Developmental Neurorehabilitation

ISSN: 1751-8423 (Print) 1751-8431 (Online) Journal homepage: http://www.tandfonline.com/loi/ipdr20

The functional effect of segmental trunk and head

control training in moderate-to-severe cerebral
palsy: A randomized controlled trial

Derek John Curtis, Marjorie Woollacott, Jesper Bencke, Hanne Bloch

Lauridsen, Sandy Saavedra, Thomas Bandholm & Stig Sonne-Holm

To cite this article: Derek John Curtis, Marjorie Woollacott, Jesper Bencke, Hanne
Bloch Lauridsen, Sandy Saavedra, Thomas Bandholm & Stig Sonne-Holm (2017): The
functional effect of segmental trunk and head control training in moderate-to-severe
cerebral palsy: A randomized controlled trial, Developmental Neurorehabilitation, DOI:
10.1080/17518423.2016.1265603

To link to this article: http://dx.doi.org/10.1080/17518423.2016.1265603

Published online: 03 Jan 2017.

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DEVELOPMENTAL NEUROREHABILITATION
http://dx.doi.org/10.1080/17518423.2016.1265603

ORIGINAL ARTICLE

The functional effect of segmental trunk and head control training in

moderate-to-severe cerebral palsy: A randomized controlled trial
Derek John Curtisa,b,c, Marjorie Woollacottd, Jesper Benckea, Hanne Bloch Lauridsena, Sandy Saavedrae,
Thomas Bandholmb,f,g, and Stig Sonne-Holma,h
a
The Gait Analysis Laboratory, Department of Orthopedic Surgery, Hvidovre University Hospital, Copenhagen, Denmark; bPhysical Medicine &
Rehabilitation Research–Copenhagen (PMR-C), Copenhagen, Denmark; cInstitute for Physical and Occupational Therapy, The Faculty of Health and
Technology, Metropolitan University College, Copenhagen; dInstitute of Neuroscience, University of Oregon, Eugene, OR, USA; eDepartment of
Rehabilitation Sciences College of Education, Nursing & Health Professions, University of Hartford, Hartford, CT, USA; fDepartment of Physical and
Occupational Therapy, Hvidovre University Hospital, Copenhagen, Denmark; gClinical Research Centre, Hvidovre University Hospital, Copenhagen,
Denmark; hDepartment of Orthopedic Surgery, Hvidovre University Hospital, Copenhagen, Denmark

ABSTRACT ARTICLE HISTORY

Purpose: To determine whether segmental training is more effective in improving gross motor function Received 14 April 16
in children and young people with moderate-to-severe cerebral palsy than conventional physiotherapy. Revised 7 November 2016
Methods: Twenty-eight participants were randomized to a segmental training or control group. Accepted 23 November 2016
Outcomes were Gross Motor Function Measure (GMFM), Pediatric Evaluation of Disability Inventory KEYWORDS
(PEDI), Segmental Assessment of Trunk Control (SATCo), and postural sway at baseline, at primary Cerebral palsy; motor skills;
endpoint (6 months), and at follow-up (12 months). Results: There were no significant differences in postural balance; physical
either GMFM, PEDI, or SATCo scores at primary endpoint or follow-up. There were significant reductions therapy modalities
in anterior–posterior head angular sway and trunk sway in the segmental training group at primary
endpoint but not at follow-up. Conclusion: Segmental training was not superior to usual care in
improving GMFM. Improvements in head and trunk sway were greater in the segmental training
group at primary endpoint but not at follow-up.

