Rehabilitation Outcomes of Children with Cerebral

Palsy

J. Phys. Ther. Sci.

26: 285289, 2014

Ebru Yilmaz Yalcinkaya, MD1)*, Nil Sayner Caglar, MD1), Betul Tugcu2),
Aysegul Tonbaklar, PhD3)
1) Department

of Physical Medicine and Rehabilitation, Istanbul Physical Therapy and Rehabilitation

Training and Research Hospital: Bahcelievler, Istanbul 34180, Turkey
2) Department of Ophthalmology, Bakirkoy Sadi Konuk Training and Research Hospital, Turkey
3) Department of Psychology, Istanbul Physical Therapy and Rehabilitation Training and Research
Hospital, Turkey

Abstract. [Purpose] To evaluate the results of Bobath-based rehabilitation performed at a pediatric cerebral palsy
(CP) inpatient clinic. [Subjects and Methods] The study subjects were 28 children with CP who were inpatients at a
pediatric service. Inclusion criteria were: being an inpatient of our hospital aged 212 with a diagnosis of CP; having
one permanent primary caregiver; and the caregiver having no medical or psychotic problems. All of the patients
received Bobath treatment for 1 hour per day, 5 days a week. The locomotor system, neurologic and orthopedic
examination, Gross Motor Function Measure (GMFM) of the patients, and Short Form-36 (SF-36) of permanent
caregivers were evaluated at the time of admission to hospital, discharge from hospital, and at 1 and 3 months after
discharge. [Results] Post-admission scores of GMFM at discharge, and 1 and 3 months later showed significant increase. Social function and emotional role subscores of SF-36 had increased significantly at discharge. [Conclusion]
Bobath treatment is promising and randomized controlled further studies are needed for rehabilitation technics.
Key words: Cerebral palsy, Rehabilitation, Bobath
(This article was submitted Jul. 9, 2013, and was accepted Sep. 10, 2013)

INTRODUCTION
Cerebral palsy (CP) describes a group of permanent disorder of the development of movement and posture causing
activity limitation, that are attributed to non-progressive
disturbances that occurring in the developing fetal or infant
brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, behavior, epilepsy, and secondary
musculoskeletal problems1).
CP is accompanied by a wide range of problems and has
a broad spectrum of symptoms, making evaluation of the
patient and setting of rehabilitation goals difficult. In the
evaluation of a child with CP, the type of involvement is
identified, the functional condition and secondary deformities are assessed, the needs of the patient are identified and
a rehabilitation program is designed 2).
Rehabilitation programs for children with CP should be
appropriate for the age and functional condition of the patients. The aim of CP rehabilitation should be to minimize
disability and to promote independence and social partici*Corresponding author. Ebru Yilmaz Yalcinkaya (E-mail:
ebru_yilmaz@hotmail.com)
2014 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-ncnd) License <http://creativecommons.org/licenses/by-nc-nd/3.0/>.

pation 2).
Although the concept of CP rehabilitation has changed
in recent years to focus on patient participation in everyday activities, the neurophysiological approach is still used
within the combined therapy methods. The neurophysiological approach is a specific strategy based on the fact that
sensory stimuli sent by various methods cause reflex motor
responses. Facilitation or inhibition of muscle groups via the
stimulation of exteroreceptors and proprioceptors is the aim
of this approach3). The Bobath technique is the most common method of motor stimulation and it is used worldwide.
In this technique, a child is positioned in reflex-inhibiting
postures (RIP) to reduce spasticity. Then, specific reflexes
and reactions are stimulated to improve normal movement
sense. Therapists stimulate key control points in the body,
triggering reflexes that provide head and body control2).
The primary aim of the present study was to evaluate
the results of Bobath-based rehabilitation for pediatric CP
inpatients. This study also evaluated some clinical characteristics of the patients.
SUBJECTS AND METHODS
The study subjects were 28 children with CP who were
inpatients at a pediatric rehabilitation inpatient clinic. Inclusion criteria were: being an inpatient of our hospital aged
212 with a diagnosis of CP; having one permanent primary caregiver; and the caregiver having no medical, chronic
or psychotic problem.

