita and strength training) depending on each
therapist and her/his training, this was taken as the baseline
physiotherapy regimen, and the same regimen continued
during the study. The content of each physiotherapy session
thus varied. However, this regimen was unchanged, and the
same local therapist treated the same child during the study
period. Similarly, all other activities (sports, additional
therapies, etc.) continued unchanged over the study period.
Two groups, A and B, were formed receiving the opposite
order of the therapy regimen. The order was randomized
before the baseline assessment by generating a random
number in Excel (Microsoft Office Excel 2003) as a
discriminant (0.5). The randomization was done by one of
the co-authors who was not involved in the study during data
acquisition. The parents agreed without knowing to which
group their child would be allocated.
Four physiotherapists assessed the children over the study
period and were blinded to the physiotherapy regimen. These
therapists were trained in administering the GMFM-66 but
did not work at the childrens institutions and did not know
them beforehand or treat them at any point in the study.
All children with incomplete data were excluded from
statistical analyses, and the reasons for those children either
stopping the study or with incomplete data were recorded.
The reasons for dropouts were impression of deterioration by
the parents (Group A: two and Group B: three children),
change of institution (Group A: two and Group B: one child),
change of therapy regimen, e.g. rehabilitation or surgery
(Group A: two and Group B: one child) and incorrect
application of the study protocol (Group A: zero and Group
B: two children).
Participating children and therapists
The children were recruited from 15 institutions in 10 cantons
covering more than one-third of Switzerland as an outpatient
setup would have been too difficult to organize for the
parents. The children were classified according to the Gross
Motor Function Classification Scale (GMFCS) [911]. They
were assessed before entering the study (A1 and B1), after
year 1 (A2 and B2) and after year 2 at the completion of the
428 A.-L. Brunner et al.
study (A3 and B3). The assessment consisted of a Gross
Motor Function Measure 66 (GMFM-66) assessment with
five dimensions. Inclusion criteria were age 616 years,
GMFCS IIIV and a diagnosis of CP (any type) or a syndrome
with very similar symptoms. The children were aged 10.32
years (mean, SD 2.91). Exclusion criteria were planned
surgery or changes in the rehabilitation programme
(e.g. botulinum toxin injections, casting and change of
physiotherapy regimen). The study was discontinued in case
of severe illness, any prolonged hospitalization or if children
or their carers wished to withdrew from the study. Children
who withdrew were excluded from statistical analysis as they
could not be followed up. The study (DRKS00004284)
received ethical approval by all involved agencies, and parents
of the participating children gave written, informed consent.
Intervention
The children received their physiotherapy from the same
physiotherapist during the study period. Group A started with
regular physiotherapy and changed to blocks in the second
year, and Group B started with blocks of physiotherapy and
changed to regular physiotherapy in the second year. As all
children were recruited from institutions, the physiotherapy
regimens were applied over one scholastic year each running
from mid-August to end of June, and the study ran over two
years.
During the other year, when blocks of physiotherapy were
not received, regular physiotherapy, as the baseline, con-
tinued. Regular physiotherapy was administered one or two
times per week (44 or 88 sessions per year) and was a
continuation of the childrens standard pre-study regimen.
The blocks of physiotherapy were double the frequency of the
regular physiotherapy regimen (two or four times per week,
44 or 88 sessions per year) given over a quarter of the
scholastic year, alternating with the same period of no
physiotherapy.
Half of the children receiving blocks of physiotherapy
started with a break and the other half started with physio-
therapy. This difference was not randomized and was
arranged to avoid additional costs and to keep the work
load for the therapists even during the study (Figure 1).
Figure 1. Scheme of the study design: cross
over-design with continuous therapy (one
year) and blocks of therapy altering with
breaks from physiotherapy (other year).
Dev Neurorehabil, 2014; 17(6): 426432
Outcome measures
Primary outcome. The GMFM-66 test was used. It is a
clinical tool designed to assess gross motor function in
children with CP as well as to detect changes. There are five
dimensions: A lying and rolling, B sitting, C crawling
and kneeling, D standing, E walking, running and jump-
ing with numbers from 0 to 3 [9, 1214]. The GMFM-66 has
the advantage over the original GMFM-88 of being less time
consuming and tiring out for the patients, and is thus usually
used (Table I). The items test a wide spectrum of activities in
lying, rolling, walking, running and jumping [15, 16].
Data analysis
For the evaluation of the GMFM-66 scores the Gross Motor
Ability Estimator (GMAE; Can Child Center of Child
Disability Research, Ontario, 2000, Canada) software was
applied [17]. This GMAE data were used for further statistical
analysis. For data comparison, SPSS Ver.19, 2010 (IBM
Software, Armonk, NY) was used.
A simple t-test was used for age distribution and a Mann
Whitney U test for GMFCS level and GMFM-66 distribution.