Motor development in children with cerebral palsy (CP) can
be delayed and limited by reduced strength, coordination,
abnormal muscle tone together with sensory, and cognitive
disabilities. One object of physical therapy is to stimulate the
motor and sensory systems in very specific ways to help the
child to compensate for their disability. Interventions such as
strength training, balance and functional training have been
widely used for children with CP to improve motor function
by impacting impairments such as spasticity, reduced postural
stability, reduced strength, reduced range of motion, and
reduced endurance. These factors are significantly related to
motor function in CP.1,2 Further to this, a recent study has
shown a close relationship between segmental trunk and head
control and gross motor function and functional mobility in
children and young people with CP.3
Published studies concerning the training of trunk and
head control illustrate a number of different approaches.
Some studies have investigated the effect of passive interven-
tions such as splinting with lycra suits4 or trunk braces5 or
functional electrical stimulation (FES).6,7 Other studies have
investigated active interventions such as using vibration8 or
introducing instability during activity9 or introducing novel
activities using virtual reality gaming.10 The more specific
active training methods are often limited to children with
better motor function or better cognition. Specific training
of children with moderate-to-severe CP is more challenging.
One potential training intervention that can be used for this
group of children is targeted training.11 This training technique
has been developed and used clinically for 18 years with promising
clinical results. There is, however, little published evidence of its
efficacy. The best evidence published to date is a case series of six
children with CP aged from 2 years and 5 months to 7 years and 5
months without independent sitting balance, who were studied
under a random order of three conditions: targeted training, sham
targeted training, and treatment as usual.12 The attainment of
independent sitting balance and the Segmental Assessment of
Trunk Control (SATCo) test13 were used as the outcome mea-
sures. All six children showed an increase in their movement
control and attained independent sitting balance within 12–25
weeks. The study concluded that targeted training may be an
effective means of promoting movement control and functional
ability. This study used the children as their own control but had
few participants, and the intervention length and time of assess-
ment were not standardized.
The aim of this study was, therefore, to determine whether
segmental training is more effective in improving gross motor
function in children and young people with moderate-to-
severe CP compared to conventional physiotherapy. Gross
motor function was chosen as the primary outcome as this
was considered to be the most clinically relevant outcome
when comparing the effects of conventional physiotherapy
and segmental training.

CONTACT Derek John Curtis decu@phmetropol.dk Institute for Physical and Occupational Therapy, The Faculty of Health and Technology, Metropolitan
University College, Sigurdsgade 26, DK-2200 Copenhagen, Denmark.
© 2016 Taylor & Francis
2 D. J. CURTIS ET AL.
Methods
Trial design
The study design was an assessor-blind randomized con-
trolled superiority trial of targeted trunk control training
compared to conventional physiotherapy, with outcome
assessments before training start (baseline), and 6 (end of
training, primary endpoint) and 12 (follow-up) months after
the baseline assessment. The study was approved by the
Capital Regional Committee on Health Research Ethics, pro-
tocol number H-2-2009-124 and the Danish Data Protection
Agency 2010-41-5009. The trial was registered with
ClinicalTrials.gov (identifier NCT01357954). The reporting
of the study follows the CONSORT reporting guidelines for
parallel group randomized trials.14 Written informed consent
was obtained from the parents and informed consent obtained
from the participants in this study.
Sample size
Sample size estimation was carried out using G*Power 3.115
and was based on a minimum clinically important difference
of three and a half GMFM points16,17 and an estimated
standard deviation of three GMFM points in the primary
outcome based on unpublished pilot data from the
University of Oregon. To achieve 80% power of detecting a
difference with 95% confidence with a two-tailed test, a sam-
ple size of 12 participants in each group was required.
Randomization
Randomizing was carried out in two groups of 14 participants.
Participants in each group were listed in a rank order strati-
fied according to GMFCS and then age. The ranked list was
then split into seven blocks each with two participants by
pairing adjacent participants from the list. Each participant
in the pair was then randomly assigned to the segmental
training or conventional physiotherapy group using a compu-
terized random number generator by an independent
researcher.
Participants
Participants were enrolled through contact with pediatric
physical therapists working in a large regional hospital and
special physical therapy clinics, schools, and kindergartens
within the region. To be included participants had to have a
diagnosis of CP classified as levels III–V of the Gross Motor
Function Classification System (GMFCS),18 be aged between 2
and 15 years, and have trunk or head postural control deficits.
Volunteers were excluded if they had contracture or joint
deformity inhibiting a neutral vertical trunk or head posture,
had undergone surgery or received a change in medication
affecting their motor function in the preceding 6 months, and
were due for surgery or change in medication affecting their
motor function during the 12-month period of the study or if
they were unable to train five times a half hour each week for
a period of 6 months. Joint deformity and contracture were
tested using passive range of motion tests with the subject
supine.
Setting
Testing took place in the pediatric physiotherapy department
and movement laboratory of a regional hospital.
Interventions
The reporting of the interventions below follows the better
reporting of interventions: template for intervention descrip-
tion and replication (TIDieR) checklist and guide.19
Segmental training group: Participants allocated to the
segmental training group replaced their usual physical therapy
with a system of training known as targeted training.12 They
trained head and trunk control using this system for up to a
half hour, 5 days a week for a period of 6 months. A published
algorithm was used to guide decision-making in this training
intervention.11 Training was carried out either at home by the
parents, if they chose to do this, otherwise in the school or
kindergarten setting by a combination of staff and physical or
occupational therapists. The equipment which was used is
illustrated in Figure 1. The segmental training group returned
to conventional physiotherapy in their usual special physical
therapy clinic, school, or kindergarten during the follow-up
period.
Conventional physiotherapy group: Participants allocated
to the conventional physiotherapy group continued with their
usual physiotherapy during the intervention and follow-up
periods. Physiotherapy for this group consisted of a range of
interventions that were not standardized—but reflected clin-
ical practice—including strength training, passive stretching,
functional training, and balance and coordination training.
These interventions were carried out by the child’s own phy-
siotherapist in their usual special physical therapy clinic,
school, or kindergarten.
Training log books were issued to both groups to monitor
compliance and intensity of training for the two groups. Both
groups continued with their usual occupational therapy and
recreational activities during the study period.
Outcomes
Outcome measures were administered at baseline, primary
endpoint, and follow-up. Baseline characteristics recorded
included age, gender, Gross Motor Function Classification
System (GMFCS) level, and primary motor disability.
Outcome measures were selected to determine the effect of
the intervention on body structure and function level and
activities level of the International Classification of
Functioning, Disability and Health for Children and Youth
(ICF-CY).20 A review article by Ketelaar et al. (1998) identi-
fied the Gross Motor Function Measure (GMFM) and the
Pediatric Evaluation of Disability Inventory (PEDI)21 as the
only two evaluative assessment measures that fulfilled the
criteria of reliability and validity with respect to responsive-
ness to change.22 A later study concluded that both the PEDI
and GMFM were responsive to change in motor ability over