286 J. Phys. Ther. Sci. Vol. 26, No. 2, 2014

A CP evaluation form was completed during detailed
locomotor system, neurologic and orthopedic examinations prior to the rehabilitation program. The Gross Motor
Function Measure (GMFM) was evaluated and the scores
of the patients were recorded. The patients were categorized
according to Gross Motor Function Classification System
(GMFCS). GMFCS is a standard 5-level system used to
classify the gross motor functions of children with CP,
which was developed by Palisano et al. in 19974). The reliability of the Turkish version of the scale was previously
demonstrated5).
GMFM is a standardized observational test used to measure temporal changes in gross motor functions of children
with CP. A manual and CD of the criteria were prepared,
with the approval of Russel et al., and were bought to the
study sessions, and patients were scored according to this
manual6).
All of the patients received Bobath treatment, administered by a physiotherapist, for 1 hour per day, 5 days a
week. Patients with limited joint movement also performed
stretching exercises. Assistance and orthoses were provided
according to clinical, neurological and orthopedic evaluations. Furthermore, during the hospitalization period the
patients permanent caregivers were informed about CP and
were given instruction in a home exercise program.
The locomotor system, neurologic and orthopedic examination, GMFM, and GMFCS evaluations, were evaluated
at the time of admission to hospital, and again at discharge
from hospital, and at 1 and 3 months after discharge. The
duration of hospitalization was determined by a physiatrist
supervisor who was unaware of which patients were included in the study.
The patients were evaluated by an ophthalmologist. Interesting toys were used during the examination. Agitated
patients were given anxiolytic syrup. The examination used
evaluation methods such as visual acuity, eye movements,
VEP (visual evoked potential), and ERG (electroretinography).
Children in the 412 age group were evaluated using the
SD Porteus and Kent EGY tests by a psychologist specializing in related tests.
The time of discharge was decided by a clinical trainer
specialist who was unaware of which children were included in the study.
Approval for this study was obtained from the ethics
committee of our hospital. Since the patients were of pediatric age, written consent for participation was obtained
from their parents or legal guardians.
The Wilcoxon paired test and paired t-test were used
after repeated measures ANOVA, to compare patient data
recorded at different times. Spearmans correlation test was
used to assess the correlation between CP type and mental
condition.
RESULTS
A total of 43 CP patients were initially included in this
study. However, 15 patients were excluded from the study
and the results of only the remaining 28 patients were eval-

Table 1. Classification of our CP patients (according to

European CP follow-up group)1)
SP type (new classification)

