Functional therapy for An ecological approach, where the aim is to promote better

functioning in the context of daily life settings, can serve as an

effective framework for physical therapy (Ketelaar et al. 2001).
children with cerebral This approach encompasses two aspects of children’s devel-
opment in relation to the environment: development in the
palsy: an ecological sociocultural context (Bronfenbrenner 1986) and develop-
ment through the children’s perceptual-motor exploration of

approach 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
Lena Ekström Ahl* MSc PT PCS, Child and Youth that arise in situations they desire to master (Gentile 1998,
Habilitation, Uppsala; Lesensky and Kaplan 2000). The approach is called ‘functional’
Eva Johansson PhD PT, Mälardalen University, Västerås; as primarily functional skills (e.g. dressing and climbing stairs),
Tina Granat PhD, Clinical Psychologist, Child and Youth are practised to achieve functional goals. Furthermore, this
Habilitation, Uppsala; approach offers a good basis for individualized planning,
Eva Brogren Carlberg PhD PT PCS, The Research Unit, stressing the importance of developing skills that are meaning-
Handicap and Habilitation, Stockholm, Sweden. ful for the children and their parents (Law et al. 1998,
Rosenbaum et al. 1998, Bower et al. 2001). Defining specific
*Correspondence to first author at Child and Youth goals can enhance motivation and, possibly, the child’s capaci-
Habilitation, Box 260 74, S-750 26 Uppsala, Sweden. ty to learn (King et al. 1999). In this context the child can
E-mail: lena.ekstrom.ahl@lul.se 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,
The aim of this pilot study was to evaluate functional training throughout the day.
for children with cerebral palsy (CP). The outcomes Recently, Jansen and coworkers (2003) presented an excel-
examined were goal-achievement, gross motor function, lent review of the literature on parental participation in physi-
performance of everyday activities, caregiver assistance, cal therapy for children with physical disabilities. They pointed
parents’ perception of family-centredness, and preschool out that parents who participate in physical therapy are likely
assistants’ feeling of competence in the care of the children. to develop a more realistic view of their child’s potential in
The outcome measures used were goal attainment scaling, terms of daily functioning. The authors suggest that this could
Gross Motor Function Measure, Pediatric Evaluation of increase parents’ confidence in their own competence and
Disability Inventory (functional skills and caregiver reduce parental stress. Jansen et al. call for studies in which the
assistance scales), Measure of Processes of Care, and a effect of therapy on both parents and children is evaluated in
questionnaire. The intervention was carried out in the context order to shed light on the complex interactions that bring
of daily life settings, i.e. in an ecological framework. Fourteen about a child’s development. They considered the Measure of
children (three females, 11 males; age range 1y 6mo to 6y) Processes of Care (MPOC; King et al.1995) to be a good evalua-
with diplegia and tetraplegia, classified at Gross Motor tive tool for parental participation.
Function Classification System levels II–V, participated in the The aim of this study was to evaluate the effect of training in
five-month intervention. Frequency of training towards a daily life settings for preschool children with cerebral palsy
specific goal varied between twice a day and 23 times a day, (CP) with respect to (1) goal attainment, (2) gross motor func-
depending on the type of goal. Seventy-seven per cent of goals tion, (3) performance of daily activities, and (4) amount of care-
were fully attained. Gross motor function and performance of giver assistance required. Furthermore, this study examined
daily activities, including social function, improved significantly. whether the parents’ and assistants’ perceptions of family-cen-
A decrease in caregiver assistance was noted in relation to the tredness and competence in the care and training of their child
children’s mobility. Parents’ perception of family-centredness was affected by the intervention procedure.
improved in all domains. Furthermore, the children’s preschool
assistants felt more competent in their care of the children. 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.