Figure 1. Targeted training equipment used to train a child (a) learning head control, (b) learning mid-thoracic control, and (c) lower lumbar reactive control (with
the use of a rocking base).
time in 55 children with CP aged 2–7 years, but mostly in
children under 4 years.23
The primary efficacy outcome that was chosen for this
study was the change (from baseline) in gross motor function
at the primary endpoint. Due to the reported reliability, valid-
ity and responsiveness, the GMFM-66 was selected as the
primary outcome measure. We chose to use the GMFM-66
Item Set (GMFM-IS)24 approach, which reduces number of
items and time required to complete the test. The GMFM-IS
and GMFM-66 have a high absolute agreement with an ICC
of 0.994 (95% CI 0.993–0.996) at a single measurement and an
ICC of 0.92 (95% CI 0.89–0.95) across repeat measurements
in a population of 227 children and young people with all
levels of GMFCS.24 A later study including 26 children with
CP showed the GMFM-IS to have a high level of concurrent
validity to the GMFM-66 (ICC 0.994 95%CI 0.987–0.997) and
a high test–retest reliability (ICC 0.986 95%CI 0.969–0.994)
with a standard error of measurement (SEM) of 1.91 points.25
The GMFM-IS was administered at the hospital physical
therapy department by a single experienced physical therapist
who was blinded to group allocation. The test was video
recorded. When the study was completed, the three record-
ings for each participant were scored by another experienced
assessor blinded both to the group allocation and chronology
of the tests.
DEVELOPMENTAL NEUROREHABILITATION 3
The PEDI test self-care and mobility domain question-
naires were sent to the participant’s guardians prior to their
test visits, and the guardians had the option of self-adminis-
tering the test or completing it on the test day. The scaled
scores for the self-care and mobility domains were calculated
and used in the analysis. The Danish translation of the PEDI
test was used in this study.26,27
The SATCo test13 was selected as it is the only published test
that can determine trunk postural control on a segmental basis
and was administered to the intervention group as part of the
intervention. The relative reliability of the SATCo test has been
reported as good in children with neuromotor disability (ICC
0.80–0.82), and the concurrent validity with the GMFM dimen-
sion B was also good (Pearson correlation 0.731–0.833).13 The
SATCo test was administered in accordance with the published
test guidelines13 and recorded using video cameras recording
sagittal and frontal videos by a single tester who was not
blinded. The videos were scored after completion of the study
by two experienced pediatric physical therapists who routinely
use the test and were blinded to the participant allocation and
the test chronology. A consensus meeting was held to resolve
any score differences between the scorers.
Static sway kinematics were captured in a biomechanical
gait laboratory using a Vicon 612 eight-camera system (Vicon
Motion Systems Ltd., Oxford, UK) sampling at 100 Hz. The
4 D. J. CURTIS ET AL.