Spastic bilateral
Spastic unilateral
Dyskinetic
Mixed

20
4
2
2
28

71.43
14.29
7.14
7.14
100

Table 2. Classification of our CP patients

CP type

Spastic diplegic
hemiplegic
quadriplegic
Ataxic
Hypotonic
Mixed

13
4
7
1
1
2
28

46.4
14.29
25.00
3.57
3.57
7.14
100

uated. The reasons for exclusion from the study included

patients desire for discharge before the completion of rehabilitation aims, 2 patients, and irregular or non-attendance
at follows up for the remainder.
The 28 children with CP who were evaluated were within the 212 age group (mean 6.962.82years), 12 (42.9%)
were male, and 16 (57.1%) were female. Twenty-four of the
patients were spastic in terms of clinical type (Tables 1 and
2).
Family histories showed that the parents of 10 (35.7%) of
the participants were first-degree relatives.
Average age of diagnosis was 11.914.19 months; average age until rehabilitation was 35.630.56 months.
The average interval from time of diagnosis to start of
rehabilitation was 23.729.88 months. Although 71.4% of
the children were identified with a problem within their first
two years, only 9 (32.1%) started rehabilitation (Table 3).
Of the 28 patients, 20 were evaluated by a specialist
ophthalmologist. One patient was found to have a normal
eye examination. Hypermetropia, myopia and astigmatism
were not considered as refraction defects. These were the
most frequent findings, followed by strabismus and optic
disc paleness which is a retinal examination finding (Table
4).
Analysis of speech problems showed that 6 (21.43%) patients had normal speech, while 7 (25%) had dysarthria, 9
(32.4%) were able to speak 12 words and 6 (21.43%) could
not speak.
Twenty patients were tested by a psychologist to determine their mental condition. Three (15%) were found to
have normal intelligence; 7 (35%) had mild mental retardation; 8 (40%) had moderate mental retardation, and 2 (10%)
had severe mental retardation. We found no correlation between the degree of mental retardation and CP type (r=0.11
p=0.932).

287
Table 3. Identification of the problem and rehabilitation starting time in CP patients
n
Identification of the problem before 12 months of age
Identification of the problem after 12 months of age
Starting rehabilitation before 12 months of age
Starting rehabilitation after 12 months of age

Table 4. Diagnosis of CP patients after eye examination

Diagnosis
Refraction
defect
Strabismus

Sub-group diagnosis
Hypermetropia
Myopia
Astigmatism
Esotropia
Exotropia

Pale optic disc

Other

Optic nerve coloboma

Traumatic optical atrophy

20
8
9
19

%
71.4
28.6
32.14
67.86

Table 5. Comparison of GMFM Scores

GMFM total score

MeanSD

14
4
12
4
3
6
1
1

Admission
Discharge
Admission
1 month follow-up
Admission
3 month follow-up
Discharge
1 month follow-up
Discharge
3 month follow-up
1 month follow-up
3 month follow-up

34.0228.95
41.0828.55
34.0228.95
39.6226.50
34.0228.95
40.3527.02
41.0828.55
39.6226.50
41.0828.55
40.3527.02
39.6226.50
40.3527.02

The mean hospitalization time for rehabilitation was

50.9 18.45 days.
The patients were grouped according to GMFCS. Level
5 included 9 patients at the time of admission and 6 at the
3-month follow-up. Similarly, the number of patients in
Level 4 decreased from 11 at the time of admission to 9 at
the 3-month follow-up. Conversely, the number of patients
in Level 3 increased from 2 to 7.
There was no significant difference in the GMFM total
score between 1 and 3-month follow-up. However, in a comparison of pre-hospitalization score with post-discharge
scores at 1 and 3 month follow-up, both the post-discharge
scores showed significant increases when comparing with
admission. However there was a significant decrease in
GMFM score between discharge and 1st month (Table 5).
Sub-group scores were calculated separately. Comparison among the four evaluation times showed a significant
increase in sitting and standing parameters at 1-month
and 3-month follow-up (p<0.05). Crawling and kneeling
sub-groups only showed a significant decrease between
discharge and 1-month follow-up scores. Similarly, walkingrunningjumping scores showed a significant increase
at the time of discharge, a decrease at 1-month follow-up
and an increase at 3 month follow-up (p<0.05)
Of the permanent caregivers, 24 (85.71%) were the patients mother, while the caregivers in 4 cases (14.29%) were
other relatives (aunt, grandmother, stepmother).
DISCUSSION
CP has a mean incidence of 23/1000, although it shows
variations on a country basis7). In a multi-centric cross-sectional study carried out in 27 cities in 1996 including 146
doctors 50,000 children aged 016, the prevalence of CP
was 0.2% in Turkey8).
Since the presence and severity of accompanying prob-