For ordinal data (GMFM-66) a Friedman test for repeated
measurements was applied and in case of significance a sign
test as a post hoc test was added, which allowed for the
differences in either study year. Effect size was evaluated with
Cohens d test, and confidence intervals were calculated. The
data of groups A and B were analysed separately. The
dependent variables were the differences of the GMFM-66
scores between the two groups. The independent variable was
block or regular physiotherapy. Confounding variables known
in advance were additional therapies in case of improvement
or deterioration of the children. Both these situations might
have been a reason for changing the protocol as it would have
been unethical to withhold additional therapy, such as surgery,
which could improve the childs condition.
Results
Flow of participants through the study
Initially, 39 children were included. Thirteen children (33%)
did not complete the study, and the reasons for
DOI: 10.3109/17518423.2014.923057 Continuous vs. blocks of physiotherapy 429
Table II. Characteristics of the children in the two groups.

Statistically evaluated (study completed) Statistically not evaluated (study not completed)
Total Group A Group B Total Group A Group B
Total number of children 26 13 13 13 6 7
Female (f) 10 5 5 7 3 4
Male (m) 16 8 8 6 4 2
Type of cerebral palsy
Bilateral spastic 3 3
Bilateral spastic predominantly legs 2 3
Unilateral spastic 3 3
Bilateral ataxic 1 2
Bilateral dystonic 2 2
Bilateral syndromic (diagnosis unclear, 1
poor motor control)
Trisomia 22 1 0
Additional Treatments
Hippotherapy 2 0
Occupational therapy 5 3
Hippotherapy and occupational therapy 0 1
Ankle foot orthosis/demi ankle foot orthosis 8 10
Spinal brace 0 1
Additional informations
M. perthes (7 years) 1 0
Hip reconstruction (4 years) 0 1
Botulinum toxin to calf muscles/hamstrings 1 3
GMFCS II 15 8 7 4 3 1
GMFCS III 4 2 2 4 0 4
GMFCS IV 7 3 4 5 4 1
Mean GMFCS II and III + IV 6.5 6.5
MannWhitney U test (p) 1.0
Age 69 (years) 12 5 7 6 3 3
Age 1013 (years) 8 4 4 6 3 3
Age 1416 (years) 6 4 2 1 1 0
Minimum 8 6
Maximum 15 16
Arithmetical mean 11.462 9.692
SD 2.85 2.81
t-test (p) 0.118
GMFM start (mean) 65.76 59.97
Mann-Whitney U test (p) 0.418

GMFCS: Gross Motor function Classification System and GMFM: Gross Motor Function Measurement.

discontinuation were as follows: clinical deterioration
(five parents thought their child was deteriorating), change
of institution (three children), incomplete study protocol
(two children), surgery (two children) and significant change
in physiotherapy regimen (one child). The withdrawals were
equally distributed considering the type of therapy setting:
Group A first year: three, second year: three, Group B first
year: four and second year: three children. The number of
discontinuations was similar in both groups (six regular and
seven blocks of physiotherapy). The results for the remaining
26 children, who completed the study, were analysed
statistically and are displayed in Table II and Figure 2.
The two groups did not differ in age (p 0.118), GMFCS
level (p 1.0) or GMFM-66 values at the initiation of the
study (p 0.418).
GMFM-66 values
The GMFM-66 values for both groups improved over the two
years in both groups (Group A by assessment A1A3
(p 0.022, 95% CI: 2.694.31, d 0.27) and Group B by
B1B3 (p 0.039, 95% CI: 2.033.21, d 0.15). The
dimensions A to C did not change statistically.
Comparing the two physiotherapy regimens, there
were only significant effects in regular physiotherapy in
dimensions D and E of GMFM-66. Improvements in
GMFM-66 scores were seen only after periods of regular
therapy (Figure 3). On an average, Group A improved by 4.8
points on dimension E after regular therapy (p50.05) and
showed no significant change after blocks of physiotherapy.
On an average, Group B improved by 2.1 points on dimension
D and by 2.2 points on dimension E after regular therapy
(p50.05), again with no significant changes after blocked
therapy.
Discussion
This prospective study compared regular physiotherapy
(NDT, Bobath, Peto, Vojita and strength training) with
blocks of physiotherapy, each lasting a year. The number
of physiotherapy sessions was the same in both parts of
the study. The GMFM-66 parameters improved over the
whole study period in both groups. It is, however, not
possible to ascribe this improvement to physiotherapy alone
as growth and developmental progress may also contribute.
On further analysis, only regular physiotherapy was
430 A.-L. Brunner et al.
Figure 2. Flow diagram of the study.
associated with a significant improvement of GMFM-66, in
contrast to blocks of physiotherapy. This is in contrast to the
results of a recent review where the therapy modalities,
especially based on a neurodevelopmental approach, were
classified as poor or non-effective [18]. It is possible that our
results may have been different had larger numbers of
children been studied or after longer follow-up, but it would
be difficult to eliminate confounding factors such as the
natural history of CP or changes in function due to growth.
The results are also in contrast to reports about various
management modalities of physiotherapy. Tsorlakis et al.
found a better outcome directly after intensive physiotherapy
(five times a week for 16 weeks) compared to physiotherapy
only twice a week in children in GMFCS levels IIII [5].