participants were seated on a height-adjustable bench with achievement of a goal set at baseline using a modified Goal
their knees and hips at right angles, hands free of their bodies Attainment Scale (GAS). The ultrasound assessment was in the
and the bench, and foot contact with the floor. The strapping majority of cases impossible as it required the children to lay
system described in the guidelines for the SATCo test was prone and relaxed. This was extremely difficult for the group of
used to stabilize the pelvis. A trunk support device consisting children included in this study, so this outcome measure was
of adjustable rear, side, and front supports mounted on a solid abandoned. The GAS scores are not reported as the goals
height-adjustable pillar was then used to support the partici- chosen by the parents, and therapists for the children were too
pant firmly directly beneath the trunk segment that was to be varied to allow for meaningful reporting in connection with the
tested so that the free portion of the body above the support focus of the study which is gross motor function.
was able to come to a neutral vertical posture
A video screen was positioned at a height corresponding to
their eye level when sitting with an upright posture to ensure Results
that the child looked ahead. The trial continued until 30
seconds of static sitting was captured. Study flow and characteristics
Trunk sway amplitude and velocity in the anterior–poster- A total of 28 participants were included in the study between June
ior (AP) and mediolateral (ML) directions were calculated 2010 and May 2012. Fourteen of the participants were rando-
from the transverse plane movement of a marker attached to mized to the segmental training group and 14 to the conventional
the spinous process of C7 in relation to the marker mounted physiotherapy control group. The characteristics of the partici-
on the trunk support adjacent to the spine. Head sway and pants included in the study and the participants included in the
kinematics were calculated using a published protocol.28 analysis of the primary outcome at primary endpoint are detailed
Sway was measured with separate trials for all segmental in Table 1.
levels of the trunk and continued until the trunk support was Figure 2 shows the flow of participants through the study. No
as low as the participant could manage. Prior to the study, participants were lost in the segmental training group. In the
repeatability was determined for a sample of 20 healthy children conventional physiotherapy group, one participant withdrew
using the same protocol. Children under ten years showed a low immediately following allocation to this group, a further two in
typical error of measurement (TEM) for angular AP head sway the intervention period, one participant was lost in the follow-up
of 1.2° and angular ML sway of 0.7°. Trunk AP amplitude and period, and one was not tested at the end of the study. Reasons for
velocity had a SEM of 3.0 mm and 4.1 mm/s, and trunk ML the losses are detailed in the flow chart (Figure 2). Participants in
amplitude and velocity had a SEM 3.2 mm and 4.4 mm/s, the segmental training group trained an average of 84(SD 39)
respectively. Children ten years and over showed even better minutes per week during the intervention period and the conven-
repeatability with angular AP head sway of 0.4° and angular ML tional physiotherapy group received their usual physical therapy
sway of 0.1°. Trunk AP amplitude and velocity had a SEM of with an average of 77(SD 44) minutes per week. In the follow-up
2.5 mm and 0.5 mm/s, and trunk ML amplitude and velocity period, participants in the segmental training group trained an
had a SEM 0.7 mm and 0.3 mm/s, respectively. average of 72(SD 30) minutes per week and the conventional
physiotherapy group trained an average of 84(SD 46) minutes
Statistical methods per week. There was no significant difference in the total training
times between groups either during the intervention or follow-up
Data were tested for normal distribution using a Shapiro– (p = .689 and .587, respectively). Conventional physiotherapy
Wilk test. Independent samples t tests were used to determine recorded in the training log books for the children included in
differences in change scores between the segmental training
group and the conventional physiotherapy group during the
intervention period (primary endpoint) and the for the entire Table 1. Characteristics of participants included in the study and in the analysis
of the primary outcome (GMFM) at primary endpoint (6 months).
study period to follow-up for data that were normally distrib-
Primary outcome and
uted. A Mann–Whitney U test was used for the same compar- Baseline endpoint
isons between the ordinal data for the two groups. These Segmental Segmental
analyses were performed as intention to treat, using mono- training Control training Control
tone multiple imputation to impute missing values. (n = 14) (n = 14) (n = 14) (n = 10)
Trunk sway was analyzed for the trunk support level Age at baseline (SD) 8 years 5 8 years 6 8 years 5 7 years
months (4 months months (4 4
determined by the SATCo test at baseline for each participant. years 0 (4 years years 0 months
Statistical analysis was performed using IBM© SPSS© months) 7 months) (4 years
Statistics version 19. A p-value of less than 0.05 was consid- months) 3
months)
ered statistically significant. Sex (female) 3 7 3 6
GMFCS
III 2 (14%) 3 (21%) 2 (14%) 2 (20%)
Deviations from the approved protocol and trial IV 4 (29%) 2 (14%) 4 (29%) 2 (20%)
V 8 (57%) 9 (64%) 8 (57%) 6 (60%)
registration Primary motor disability
Spastic 7 (50%) 9 (64%) 7 (50%) 7 (70%)
The following outcomes were listed in the approved protocol Dyskinetic 7 (50%) 5 (36%) 7 (50%) 3 (30%)
and trial registration: Change from baseline in thickness of the Ataxic 0 0 0 0
erector spinae muscles measured with ultrasound and degree of