p value
0.002*
0.001*
0.001*
0.006*
0.007*
0.096

*p<0.01

lems shows wide variation, CP is regarded as a group of

symptoms rather than a disease. Therefore, rehabilitation of
individuals with CP requires a multidisciplinary approach
that addresses the patients needs more than the disease.
Evaluation of CP rehabilitation results are rather difficult,
since patients have differing developmental and motor levels. It is therefore difficult to determine whether observed
improvements are the result of rehabilitation or a natural
outcome of growth and development.
This study evaluated the rehabilitation results of 28 pediatric CP inpatients. The literature in Turkey contains a
limited number of such studies. The use of 1-month and
3-month follows- ups permitted ongoing monitoring of rehabilitation and developmental outcomes at home following
discharge from the hospital. Thus, the information provided
to caregivers about their childrens condition was repeated,
and they were encouraged to perform certain exercises at
home. However, a large proportion of patients failed to attend the follow-ups, and were lost to follow-up.
In the present study, 57.1% of patients were female and
42.9% were male. This differs from a study carried out in
14 centers in Europe, which reported that the proportion of
male patients was higher (M/F=1.33)9).
The spastic type of CP is most prevalent1), comprising
approximately 75% of all cases7). Recent prevalence studies
validate this finding9, 10). Similarly, in this study, the spastic
type had the highest prevalence.
Early diagnosis of CP is important for the start of early
rehabilitation. The caregivers were asked to report the first
identification of the childs problem. Although 71.4% of the
patients were identified with problems in the first year of

288 J. Phys. Ther. Sci. Vol. 26, No. 2, 2014

life, only 31.4% started rehabilitation in the first year. In a
CP population analyzed by Boyle et al., the level of diagnosis before the age of 2 was 35%, while 87% of patients were
diagnosed before the age of 511).
Among our patients, 14 had hypermetropy, 12 had astigmatism and 4 had myopia. Similarly, 7 patients had strabismus, and 6 patients had pale optic disc, which is a retinal examination finding. In a study by Yksel et al. of 41
CP patients, 24 (58.6%) had various visual impairments.
They found that 43.9% of patients had strabismus, while
24.3% had refraction defects12). Similarly, in a meta-analysis, Ashwal et al. reported that 28% of CP patients had
visual impairment and ocular motility13). In a multicentric
study carried out in Europe, 11.1% of the patients with CP
were reported to have severe visual defects9). The differing
prevalence of visual impairment conditions is associated
with variations in the time and severity of brain damage,
involvement location, and thus the occurrence of different visual problems according to CP type. The literature
contains studies to define visual findings in a CP type14, 15).
However, the important thing is that children with CP commonly experience visual problems; therefore, eye examination should certainly be made, even if there is no visible
finding. The importance of a multidisciplinary approach is
emphasized once more.
Mental retardation is another problem of CP patients.
The incidence of mental retardation was reported as 30
50%16, 17). In our study, 3 (15%) patients had normal intelligence, 7 (35%) had mild mental retardation, 8 (40%) had
moderate mental retardation and 2 (10%) had severe mental
retardation. Approximately one-third of those with mental retardation had a mild degree of retardation. Athetotic
types have better mental conditions than others. On the
other hand, severe mental retardation is observed in spastic
quadriplegic children with rigid, atonic and severe involvement1619). In this study, there was no correlation between
the degree of mental retardation and cerebral palsy type.
Another significance of mental condition in children with
CP is that, as the degree of mental retardation increases, life
expectancy decreases18).
We used GMFM to evaluate rehabilitation results.
GMFM is a motor function criteria designed by Russel et
al.20) to measure the effectiveness of physical therapy in
CP patients. In a study of 111 children with CP, evaluation
scores of physiotherapists, families and blind evaluators
were found to be significantly correlated. Thus, GMFM is
sensitive to positive and negative changes in patients condition 20). Nordmark et al. reported that GMFM provided
reliable scoring between different evaluators and scoring at
different times by the same evaluators21). GMFM is a valid
and reliable method that has been commonly used in recent
years to evaluate the effects of physical therapy, medical
therapy and orthopedic therapies on motor functions among
children with CP. There is a large body of research on botulinum toxin, pallus stimulation, therapeutic electrical stimulation, muscle tendon surgery, walking aids and orthosis,
hippotherapy, strengthening walking exercises6).
In this study, mean GMFM score was 34.02 28.95 at the
time of admission and it increased significantly to 41.08

