Functional therapy for
functioning in the context of daily life settings, can serve as an
children with cerebral
palsy: an ecological
approach
Lena Ekström Ahl* MSc PT PCS, Child and Youth
Habilitation, Uppsala;
Eva Johansson PhD PT, Mälardalen University, Västerås;
Tina Granat PhD, Clinical Psychologist, Child and Youth
Habilitation, Uppsala;
Eva Brogren Carlberg PhD PT PCS, The Research Unit,
Handicap and Habilitation, Stockholm, Sweden.
*Correspondence to first author at Child and Youth
Habilitation, Box 260 74, S-750 26 Uppsala, Sweden.
E-mail: lena.ekstrom.ahl@lul.se
The aim of this pilot study was to evaluate functional training
for children with cerebral palsy (CP). The outcomes
examined were goal-achievement, gross motor function,
performance of everyday activities, caregiver assistance,
parents’ perception of family-centredness, and preschool
assistants’ feeling of competence in the care of the children.
The outcome measures used were goal attainment scaling,
Gross Motor Function Measure, Pediatric Evaluation of
Disability Inventory (functional skills and caregiver
assistance scales), Measure of Processes of Care, and a
questionnaire. The intervention was carried out in the context
of daily life settings, i.e. in an ecological framework. Fourteen
children (three females, 11 males; age range 1y 6mo to 6y)
with diplegia and tetraplegia, classified at Gross Motor
Function Classification System levels II–V, participated in the
five-month intervention. Frequency of training towards a
specific goal varied between twice a day and 23 times a day,
depending on the type of goal. Seventy-seven per cent of goals
were fully attained. Gross motor function and performance of
daily activities, including social function, improved significantly.
A decrease in caregiver assistance was noted in relation to the
children’s mobility. Parents’ perception of family-centredness
improved in all domains. Furthermore, the children’s preschool
assistants felt more competent in their care of the children.
Developmental Medicine & Child Neurology 2005, 47: 613–619 613
An ecological approach, where the aim is to promote better
effective framework for physical therapy (Ketelaar et al. 2001).
This approach encompasses two aspects of children’s devel-
opment in relation to the environment: development in the
sociocultural context (Bronfenbrenner 1986) and develop-
ment through the children’s perceptual-motor exploration of
their surroundings (Gibson and Pick 2003). Physical therapy
in this context emphasizes the interaction between the indi-
vidual, the task, and the environment as a basis for the child to
learn; children actively seek effective solutions to problems
that arise in situations they desire to master (Gentile 1998,
Lesensky and Kaplan 2000). The approach is called ‘functional’
as primarily functional skills (e.g. dressing and climbing stairs),
are practised to achieve functional goals. Furthermore, this
approach offers a good basis for individualized planning,
stressing the importance of developing skills that are meaning-
ful for the children and their parents (Law et al. 1998,
Rosenbaum et al. 1998, Bower et al. 2001). Defining specific
goals can enhance motivation and, possibly, the child’s capaci-
ty to learn (King et al. 1999). In this context the child can
become an active problem solver instead of a passive recipient
of treatment. To provide frequent opportunities for training,
the participation of parents and caregivers is very important.
They provide possibilities to practise activities towards pre-
defined goals, in many situations and on many occasions,
throughout the day.
Recently, Jansen and coworkers (2003) presented an excel-
lent review of the literature on parental participation in physi-
cal therapy for children with physical disabilities. They pointed
out that parents who participate in physical therapy are likely
to develop a more realistic view of their child’s potential in
terms of daily functioning. The authors suggest that this could
increase parents’ confidence in their own competence and
reduce parental stress. Jansen et al. call for studies in which the
effect of therapy on both parents and children is evaluated in
order to shed light on the complex interactions that bring
about a child’s development. They considered the Measure of
Processes of Care (MPOC; King et al.1995) to be a good evalua-
tive tool for parental participation.
The aim of this study was to evaluate the effect of training in
daily life settings for preschool children with cerebral palsy
(CP) with respect to (1) goal attainment, (2) gross motor func-
tion, (3) performance of daily activities, and (4) amount of care-
giver assistance required. Furthermore, this study examined
whether the parents’ and assistants’ perceptions of family-cen-
tredness and competence in the care and training of their child
was affected by the intervention procedure.
Method
PARTICIPANTS
Fourteen children (three females, 11 males; age range 1y
6mo to 6y) with CP without severe learning disability*, living
in Uppsala, Sweden, were invited to take part in the study
(n=16); all participants completed the evaluations. Children
had spastic diplegia or tetraplegia and their functional per-
formance was classified between levels II–V of the Gross
Motor Function Classification System (GMFCS; Palisano et
al. 1997). The children were divided into two groups to facil-
itate training and teaching (Table I). There was no control
*US usage: mental retardation.
group due to a lack of children who were matched for severity
of disability, age, and sex. The ethics committee of the Faculty
of Medicine at Uppsala University approved the study. Parents
gave their informed consent. Those in charge of the children’s
preschools were informed about the content of the interven-
tion and agreed to participate.
OUTCOME MEASURES
Considerable attention was given to identifying and evaluat-
ing individual goals for each child. Goals were set in close col-
laboration with the parents, the child (as much as possible),
the child’s 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 posi-
tion. 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 supple-
mented with four questions to cover areas of interest not cov-
ered 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 exten-
sive (12–25y) rehabilitation experience and were familiar with
using the various assessments.
INTERVENTION
The intervention period started with a structured four-day live-
in course for the participating families and the preschool assis-
tants, 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 med-
ical doctor, physiotherapist, special needs teacher, psycholo-
gist, and a social worker. The course was theoretical and
practical. To understand and participate in the training, knowl-
edge about the aetiology of CP and the consequences for
overall development, normal and abnormal motor develop-
ment, motor learning, psychological aspects, and motivation
were considered essential. During the four days the children
started their training. This began the process of practical guid-
ance for parents and preschool assistants.
During the following 5 months, goal-directed functional
therapy was mainly carried out in the child’s normal settings at
home and at preschool. Throughout the intervention period,
continuous discussions were held with, and advice and sup-
port given to trainers during regular home and preschool vis-
its. 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 tech-
niques. 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