Assessed for eligibility (n=32 )
Randomized (n=28)
Allocated to control (n=14)
Withdrawal immediately following allocation (n=1)
(n=13)
Conventional physiotherapy
Withdrawn due to gastric pain (n=1)
Withdrawn due to unscheduled surgery (n=1)
Lost to follow-up testing due to non-compliance (n=1)
(n=10)
Conventional physiotherapy
Lost to follow up unscheduled surgery (n=1)
(n=9) 6 month follow up tests
Figure 2. Flow of participants through the trial.
the study consisted of strength training, functional training, pas-
sive and active stretching, cardiopulmonary exercise, and balance
training. A typical goal for a child in the conventional physiother-
apy group with GMFCS V was to hold their head in midline for a
period of a few seconds, for GMFCS IV to improve eating skills in
adapted seating, and for GMFCS III to improve walking speed or
distance using their assistive device.
Mean outcomes for GMFM, PEDI and head and trunk
kinematics, and SATCo test are shown in Figure 3 and
Table 2.
Primary outcome
Following 6 months of training, the change in gross motor func-
tion (GMFM-66-IS) of the participants in the segmental training
group was no different from the control group (mean difference
1.1 points; 95% CI–2.2 to 4.4 points). This was also the case at
follow-up (mean difference 0.1 points; 95% CI–3.6 to 3.3 points).
Secondary outcomes
There were no significant differences between groups in the
change in PEDI scaled scores or in SATCo scores. Trunk sway
DEVELOPMENTAL NEUROREHABILITATION 5
Not meeting inclusion criteria (n=2)
Declined to participate (n=2)
Allocated to intervention (n=14)
Baseline tests (n=14) Month 0
Segmental training
5 x weekly
Primary endpoint tests (n=14) Month 6
Conventional physiotherapy
(n=14) Month 12
velocity and mediolateral sway amplitude showed no statistical
between group difference, but sagittal plane trunk sway ampli-
tude was significantly reduced in the segmental group compared
with the conventional physiotherapy group (mean difference
17.2 mm 95% CI −31.6 to −2.7 mm, p = .019). Head kinematics
did not vary between groups with the exception of the change in
the standard deviation in head pitch which was significantly
reduced in the segmental group (mean difference −6° 95%
CI −11.0 to −1.0°, p = 0.017). Effect sizes for sagittal plane
trunk sway amplitude and standard deviation in head pitch
were both large (Cohen’s d 1.1 for both outcomes).
There were no statistically significant intergroup differ-
ences in the change from baseline for PEDI, SATCo, trunk
sway, or head kinematics at follow-up.
Discussion
The main finding of the present study was that segmental
training was not superior to conventional physiotherapy in
improving the primary outcome, gross motor function, at the
primary endpoint (after 6 months training) in children and
young people with moderate-to-severe CP. Treatment effects
for the secondary biomechanical variables AP head and trunk
6 D. J. CURTIS ET AL.
(a)
(b)
Figure 3. Figure showing means and 95% CI for (a) GFMF, PEDI, and trunk sway and (b) head sway at baseline, primary endpoint, and 6-month follow-up for the
segmental training and conventional physiotherapy groups.
sway were in favor of the segmental training with large effect
sizes.
A recent systematic review29 identified 45 studies reporting
13 exercise interventions aimed at improving postural control
in children with CP. Of these 45 studies, only four studies that
reported GMFCS levels included children in GMFCS IV and
V. These studies reported results from three interventions:
hippotherapy, hippotherapy simulator, and NDT. Of the stu-
dies investigating hippotherapy simulators, two level II studies
of children in GMFCS levels showed a mixed ability to
improve postural control. Borges et al.30 measured the effect
of hippotherapy simulators using stabilometry (voluntary cen-
ter of pressure movement in sitting) on 20 children from
GMFCS II-IV. Herrero et al.31 measured the effect of hip-
potherapy simulators on the Sitting Assessment Scale (SAS)
and GMFM total and dimension B (sitting) score for 38
children from GMFVS I-IV. The study by Borge et al.
reported a significant improvement in stabilometry measure-
ments for 20 children GMFCS II-V who received NDT for 8
hours during a 6-week period. Hippotherapy for a group of 3
children with CP GMFCS V produced no change in their
sitting postural control measured using SAS or their gross
motor function using GMFM total score or dimension B.
Similarly to this study, the changes induced using the hip-
potherapy simulator, hippotherapy, or NDT when measured
functionally using either GMFM or the SAS showed no
change, but stabilometry showed a significant improvement
in AP and ML postural control. It is clear from this review
that there are few published therapeutic methods to treat
postural control deficits in children with moderate-to-severe
Table 2. Outcomes and changes within groups from baseline to primary endpoint and follow-up for GMFM, PEDI, and kinematics.