28.55 at the time of discharge. This result indicates that rehabilitation during hospitalization was effective at improving motor function. Furthermore, there was a statistically
significant difference between the 1-month and 3-month
follows-up compared with the admission total score. There
was a significant difference between discharge total score
and 1-month and 3-month follow up. This suggests that the
information and home-based exercise training provided for
caregivers in order to enhance daily living activities might
have maintained the significant increase in GMFM total
score comparing with admission. Decrease in GMFM at 1st
month comparing with discharge could be the adaptation of
home again. However, the increase in total scores between
the 1-month and 3-month follows-up was not significant. It
can be inferred from the finding that the mothers were motivated and eager in the first month after discharge from
hospital, but subsequently lost motivation. In a previous
Turkish study, Doan et al. analyzed GMFM scores at the
time of admission and discharge among children hospitalized with CP. Their study reported mean age, female/male
ratio and mean hospitalization stay similar to those of the
present study22). Similarly, there was a significant increase
in GMFM and discharge total and sub-group scores. These
findings suggest that rehabilitation programs have a positive impact on the gross motor functions of children.
There is a large body of research on the effects of various
treatment methods for CP, many of which have investigated
methods to reduce spasticity. Knox et al. (2001) analyzed
the effect of therapy methods using GMFM. Total scores increased significantly among children who received 6-weeks
of Bobath therapy23).
In another study that used GMFM, patients who received
a combination of physiotherapy, hypnotherapy, hydrotherapy and occupational therapy were followed for 18 months
after the therapy24). Analysis of two different groups that
received either intensive therapy or routine physiotherapy
showed no long-term difference in GMFM.
Although that study had a different aim, it resembles the
present study in terms of evaluation of rehabilitation results
and the use of GMFM; patients received physical therapy as
outpatients; and the use of 18-month follow-up enabled the
researchers to observe long-term outcomes.
Doan et al. evaluated rehabilitation outcomes of children with CP. Patients were allocated to sub-groups according to calendar age and the Denver Development test age.
Patients were evaluated according to the GMFCS with respect to CP type22). Due to the small number of patients in
the present study, and since GMFCS provides better indication of motor development, we preferred not to make comparisons according to CP type; instead, our patients were
allocated to monitoring sub-groups according to the GMFCS. The present study aimed to analyze the distribution
in groups rather than measuring changes in motor function.
The limitations of our study include:
1) The children in this study had different types of CP
and GMFCS levels, so we were comparing the rehabilitation results of a heterogeneous group. However, all of the
participants were children diagnosed with CP who were
treated via physiotherapy as inpatients. Furthermore, the

289
literature contains other studies that included participants
with different GMFCS levels and different types of CP24).
2) Duration of inpatient stay differed. However, an upper
limit was set according to Bobath, and the duration of hospitalization was determined by a physiatrist supervisor who
was unaware of which patients were included in the study.
3) The study included no control group; however, potential delays associated with such a methodology mean that it
is ethically inappropriate to exclude a child with CP from
rehabilitation for a period longer than 3 months.
In light of the research findings, and considering the
limitations of similar studies, there is a need for further
randomized controlled studies with more activity and participation parameters and a larger sample of CP patients.
ACKNOWLEDGEMENTS
Authors would like to thank physiotherapist Eylem Evin,
Ayse Akdogan, Ozlem Akbas and Serap Sumer. Authors
would also like to thank Prof. Resa Aydin and Dr. Berrin
Huner, the leader and the secretary of Istanbul Cerebral
Palsy Study Group, respectively, who served as scientific
advisors.
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