Table I: Children included in study (n=14)

Participant Age at start Diagnosis GMFCS Other impairments Group

of study (y:m)

A 2:6 SpDi III – 1

B 2:11 SpDi III – 1
C 4:0 SpDi III No speech 1
D 4:1 SpDi III No speech 1
E 4:2 SpDi IV No speech, visual 1
F 4:2 SpDi III – 1
G 4:9 SpTet V – 1
H 5:4 SpDi IV – 1
I 6:0 SpDi II – 2
J 1:6 SpDi III – 2
K 1:9 SpDi III No speech 2
L 3:4 SpTet V No speech 2
M 3:0 SpDi III Visual, epilepsy 2
N 2:8 SpDi IV No speech 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 Developmental Medicine & Child Neurology 2005, 47: 613–619

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 reach-
ing 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 activi-
ties, i.e. climbing down stairs and pavements, moving along
holding on to furniture when playing with friends, and stand-
ing up from a chair.
Participants were encouraged to perform the different activ-
ities in a variety of ways; activities were discussed and suitable
solutions were tried out. The physiotherapist’s 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 strengthen-
ing as an integrated part of the activities. Stronger leg-muscles
would allow her to perform the task with less assistance.
DATA ANALYSIS
As no significant difference was found between the two training
groups in any of the measured aspects, data were pooled.
Because the data were not normally distributed, the non-para-
metric Wilcoxon’s matched pair test was used to evaluate
changes in PEDI and GMFM-66 scores. Furthermore, Fried-
man’s analysis of variance by ranks was used for multiple com-
parisons with the GMFM-66. To calculate differences in the
MPOC scores, parametric statistics (t-test) were applied accor-
ding to recommendations in the manual, as data were not
skewed (King et al. 1995). The same procedures were used for
non-skewed data from the additional questionnaire (Appendix
I). To test associations between age and gross motor change,
Spearman’s rank correlation (rs) was used. Significance was set
at p<0.01.
Results
FREQUENCY ACCORDING TO THE DIARY
The training diary reflected the true intensity of the training.
Frequency of training varied considerably. Variation was related
to type of goal and how frequently the task occurred in daily
life. For example, a goal to maintain range of motion in the
hamstrings was trained twice a day, whereas a goal aimed at
standing up from a chair could result in over twenty practice
occasions.
GOAL ATTAINMENT
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 child’s ability to play with peers. The remain-
ing 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 ful-
filled completely and 25 were partially completed. After five
months, 76 goals were fulfilled completely and 19 were partial-
ly completed (Fig. 2). At eight months’ follow-up goal attain-
ment was sustained.
GMFM
GMFM scores did not change significantly during the base-
line period. Two children, however, had an unstable base-
line. 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 signifi-
cantly 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
1.47–6.79; Fig. 3). The improvement was most pronounced