Change within groups
Baseline Primary Follow-up Baseline to Baseline to
month 0 endpoint month 6 month 12 primary endpoint follow-up
Outcome Segmental Conventional Segmental Conventional Segmental Conventional Segmental Conventional Segmental Conventional
measure training physiotherapy training physiotherapy training physiotherapy training physiotherapy training physiotherapy
GMFM-IS 36.6 (10.6) 35.3 (9.7) 38.4 (10.6) 35.9 (8.8) 36.9 (10.3) 35.7 (10.9) 1.8 (4.0) 0.7 (3.3) 0.3 (2.9) 0.5 (4.7)
PEDI SS SC 40.0 (10.7) 38.3 (14.5) 41.5 (10.5) 36.5 (17.4) 42.9 (11.7) 41.7 (18.0) 1.5 (4.2) −1.8 (10.2) 3.0 (4.7) 3.4 (6.3)
PEDI SS SC-CA 29.6 (20.2) 28.6 (22.0) 30.2 (20.0) 27.1 (23.3) 31.1 (20.6) 28.2 (24.2) 0.7 (7.2) −1.5 (8.4) 1.5 (13.5) −0.4 (8.9)
PEDI SS Mob 26.0 (15.1) 24.3 (17.3) 26.8 (14.4) 25.3 (20.0) 28.8 (15.9) 25.4 (20.0) 0.9 (8.4) 1.0 (7.6) 2.8 (9.0) 1.1 (6.4)
PEDI SS Mob-CA 29.2 (18.3) 23.7 (22.8) 30.3 (20.0) 22.8 (26.5) 25.0 (19.5) 23.0 (25.3) 1.1 (12.6) −0.9 (6.6) −4.2 (17.2) −0.6 (5.8)
Trunk AP amplitude 23.2 (14.1) 8.5 (6.5) 17.7 (8.9) 20.2 (15.4) 14.1 (10.3) 10.1 (6.7) −5.5 (15.1) 11.7 (11.5) −9.1 (20.0) 1.6 (10.8)
Trunk AP velocity 19.5 (10.1) 10.1 (5.9) 18.5 (12.1) 16.3 (9.5) 18.5 (13.7) 14.7 (10.7) −1.0 (13.8) 6.2 (7.4) −1.0 (18.6) 4.7 (13.0)
Trunk ML amplitude 8.2 (5.7) 5.3 (4−3) 9.1 (6.9) 9.6 (10.2) 11.9 (8.5) 10.8 (8.0) 0.9 (9.2) 4.3 (7.5) 3.3 (11.0) 5.5 (5.9)
Trunk ML velocity 12.6 (6.2) 7.2 (5.0) 12.5 (7.2) 11.4 (7.6) 17.3 (11.7) 14 (13.0) −0.2 (9.2) 4.2 (6.0) 4.7 (11.7) 6.8 (10.8)
Mean head pitch 6.3 (8.2) −3.1 (6.0) 5.2 (19.7) 0.7 (13.7) 5.4 (13.4) −12.3 (12.13) −1.1 (19.5) 3.8 (11.8) −0.9 (12.6) −9.2 (9.7)
SD head pitch 8.3 (4.8) 4.8 (2.1) 6.1 (2.7) 8.7 (5.7) 12.1 (11.7) 8.3 (7.4) −2.1 (4.6) 3.9 (5.3) 3.9 (11.2) 3.5 (7.0)
Mean head roll 2.6 (10.6) 8.2 (12.9) 2.0 (11.5) −3.4 (9.2) 8.0 (18.3) −7.4 (12.6) −0.6 (10.2) −11.7 (19.0) 5.4 (19.8) −15.6 (18.7)
SD head roll 6.3 (3.3) 4.6 (4.3) 6.8 (6.7) 4.8 (4.1) 6.8 (7.3) 7.5 (6.8) 0.5 (7.0) 0.1 (2.9) 0.5 (6.6) 2.9 (6.8)
Mean head yaw 1.4 (17.8) −0.2 (6.2) −1.6 (10.0) −3.5 (3.2) −2.5 (12.0) 7.8 (8.6) −3.0 (19.5) −3.3 (8.6) −3.8 (27.2) 8.0 (10.0)
SD head yaw 9.0 (5.8) 4.5 (3.3) 7.6 (4.8) 4.0 (3.2) 10.3 (7.1) 8.3 (10.0) −1.3 (5.3) −−0.5 (4.4) 1.3 (3.7) 3.8 (10.6)
SATCO Static 2 (1:4) 1 (1:4.5) 2.5 (1:4.25) 1 (1:4.25) 2.5 (1:4) 2.5 (1:4) 0 (−0.25:0.25) 0 (0:0) 0 (−1:1) 0 (0:0)
SATCO Active 1 (1:3) 1 (1:3) 2.5 (1:5) 1 (1:2.5) 2.5 (1:4) 1 (1:2.5) 0 (0:0.25) 0 (0:0) 0 (0:1) 0 (0:0)
SATCO Reactive 3 (1:4.5) 4 (0.75:5) 3 (2:4) 5 (1:6) 3 (2:4) 3 (3:5) 0 (0:1) 0 (−0.5:1) 0 (−1:0) 0 (−2:0)
GMFM-IS = Gross Motor Function Measure Item Set, PEDI SS = Pediatric Evaluation of Disability Inventory scaled score, SC = self-care, Mob = mobility, CA = caregiver assistance, AP = anterior–posterior, ML = medial lateral, SD
= standard deviation. SATCo = Segmental Assessment of Trunk Control. GMFM and PEDI are measured in points, amplitude in mm, velocity in mm/s, pitch, roll and yaw in degrees and SATCo in control level. Values are mean
(SD) except SATCo which is median (quartiles).
DEVELOPMENTAL NEUROREHABILITATION
7
8 D. J. CURTIS ET AL.
CP and that the changes that are induced by the therapy are
difficult to document using existing functional measurement
instruments.
The outcome measures used in the present study are designed
to measure the full range of motor abilities found in CP and do
not measure the improved quality of an existing function such as
head control. This could indicate that future studies should pos-
sibly focus on other meaningful functional changes for children
such as visual function, look time, social interaction, feeding, and
eye hand coordination.
All of the outcome measures were made during a single day;
there was therefore only one measurement session for each child
at baseline, primary endpoint, and follow-up. The outcome mea-
sures were therefore dependent upon the child’s performance on
that day. For healthy adults, this may produce little variation for a
measure of motor function, but in this group of children the
parents reported varying abilities from day-to-day. Children
with moderate-to-severe CP experience pain more frequently
and with greater severity than children with mild CP32 have
more afebrile seizures33, more sleep disorders34, poorer respira-
tory status, poorer nutritional status, and a greater use of resources
such as days in hospital, physician visits, missed school, days spent
in bed, and inability to perform usual activities.35 All of these
factors could be expected to affect motor performance. Future
studies should include more than three assessments to reduce the
effect of day-to-day variations on the outcomes.
In this study, segmental training produced similar results
to conventional physiotherapy in the attainment of improved
gross motor function. Segmental training is a very flexible
therapy requiring only the equipment and a person to train
