Making it possible – interventions for children with cerebral palsy


  • Eva Beckung

    1. Department of Physiotherapy and Occupational Therapy, Sahlgrenska University Hospital, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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This commentary is on the original article by Bartlett et al.[1].

What combination of child, family, and service factors explain the change in motor abilities of young children with cerebral palsy (CP)? We all want to know!Bartlett et al. should be complimented for their comprehensive work.[1] Analysis of change in motor function over 1 year showed that primary and secondary impairments explained 58% and 75% of the variance in motor function when analyzing determinants of gross motor function in 429 young children with CP.

Some considerations. Early childhood is a sensitive period for development, and when children present signs of impaired motor development therapists aim to start interventions even if the value of certain methods and early interventions still are limited, especially in a condition such as CP with its wide variation and complexity. At the onset of the Bartlett study the children were very young, 18 to 60 months of age, and some of them may not have had an ascertainment of the diagnosis of CP at the age of 4 years as recommended by the Surveillance of Cerebral Palsy in Europe, SCPE.[2]

The classification levels in the Gross Motor Function Classification System (GMFCS) are well known, fairly stable, and extremely useful in the clinic as well as in research. It is a pity that the authors were not able to keep the five levels in the model tested. The children in this study were divided into two groups based on merged GMFCS levels. At 1 year some of the children labeled as being at GMFCS level III might have changed to a milder or a more severe level.

In a comprehensive review, Chiarello et al. started building the multivariate model of change used in the paper above.[1] A range of factors associated with the motor function in CP was reported.[3] Pain in children with CP was not one of the factors. The Study of Participation in Children with CP Living in Europe, (SPARCLE), reported the estimated population prevalence of self-reported pain for children 8 to 12 years of age, in the previous week, to be 60%[4] and of young people, 13 to 17 years of age, to be 74%.[5] Pain in children with CP is common and needs to be considered also in the very young.

Bartlett et al. conclude that motor function in young children with CP is supported by optimizing body structures and function. Fine, but let′s not forget to put this focus in an activity and participation context. In the model of determinants for gross motor function the intensity of therapy was included. Let us also discuss and evaluate how therapists should contribute.

Physiotherapy interventions focusing on children with CP should, according to the literature, be based on a functional and environmental perspective with task-specific functional activity, motor learning processes, and family-centred service, i.e. to enhance motor ability and improve capacity so that the child can perform the tasks necessary to participate actively in everyday life. Larsson et al.[6] identified three qualitatively different descriptive categories:

  1. Making it possible – a functional-based intervention based on the biopsychosocial health paradigm, and the role of the physiotherapist as collaborative, interacting with the child and family in goal setting, intervention planning, and evaluation.
  2. Making it work – an impairment-based intervention built on a mixed health paradigm (biomedical and biopsychosocial), and the role of the physiotherapist as a coach, leading the goal setting, intervention planning, and evaluation, and instructing family members how to carry out physiotherapist-directed orders.
  3. Making it normal – an impairment-based intervention built on a biomedical health paradigm, and the role of the physiotherapist as an authoritative expert who determines goals, intervention planning, and evaluation.

Let′s go for 1 – making it possible!