Gross Motor Function Measure-66 assessments

Baseline Baseline Post- Post- Post-

I II 1mo 2mo 3mo 4mo 5mo intervention intervention intervention
I III III

Training Training Training

diary diary diary
PEDI PEDI
Goal attainment MPOC Goal
MPOC
Additional questionnaire attainment
Additional questionnaire
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 Ekström Ahl et al. 615
during the first two months of the intervention (Wilcoxon
p<0.01). Between the following assessments a steady upward
trend was found, but the change did not reach significance (p
values ranging from 0.02–0.05). Between the last three assess-
ments performed post-intervention, no significant change was
seen, indicating that functions gained through training were
sustained. The amount of change in gross motor function was
not related to age at onset of the intervention (rs=–0.17).
PEDI
According to the parents, the children significantly improved
self-care performance (median 44 vs 49.2, p<0.001), mobility
(median 41.3 vs 43.8, p<0.01), and social function (median
53.4 vs 56, p<0.01) after the intervention period (Fig. 4).
Variation between children on the mobility domain was con-
siderable (see Fig 4). The amount of assistance from caregivers
in daily life activities changed significantly only on the mobility
domain (p<0.001; Fig. 5).
MPOC
Mothers and fathers in nine families, and preschool assistants
in two families, completed the MPOC questionnaire. In four
families only the mother of the child returned a filled-in ques-
tionnaire: in three of these the child’s assistant also answered
the questions. For one child only, the assistant replied.
Parents’ perceptions of services received from the habilitation
team during the intervention period significantly improved in
all domains after the training period (t-test p<0.001) although
variability was large, especially before the intervention (Fig. 6).
Mothers and fathers exhibited significantly different opin-
ions before and after the intervention in the domains of
enabling and partnership: (t-test p<0.01; pre: mother 4.7 [SD
1.8], father 5.1 [SD 1.4]; post: mother 6 [SD 1.2], father 6.5 [SD
1]); and coordinated and comprehensive care (pre: mother 4.5
[SD 1.9], father 5 [SD 1.7] post: mother 6.2 [SD 1.2], father, 6.6
[SD 0.9]). Mothers indicated a lower level of satisfaction with
the intervention than fathers. In the domain of respectful and
supportive care the fathers rated a higher grade of satisfac-
tion with the services after the intervention than the mothers
(t-test p<0.01; father 6.9 [SD 0.4], mother 6.4 [SD 1]).
Six preschool assistants partially filled in the questionnaire.
QUESTIONNAIRE
The supplementary questionnaire was completed to a larger
extent than the MPOC, by mothers (n=11), fathers (n=9),
and assistants (n=10). Preintervention, fathers had the lowest
score relating to all four questions. After the intervention the
scores indicated a significant change in the knowledge they
had acquired (questions 1, 2, 3) and how clear the goals were
(p<0.001). Mothers also expressed that they had an enhanced
knowledge in response to all four questions. Preschool assis-
tants initially graded the last three questions higher than the
parents; no significant change caused by the intervention was
found. However, assistants felt they had acquired more knowl-
edge on training the child during the intervention period
(p<0.01).
Discussion
Functional, goal-directed therapy carried out in daily life settings
of 14 children with CP influenced their gross motor capacity
and their performance in self-care, mobility, and social function
over a five-month training period. The goals set were reached
in 77% of cases. Parents expressed a more positive perception
of service delivery after the training period than before. Also, the
children’s preschool assistants showed that they had acquired
more knowledge on how to train and motivate the child.
A fundamental aspect of cooperation between families and
others actively involved in daily care of children with CP is the
formulation of specific goals for treatment (Bower et al. 2001,
Ketelaar 2001). Goals can be viewed as being the ‘cement’ that
can assist in avoiding fragmentation of services. By making
individual goals clear, everyone involved with the children
can understand them and can unite and work together with
the children to achieve them. Goals that are understandable,
60
55
50
GMFM-66 score

In the two domains, enabling and partnership and coordinated 45

and comprehensive care, their ratings were higher after the
intervention (t-test p<0.01). 40

35
Participants
30 A
B
C
D
E
25 F
G
Assessment times

8 Intervention H
I
J
20 K
L
BL I
II

o
o
o
o
o

III

5
Po II
Po I

M
BL

1m
2m
3m
4m
5m

st
st
(mo)

st

N
Po

3
Assessments
Figure 3: Change in (Gross Motor Function Manual–66
0 20 40 60 80 98 (GMFM-66) scores; Russell et al. 2002). Different traces
indicate change in GMFM-66 score (y-axis) in individual
Number of goals children over 10 assessments (x-axis). GMFM-66 consists of 66
items grouped into five dimensions. Items form a hierarchical
Figure 2: Goal attainment. Black bar, seven goals set for each structure with interval scaling, ranging from 0 (low motor
child (n=98). Striped bars, goals fully achieved at 3, 5, and 8 ability) to 100 (high motor ability). BL, Baseline; Post, post
months’ follow-up. White bars, goals partially achieved. intervention.