the child, together with a therapist who sets the equipment up
and reviews the therapy every 8 weeks. It is possible that
segmental training could either be a supplement to existing
therapy or an alternative for children who live remotely from
a center with qualified therapists.
The only previous study of the effect of segmental
training12 included six children (aged 2 years 5 months to
7 years 5 months) with CP using the SATCo test and a
functional test of individual sitting balance. Five of the six
children had normal head control, but all required support
for sitting at the start of the study. None of the children
were independent walkers. All of the children in this study
achieved independent sitting balance within 12–25 weeks.
One of the possible reasons for the divergence between
these results and the present study is the participants.
Children in the present study are both older and have a
more severe form of CP. A total of 12 children from the 28 in
the study were working for head control and a further four
were working for upper thoracic control. As can be seen from
Table 1, 17 of the 28 participants in this study are in GMFCS
category V. It can be seen from the motor growth curves36 that
children and young people with severe CP develop motor skills
at a slower rate than that of children with moderate or mild CP.
Motor development is also more rapid for younger children
and peaks for GMFCS IV and V at 6 years and 11 months of
age37. The potential to improve gross motor function for the
children in the present study may therefore explain the appar-
ent difference in response to the intervention between these
two studies.
We do not at the present time know whether the
response to targeted training is related to age, GMFCS,
and motor disability. Future studies with a larger number
of participants are necessary in order to quantify these
possible relationships using multiple regression analysis.
Interventions aimed at the achievement of head control are
lengthy. Typical periods of targeted training are around 9
months for children with deficits in trunk control and 18
months for those working on head control (Dr. Penny
Butler, personal communication). Ceasing training before
improvements in head control become functional is unlikely
to produce a lasting change when the new skills are no longer
practiced. In this study, the intervention was stopped after 6
months regardless of the stage of head control that had been
achieved. This comparatively short time-limited intervention
is unlikely to produce functional change in a child with head
control issues, and this could help to explain the return to
baseline at the follow-up measure for head kinematics.
The link between the improvements seen in sway para-
meters in the segmental training group in this study and
functional improvement is tentative. Steady-state sway has
been used as a surrogate measure of postural control in a
number of studies38–40 investigating seated postural control
in children with CP. A study by Curtis et al. showed a
significant and strong relationship between head and trunk
postural control and gross motor function measured using
GMFM and functional abilities using the PEDI test self-care
and mobility domains3. A number of studies have also linked
decreased sway with increased motor function39,41,42 in chil-
dren with CP.
In order to improve the efficacy of segmental training,
it is possible that interactive computer play (ICP) as
described in the study by Barton et al.10 could be a
supplement used during the segmental training periods.
This could provide additional motivation for training par-
ticipation for children with CP. A recent review43 con-
cluded that the body of literature evaluating ICP to
improve gross motor function in individuals with CP
showed probable effectiveness (level B) evidence. This
review identified two studies which included children in
GMFCS IV and V. The first study44 showed an increase in
the total GMFM-88 score of 7% when using Nintendo Wii
2 days a week for 6 weeks in a group of children who were
either capable of unsupported sitting or standing. The
second study45 included children from GMFCS IV and V
who had achieved either independent sitting or prop-sit-
ting. This study used a seat platform sensitive to move-
ments in center of pressure coupled to a computer with
games controlled by output from the platform. The study
reported no change in the Chailey level of box sitting, but
significant increases in a number of overall scores in the
seated assessment of children with neuromotor disability
test. This study concluded that sitting activities where the
focus is on self-guided play could be beneficial for
improving sitting ability. The support provided by the
segmental training equipment could allow more severely
affected children to train through computer play in a
similar way to their more able-bodied peers while training
specific postural control skills.