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

group due to a lack of children who were matched for severity in the training of the children. All physical therapists had exten-
of disability, age, and sex. The ethics committee of the Faculty sive (12–25y) rehabilitation experience and were familiar with
of Medicine at Uppsala University approved the study. Parents using the various assessments.
gave their informed consent. Those in charge of the children’s
preschools were informed about the content of the interven- INTERVENTION
tion and agreed to participate. The intervention period started with a structured four-day live-
in course for the participating families and the preschool assis-
OUTCOME MEASURES tants, together with staff from a habilitation team. Intervention
Considerable attention was given to identifying and evaluat- took place at a foundation in the countryside owned by the
ing individual goals for each child. Goals were set in close col- association of parents of children with CP. Staff included a med-
laboration with the parents, the child (as much as possible), ical doctor, physiotherapist, special needs teacher, psycholo-
the child’s preschool assistant, and staff from the habilitation gist, and a social worker. The course was theoretical and
team (i.e. physical therapist, special needs teacher). Seven practical. To understand and participate in the training, knowl-
specific and measurable goals were set for each child. Goal edge about the aetiology of CP and the consequences for
attainment was graded as complete (100%), partial (≥50%), or overall development, normal and abnormal motor develop-
no improvement (<50%). An example of a set goal might be ment, motor learning, psychological aspects, and motivation
for the child to get up from a prone position to a sitting posi- were considered essential. During the four days the children
tion. Goal attainment would be graded as partial, for example, started their training. This began the process of practical guid-
if the children rolled over on their side, placed weight on the ance for parents and preschool assistants.
elbow, and was able to stretch the arm to sit up, but was During the following 5 months, goal-directed functional
unable to sit up completely. therapy was mainly carried out in the child’s normal settings at
Change in gross motor function was assessed using the home and at preschool. Throughout the intervention period,
Gross Motor Function Measure (GMFM-66; Russell et al. 2002). continuous discussions were held with, and advice and sup-
Achievement in daily life activities of self-care, mobility, and port given to trainers during regular home and preschool vis-
social function was monitored with the Pediatric Evaluation its. All children met once a week for three hours to attend
of Disability Inventory (PEDI; Haley et al. 1992) using a Swedish training at the local habilitation-centre, together with parents
version of the functional skills and caregiver assistance scales and/or preschool assistants. Group sessions also focused on
(Nordmark et al. 1999). guiding parents and preschool assistants in goal-directed
Parents’ and preschool assistants’ perception of services was training with the opportunity to discuss and practice the tech-
evaluated with a self-administrated questionnaire: the MPOC niques. Special attention was paid to making children active
(Swedish version, Bjerre et al. 1997). The MPOC was supple- participants in this process. Apart from individually tailored
mented with four questions to cover areas of interest not cov- guidance, in group sessions children could meet peers, play,
ered by it (see Appendix I). To appraise the frequency of and have fun. After 5 months, group training was reduced to
training, diaries were written at home and at preschool for one one meeting per month; only occasional guidance was given
week during the 1st, 3rd, and 5th months of the intervention to parents and assistants.
(Fig. 1). Child F, a female of 5 years of age (GMFCS level III), will
Three physical therapists, sometimes together with a special serve as an example of the individually tailored intervention.
needs teacher, performed all the assessments. They followed One of the seven goals that the parents, preschool assistant,
the same children throughout the study. They also participated 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 I). To test associations between age and gross motor change,
activity was analyzed with the physiotherapist and found to Spearman’s rank correlation (rs) was used. Significance was set
contain several sub-skills that the participant needed to learn, at p<0.01.
i.e. stand up, step down a stair, move one hand during the
stepping-down transfer, walk sideways, and turn when reach- Results
ing the sink. The bathroom floor, which was often slippery, FREQUENCY ACCORDING TO THE DIARY
added to the difficulties. Training was given in the goal-activity The training diary reflected the true intensity of the training.
and its sub-skills several times each day, at home and at Frequency of training varied considerably. Variation was related
preschool. Sub-skills could be practised during other activi- to type of goal and how frequently the task occurred in daily
ties, i.e. climbing down stairs and pavements, moving along life. For example, a goal to maintain range of motion in the
holding on to furniture when playing with friends, and stand- hamstrings was trained twice a day, whereas a goal aimed at
ing up from a chair. standing up from a chair could result in over twenty practice
Participants were encouraged to perform the different activ- occasions.