616 Developmental Medicine & Child Neurology 2005, 47: 613–619

attainable, and time-limited give the child an opportunity for
active problem solving: a fundamental aspect of motor learn-
ing. The formulation of goals also provides a basis for individ-
ualized measures of outcome (King et al. 1999).
In this study the children had fully obtained 77% and partial-
ly obtained 19% of the goals at the end of the training period.
This level of goal fulfilment was maintained at follow-up.
Results support the idea that skills used every day persist even if
they are not explicitly trained (Bower and McLellan 1992). In
future studies goal-setting could be further improved by using
goal-attainment scaling with five levels (–2 to +2), making it
possible to follow the children’s development towards a goal
(King et al. 1999).
Frequency of training is important for motor progress (Taub
et al. 1999). However, it is uncertain how often children should
practise a function in order to learn it. This seems to be depen-
dent on many factors including the severity of the disability, the
task to be learned, the environment in which the function is to
be practised, the learning capacity of the child, and the method
used (Valvano and Newell 1998, Bower et al. 2001, Trahan and
Malouin 2002, Shumway-Cook et al. 2003). In this study, fre-
quency was measured using training diaries, a method not
tested for reliability. However, the diaries were filled in consc-
ientiously showing that all goal activities received training for at
least five days each week, which indicated that frequency might
play a role in the success of the intervention. However, varia-
tion in frequency was related to type of goal and how often the
task occurred in daily life. Therefore, it was not feasible in this
pilot study to relate the frequency to goal attainment.
Children’s gross motor function improved significantly
during the five months of intervention: the rate of improve-
ment was most pronounced during the first two months.
This indicates that although the training was predominantly
specific, it had general effects. It was queried whether some of
the improvement could be due to natural development: a
stable baseline before and after the intervention is one indi-
cation of improvement being training-related.
Five ‘gross motor curves’ corresponding to the five GMFCS
levels have been developed to give an approximate idea about
75 a b b
65
Functional scales
55
45
35
25
15
5 0
Self-care Mobility Social function
Figure 4: Change in Pediatric Evaluation of Disability
Inventory (PEDI; Haley et al. 1992) functional skill scores
(n=14). Boxplots represent 25th, 50th, and 75th centile.
Whiskers represent minimum and maximum values. White
boxplots indicate assessments before intervention and
black boxplots assessments after intervention. ap<0.001,
bp<0.01 (Wilcoxon). PEDI evaluates through a structured
interview if a child is able or unable to perform 197 skills
(score 1 or 0) in everyday life situations.
Functional Therapy in Children with Cerebral Palsy Lena Ekström Ahl et al. 617
gross motor prognosis in children with CP (Rosenbaum et al.
2002). So far, there is no statistical approach for comparing
the incline of individual children during development to the
incline of the five curves. Visual judgement of the current
results suggested that, considering the age of the children
and the severity of the disability, the incline in 13 of the 14
children was steeper then expected. This corroborates the
assumption that gross motor progress was accelerated due
to the intervention.
The PEDI served two purposes. Apart from being an out-
come measure it also formed a basis for discussing appropriate
goals for therapy. The items in the three domains of the PEDI
are aligned along an interval scale, providing an indication of the
child’s performance along a continuum from easy to difficult.
The scale can assist in providing ideas about the child’s next
developmental step in daily activities, and can indicate what
might be possible in the future. Functional goal-directed ther-
apy provides significant progress in the domains of self-care and
mobility (Ketelaar 2001). The children’s considerable progress
in social function was somewhat more surprising, as this has not
been shown previously. Many factors in the training approach
might have contributed to this development. Possibly, the oppor-
tunity to meet regularly peers in group activities was one factor
promoting social development. The goal-directed training
was also very communicative and dealt with problem solving,
causing the child to be active and expressive with regards to
feelings, solutions, and preferences.
In the mobility domain of the PEDI, the amount of care-
giver assistance was significantly reduced, indicating that the
children could exercise their newly achieved skills indepen-
dently. However, the level of caregiver assistance did not cor-
respond to the children’s progress in self-care and social
function. This might relate to the children performing the
tasks slowly due to a lack of automatization, making it difficult
to withdraw support. It also takes time to change behaviour.
Most theories on child development propose that the envi-
ronment is important for progress and, therefore, the role of
parents is imperative (Bronfenbrenner 1986). The focus of
the current study was on the special role of parents of children
80
Caregiver assistance
a
60
40
20
Self-care Mobility Social function
Figure 5: Change in Pediatric Evaluation of Disability
Inventory (Haley et al. 1992) caregiver assistance (n=14).
Boxplots represent 25th, 50th, and 75th centile. Whiskers