Study limitations
The main limitation of this study relates to the measure-
ment of outcomes. The children included in this study have
a greater day-to-day variation in their motor abilities than
their abler peers due to number of health-related factors. By
assessing the child’s performance on a single day, the effect
of these daily variations can lead to an over or underesti-
mation the child’s true level of ability. Future studies
should include repeated assessment over a number of days
to reduce the effect of day-to-day variations on the
outcomes.
Conclusions
Segmental training for children and young people with
moderate-to-severe CP was not superior to conventional
physiotherapy in improving gross motor function, func-
tional mobility, or trunk control. Improvements in head
and trunk sway were greater in the segmental training
group, but not at follow-up. Issues of access to specialist
training could make this form of training a supplement or
alternative to care as usual. Future studies in this group of
children and young people with moderate-to-severe CP are
required to investigate the clinimetrics of existing outcome
measures specifically for this group. The use of the GMFM-
88 in this group of children could also be preferable to the
GMFM-IS and might have shown change in the individual
dimensions: (1) lying and rolling and 2) sitting. The mea-
surement of outcome in future studies in this group should
be repeated to alleviate the effect of inter-day variation in
motor abilities.
Acknowledgments
The authors express their gratitude and thanks to the children and
families who participated in the study. Special thanks also go to Dr.
Penny Butler and Richard Major for extensive assistance in helping
the study group understand, plan and implement targeted training,
pediatric physical therapists Lone Nielsen, Tina Winther Jørgensen
and Christina Frank Harnfeldt who administered the GMFM assess-
ments and Helle Rasmussen who scored them. Special thanks also to
physical therapists Sarah Bew and PT assistant Lynne Ford for scoring
the SATCo tests and to The Movement Foundation/The Movement
Centre for loaning the equipment for the study and to R82 A/S for
help in transporting them.
Funding
This trial was supported financially by grants from The Association of
Danish Physiotherapist’s Foundation for Research, Education and
Development of Clinical Practice, Fund for Physiotherapy in Private
Practice and the Britta Holles Fund. The financial supporters of this
study had no involvement in the study design, data collection, data
analysis, manuscript preparation and/or publication decisions.
Declaration of interest
The authors have no conflicts of interests to report. The authors alone
are responsible for the content and writing of this paper.
DEVELOPMENTAL NEUROREHABILITATION 9
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