ities in a variety of ways; activities were discussed and suitable
solutions were tried out. The physiotherapist’s discussion with GOAL ATTAINMENT
helpers (i.e. parents and caregivers) focused on how much Ninety-eight goals were set for all 14 participants (Fig. 2). Three
assistance the participant needed to succeed while still doing goals were related to body function, i.e. increasing range of
as much as possible independently. Another important aspect motion. One goal was related to participation and aimed at
of the consultations was to support the helpers’ ability to do promoting the child’s ability to play with peers. The remain-
task-analyses, i.e. what parts does a task consist of, what are the ing 94 goals were related to activities, e.g. being able to walk
difficulties for this particular child, how can the situation be from the toilet to the sink or rise from the floor into a walker.
used for training, and how can the motivation of the child be Goals relating to eating and dressing were also common, e.g.
encouraged? For child F, the main problem was muscular taking off a sweater, cutting soft food.
weakness which contributed to her difficulties in standing up After three months of training, 46 out of 98 goals were ful-
and walking down stairs. Therefore, focus was on strengthen- filled completely and 25 were partially completed. After five
ing as an integrated part of the activities. Stronger leg-muscles months, 76 goals were fulfilled completely and 19 were partial-
would allow her to perform the task with less assistance. ly completed (Fig. 2). At eight months’ follow-up goal attain-
ment was sustained.
DATA ANALYSIS
As no significant difference was found between the two training GMFM
groups in any of the measured aspects, data were pooled. GMFM scores did not change significantly during the base-
Because the data were not normally distributed, the non-para- line period. Two children, however, had an unstable base-
metric Wilcoxon’s matched pair test was used to evaluate line. One child exhibited a change of 1, and the other, the
changes in PEDI and GMFM-66 scores. Furthermore, Fried- youngest child in the group, a change of 2.42 between the
man’s analysis of variance by ranks was used for multiple com- first and the second assessment. However, the amount of
parisons with the GMFM-66. To calculate differences in the change displayed during baseline measures was not signifi-
MPOC scores, parametric statistics (t-test) were applied accor- cantly related to age (rs=0.49). An obvious change in gross
ding to recommendations in the manual, as data were not motor function took place over the 5-month training period
skewed (King et al. 1995). The same procedures were used for (Friedman p<0.001, median change score 3.13, range
non-skewed data from the additional questionnaire (Appendix 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 QUESTIONNAIRE
p<0.01). Between the following assessments a steady upward The supplementary questionnaire was completed to a larger
trend was found, but the change did not reach significance (p extent than the MPOC, by mothers (n=11), fathers (n=9),
values ranging from 0.02–0.05). Between the last three assess- and assistants (n=10). Preintervention, fathers had the lowest
ments performed post-intervention, no significant change was score relating to all four questions. After the intervention the
seen, indicating that functions gained through training were scores indicated a significant change in the knowledge they
sustained. The amount of change in gross motor function was had acquired (questions 1, 2, 3) and how clear the goals were
not related to age at onset of the intervention (rs=–0.17). (p<0.001). Mothers also expressed that they had an enhanced
knowledge in response to all four questions. Preschool assis-
PEDI tants initially graded the last three questions higher than the
According to the parents, the children significantly improved parents; no significant change caused by the intervention was
self-care performance (median 44 vs 49.2, p<0.001), mobility found. However, assistants felt they had acquired more knowl-
(median 41.3 vs 43.8, p<0.01), and social function (median edge on training the child during the intervention period
53.4 vs 56, p<0.01) after the intervention period (Fig. 4). (p<0.01).
Variation between children on the mobility domain was con-
siderable (see Fig 4). The amount of assistance from caregivers Discussion
in daily life activities changed significantly only on the mobility Functional, goal-directed therapy carried out in daily life settings
domain (p<0.001; Fig. 5). of 14 children with CP influenced their gross motor capacity
and their performance in self-care, mobility, and social function
MPOC over a five-month training period. The goals set were reached
Mothers and fathers in nine families, and preschool assistants in 77% of cases. Parents expressed a more positive perception
in two families, completed the MPOC questionnaire. In four of service delivery after the training period than before. Also, the
families only the mother of the child returned a filled-in ques- children’s preschool assistants showed that they had acquired
tionnaire: in three of these the child’s assistant also answered more knowledge on how to train and motivate the child.
the questions. For one child only, the assistant replied. A fundamental aspect of cooperation between families and
Parents’ perceptions of services received from the habilitation others actively involved in daily care of children with CP is the
team during the intervention period significantly improved in formulation of specific goals for treatment (Bower et al. 2001,