Trahan and Malouin concluded that for children in GMFCS
levels IV and V sequences of short, intensive physiotherapy
periods alternating with longer rest periods seemed to
optimize the effects of motor training and that rest periods
were well tolerated [4]. Mayo applied intensive (one session/
week) and basic (one session/month) physiotherapy treatment
over a period of six months. The children improved during the
intensive physiotherapy [3]. Arpino et al., in a review paper,
concluded that a modest, but not significant improvement, of
functional motor outcome occurred after intensive physio-
therapy [19]. Two studies contrast with these reports. Bower
et al. evaluated children with CP using GMFM-66 after six
months of physiotherapy twice a week as baseline, followed
by six months of treatment five sessions per week and another
six months of follow-up [7]. Christiansen and Lange
Dev Neurorehabil, 2014; 17(6): 426432
compared intermittent blocks of therapy (four times a week
for four weeks, followed by six weeks without physiotherapy
repeated three times over 30 weeks) vs. continuous (once or
twice a week for 30 weeks) physiotherapy in children in
GMFCS levels IV [8]. Both studies did not support the
superiority of intensive physiotherapy (Table I). This fits well
with the results of this study, which used a crossover design,
had longer follow-up and final assessment was not done
immediately at the end of the study period in half of the
children. This time interval allowed an evaluation of the
carryover effect of the physiotherapy. Our hypothesis that
blocks of physiotherapy would be superior in promoting
motor skills was not confirmed when using the GMFM-66 as
an outcome measure. In contrast, regular physiotherapy
proved more effective. Nevertheless, the children only
improved in domains D and E. Developmental and motor
progress in these children may take several years. During such
a long period, the majority of children will require adaptations
of their physiotherapy including change of orthotics, drugs
and possibly surgery. It is thus impractical and uneconomic to
have a study where children receive a standard physiotherapy
regimen over many years [20].
Another potential problem is a high drop-out rate in longer
term studies, which, unfortunately, is typical for a CP cohort.
Kanda et al. performed a study over five years, and the drop-
out rate was 86% [21]. In our study, 33% of 39 children did
not finish the study. The main reasons were the subjective
impression of the parents of a deterioration (not shown in the
objective data) and a change of institution. These reasons,
however, were not specific to either group A or B children or
therapy regimen.
Age may be another factor influencing the study results.
Three studies [2224] considering the stability and decline in
gross motor function among children with CP showed a
plateau in gross motor function progress between 4 and
7 years of age, depending on the GMFCS level. In this study,
the children were aged between 6 and 16 years, and we did not
anticipate any major changes in GMFCS level in the light of
these studies. Puberty may bring other interests and motiv-
ations, such as personal independence and career intentions,
compared to a child in primary school where adults define the
aim of rehabilitation for them. However, the age distribution
between Groups A and B was similar. There may also be a
difference in outcomes between the children living in
institutions and those who live with their family, because
help and expectation of care givers may differ from those of
parents. Nevertheless, all participants of the study were
schoolchildren living at home and the cross-over design
controlled for most of these factors.
The strength of this study was the cross-over design, which
minimized the effects of natural aging and individual situation
on GMFM-66 outcomes. The GMFM-66 is a validated
outcome measure for children with CP; and in this study,
the various dimensions were analysed individually to gain
greater insight into the childrens function, rather than relying
on a global score.
One weakness of the study is the low number of
participants, but an increase in numbers was not possible
for reasons mentioned above. A power analysis was carried
out post hoc and revealed a power of d 0.22 (alpha error
DOI: 10.3109/17518423.2014.923057 Continuous vs. blocks of physiotherapy 431
Figure 3. GMFM values of group A and B
according to dimensions AE and total.
Group A: Study onset (white), regular
therapy (grey), block therapy (black); group
B Study onset (white), block therapy (black),
regular therapy (grey). *Iindicate signifi-
cance (p50.05) to preceding value, + to value
at study onset.

0.5) for the 26 children who finished the study. Nevertheless,
differences were statistically significant. Another possible
weakness was a lack of untreated control children,
and it is not possible to conclude on the efficacy of
physiotherapy in general. Physiotherapy is routine in
Switzerland for every baby at risk for CP, and it would be
impossible, and unethical, to have untreated controls.
Another weakness is possibly incomplete information about
additional therapies. Not having a long-term follow-up to
show an effect on general function of daily living and
life quality is a drawback. On the other hand, so many
factors influence the individual course of a patient that it is
impossible to follow the effect of a single factor at long-term.
Two years seem to be a good compromise but as the outcome
differences are low, a long-term prognosis can only be
speculative. A study with a greater number of participants
would be helpful to support the data from this study.
Another setting could be blocks included in the regular
therapy setting. However, the necessary increase in therapy
sessions required in such a study could make comparisons
difficult, and this approach might not be feasible
economically.
Conclusion
This study has shown that regular physiotherapy was more
effective than blocks of physiotherapy based on GMFM-66
outcomes for children in GMFCS levels IIIV.
Acknowledgements
We thank the participating institutions for their cooperation.
Declaration of interest
There were no conflicts of interest. We thank the Swiss
Foundation Cerebral for financial support
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