represent minimum and maximum values. White boxplots
indicate assessments before intervention and black boxplots
assessments after intervention. ap<0.001 (Wilcoxon).
Caregiver assistance is evaluated in 20 different activity areas
using a 6-point scale. A score of 5 indicates independence and
a score of 0 complete dependence on assistance.
with disabilities, and supporting them in that role. Particular
attention was given to knowledge transfer between parents
and professionals, but other forms of parental support appear
to be important (Solomon et al. 2001). Results from the MPOC
indicate that there was a substantial change in the parents’
experiences of caregiving. Considering that the MPOC is a
questionnaire and, therefore, subjective in nature, it is not
surprising that parents who have actively chosen to participate
and have dedicated much time to work together with their chil-
dren and professionals, express positive feeling towards their
experiences. Previous studies have demonstrated that MPOC is
sensitive to parents’ perceptions of various types of rehabilita-
tion efforts (King et al. 1997).
Mothers and fathers expressed different views on how
they perceived services, a finding in agreement with that of a
previous study (King et al. 1996). However, the sample in our
study was small and no general conclusion could be drawn.
Determining such perceived differences for future studies could
add valuable information to improve family-centred services,
also taking into account cultural differences.
An area calling for further exploration is the role of pre-
school assistants. Positive reactions to the approach expr-
essed by the preschool assistants during the intervention
were not reflected to the same extent in the MPOC and the
questionnaire. Assistants were given continuous consultation
and supervision throughout the intervention. The primary
aim of supervision was to enable assistants to handle the child
and to enhance the child’s participation at preschool. Thus,
their role in this approach should be considered very impor-
tant. A meticulous look at the specific role of preschool assis-
tants could form the basis for a more valid way of evaluating
their contribution.
Measure of Processes of Care scores
Assessing parental–professional interactions and the
effect of parental participation in training programmes on
parental well-being will be of importance in future studies to
elucidate the complex interactions between different facets
of an ecological framework.
Conclusion
Children with CP benefited from a functional goal-directed
training approach in their development of gross motor func-
tion and everyday activities. The ecological intervention appr-
oach was also positively perceived by the parents. The study
adds to the growing knowledge that the efficacy of treatment
lies within the child’s day-to-day environment.
DOI: 10.1017/S0012162205001210
Accepted for publication 15th September 2004.
Acknowledgements
We sincerely thank the children, their parents and assistants, and
our colleagues for making this study possible.
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Book Review
The Brain’s 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 per-
ceptual 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 (size–weight 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 Brain’s 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 prob-
lems of sen-sory conflict or ambiguity.
What is truly unique is that the book frequently high-
lights these perceptual disconnects as well as practical
examples and exercises that show how we control move-
ments, such as gaze control, posture and limb movement,
Functional Therapy in Children with Cerebral Palsy Lena Ekström Ahl et al. 619
Trahan J, Malouin F.(2002) Intermittent intensive physiotherapy in
children with cerebral palsy: a pilot study. Dev Med Child Neurol
44: 233–239.
Valvano J, Newell K. (1998) Practice of a precision isometric
grip-force task by children with spastic cerebral palsy. Dev Med
Child Neurol 40: 464–473.
Appendix I: Measure of Processes of Care: additional questions
1. Do you have adequate knowledge to train your child?
2. Can you apply the training recommendations in daily life
settings?
3. Have you received satisfactory information on how to motivate
your child?
4. Have the goals been clear-cut enough for everybody involved to
work towards the same goals?
space orientation, and gait, to guide the reader to an under-
standing of sensorimotor control. Furthermore, it often
draws upon philosophy and presents historical perspec-
tives 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 bal-
ance, 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 neurophysiol-
ogist, 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 author’s
rejection of the term ‘internal representation’. While he cor-
rectly asserts that it is too easy to hide our ignorance behind
such a generic term, considerable evidence for representa-
tions of manipulated objects and their use in proactive con-
trol has been published since this book was published.
However, as the author embraces the term ‘internal model’,
I suspect the objection largely involves the term’s overuse
and that, therefore, Berthoz’s concern merely involves
syntax.
Overall, The Brain’s Sense of Movement is a detailed and
refreshing review of sensorimotor control. The book is
filled with wonderful examples which make the presenta-
tion of material practical, fascinating, and a delight to read.
The relation of basic material to interesting clinical patholo-
gies 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