all domains after the training period (t-test p<0.001) although Ketelaar 2001). Goals can be viewed as being the ‘cement’ that
variability was large, especially before the intervention (Fig. 6). can assist in avoiding fragmentation of services. By making
Mothers and fathers exhibited significantly different opin- individual goals clear, everyone involved with the children
ions before and after the intervention in the domains of can understand them and can unite and work together with
enabling and partnership: (t-test p<0.01; pre: mother 4.7 [SD the children to achieve them. Goals that are understandable,
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 60
the intervention than fathers. In the domain of respectful and
supportive care the fathers rated a higher grade of satisfac- 55
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]). 50
Six preschool assistants partially filled in the questionnaire.
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 gross motor prognosis in children with CP (Rosenbaum et al.
active problem solving: a fundamental aspect of motor learn- 2002). So far, there is no statistical approach for comparing
ing. The formulation of goals also provides a basis for individ- the incline of individual children during development to the
ualized measures of outcome (King et al. 1999). incline of the five curves. Visual judgement of the current
In this study the children had fully obtained 77% and partial- results suggested that, considering the age of the children
ly obtained 19% of the goals at the end of the training period. and the severity of the disability, the incline in 13 of the 14
This level of goal fulfilment was maintained at follow-up. children was steeper then expected. This corroborates the
Results support the idea that skills used every day persist even if assumption that gross motor progress was accelerated due
they are not explicitly trained (Bower and McLellan 1992). In to the intervention.
future studies goal-setting could be further improved by using The PEDI served two purposes. Apart from being an out-
goal-attainment scaling with five levels (–2 to +2), making it come measure it also formed a basis for discussing appropriate
possible to follow the children’s development towards a goal goals for therapy. The items in the three domains of the PEDI
(King et al. 1999). are aligned along an interval scale, providing an indication of the
Frequency of training is important for motor progress (Taub child’s performance along a continuum from easy to difficult.
et al. 1999). However, it is uncertain how often children should The scale can assist in providing ideas about the child’s next
practise a function in order to learn it. This seems to be depen- developmental step in daily activities, and can indicate what
dent on many factors including the severity of the disability, the might be possible in the future. Functional goal-directed ther-
task to be learned, the environment in which the function is to apy provides significant progress in the domains of self-care and
be practised, the learning capacity of the child, and the method mobility (Ketelaar 2001). The children’s considerable progress
used (Valvano and Newell 1998, Bower et al. 2001, Trahan and in social function was somewhat more surprising, as this has not
Malouin 2002, Shumway-Cook et al. 2003). In this study, fre- been shown previously. Many factors in the training approach
quency was measured using training diaries, a method not might have contributed to this development. Possibly, the oppor-
tested for reliability. However, the diaries were filled in consc- tunity to meet regularly peers in group activities was one factor
ientiously showing that all goal activities received training for at promoting social development. The goal-directed training
least five days each week, which indicated that frequency might was also very communicative and dealt with problem solving,
play a role in the success of the intervention. However, varia- causing the child to be active and expressive with regards to
tion in frequency was related to type of goal and how often the feelings, solutions, and preferences.
task occurred in daily life. Therefore, it was not feasible in this In the mobility domain of the PEDI, the amount of care-
pilot study to relate the frequency to goal attainment. giver assistance was significantly reduced, indicating that the
Children’s gross motor function improved significantly children could exercise their newly achieved skills indepen-
during the five months of intervention: the rate of improve- dently. However, the level of caregiver assistance did not cor-
ment was most pronounced during the first two months. respond to the children’s progress in self-care and social
This indicates that although the training was predominantly function. This might relate to the children performing the
specific, it had general effects. It was queried whether some of tasks slowly due to a lack of automatization, making it difficult
the improvement could be due to natural development: a to withdraw support. It also takes time to change behaviour.
stable baseline before and after the intervention is one indi- Most theories on child development propose that the envi-
cation of improvement being training-related. ronment is important for progress and, therefore, the role of
Five ‘gross motor curves’ corresponding to the five GMFCS parents is imperative (Bronfenbrenner 1986). The focus of
levels have been developed to give an approximate idea about the current study was on the special role of parents of children

75 a b b
80
65
Caregiver assistance
Functional scales

a
55
60
45

35 40

25
20
15

5 0
Self-care Mobility Social function Self-care Mobility Social function

Figure 4: Change in Pediatric Evaluation of Disability Figure 5: Change in Pediatric Evaluation of Disability
Inventory (PEDI; Haley et al. 1992) functional skill scores Inventory (Haley et al. 1992) caregiver assistance (n=14).
(n=14). Boxplots represent 25th, 50th, and 75th centile. Boxplots represent 25th, 50th, and 75th centile. Whiskers
Whiskers represent minimum and maximum values. White represent minimum and maximum values. White boxplots
boxplots indicate assessments before intervention and indicate assessments before intervention and black boxplots
black boxplots assessments after intervention. ap<0.001, assessments after intervention. ap<0.001 (Wilcoxon).
bp<0.01 (Wilcoxon). PEDI evaluates through a structured Caregiver assistance is evaluated in 20 different activity areas
interview if a child is able or unable to perform 197 skills using a 6-point scale. A score of 5 indicates independence and
(score 1 or 0) in everyday life situations. a score of 0 complete dependence on assistance.

Functional Therapy in Children with Cerebral Palsy Lena Ekström Ahl et al. 617
with disabilities, and supporting them in that role. Particular Assessing parental–professional interactions and the
attention was given to knowledge transfer between parents effect of parental participation in training programmes on
and professionals, but other forms of parental support appear parental well-being will be of importance in future studies to
to be important (Solomon et al. 2001). Results from the MPOC elucidate the complex interactions between different facets
indicate that there was a substantial change in the parents’ of an ecological framework.
experiences of caregiving. Considering that the MPOC is a
questionnaire and, therefore, subjective in nature, it is not Conclusion
surprising that parents who have actively chosen to participate Children with CP benefited from a functional goal-directed
and have dedicated much time to work together with their chil- training approach in their development of gross motor func-
dren and professionals, express positive feeling towards their tion and everyday activities. The ecological intervention appr-
experiences. Previous studies have demonstrated that MPOC is oach was also positively perceived by the parents. The study
sensitive to parents’ perceptions of various types of rehabilita- adds to the growing knowledge that the efficacy of treatment
tion efforts (King et al. 1997). lies within the child’s day-to-day environment.
Mothers and fathers expressed different views on how
they perceived services, a finding in agreement with that of a DOI: 10.1017/S0012162205001210
previous study (King et al. 1996). However, the sample in our Accepted for publication 15th September 2004.
study was small and no general conclusion could be drawn.
Determining such perceived differences for future studies could Acknowledgements
add valuable information to improve family-centred services, We sincerely thank the children, their parents and assistants, and
our colleagues for making this study possible.
also taking into account cultural differences.
An area calling for further exploration is the role of pre- References
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Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Trahan J, Malouin F.(2002) Intermittent intensive physiotherapy in
(1997) Development and reliability of a system to classify gross children with cerebral palsy: a pilot study. Dev Med Child Neurol
motor function in children with cerebral palsy. Dev Med Child 44: 233–239.
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1. Do you have adequate knowledge to train your child?
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36: 237–251.

Book Review 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
The Brain’s Sense of Movement with sexy subheadings, such as ‘The Art of Breaking’ and
By Alain Berthoz ‘What If Newton Had Wanted to Catch the Apple’, that cover
Cambridge, USA: Harvard University Press, 2000 many bases of perception and action, from control of bal-
pp 352, £16.95, US$24.95 ance, limb movement, and visual gaze. The central tenant is
ISBN 0 674 00980 0 (Paperback) that the brain uses sensory information proactively. The
brain is, above all, a biological machine for moving quickly
When I began my doctoral studies in sensorimotor control, with anticipation. Berthoz, a highly regarded neurophysiol-
I was intrigued by seemingly unexplainable phenomena ogist, boldly asserts that the brain uses configurations of
associated with both perceptual illusions and altered per- receptors to work out a perception and action. As the
ceptual experiences following unique brain lesions. How author acknowledges, science moves quickly. But despite
could vibrations applied to biceps while the fingertip is on having been published almost five years ago, the work was
the nose lead to the perception that the nose is growing ahead of its time and this has been reinforced by subsequent
(Pinocchio illusion)? How could two objects of identical experimental work. However, one exception is the author’s
weight but different size be perceived to have different rejection of the term ‘internal representation’. While he cor-
weights (size–weight illusion)? How could patients with rectly asserts that it is too easy to hide our ignorance behind
parietal area lesions not recognize one half of their body or such a generic term, considerable evidence for representa-
visual field (unilateral neglect)? What underlies amputees’ tions of manipulated objects and their use in proactive con-
perception that their amputated limb still exists or hurts trol has been published since this book was published.
(phantom limbs)? To me, answers to these questions However, as the author embraces the term ‘internal model’,
appeared to be the key to understanding sensorimotor I suspect the objection largely involves the term’s overuse
interactions in the brain. In The Brain’s Sense of Movement and that, therefore, Berthoz’s concern merely involves
(translated from French) the author, Alain Berthoz, uses syntax.
these or similar examples of perceptual disconnects as a Overall, The Brain’s Sense of Movement is a detailed and
guide to describing the relationship between perception refreshing review of sensorimotor control. The book is
and action. As stated by the author, the book is a reflection filled with wonderful examples which make the presenta-
on how the brain works proactively, with perception being tion of material practical, fascinating, and a delight to read.
much more than an interpretation of sensory messages. The relation of basic material to interesting clinical patholo-
Perception is proposed to be inseparable from action, and it gies makes it all the more interesting to clinicians. This book
is suggested that perceptual illusions are solutions to prob- contains information that should inspire research in clinical
lems of sen-sory conflict or ambiguity. motor control for decades to come.
What is truly unique is that the book frequently high-
lights these perceptual disconnects as well as practical DOI: 10.1017/S0012162205001283
examples and exercises that show how we control move-
ments, such as gaze control, posture and limb movement, Andrew M Gordon

Functional Therapy in Children with Cerebral Palsy Lena Ekström Ahl et al. 619