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 designed2 .
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 participation2 .
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 .
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 .
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 .
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 )
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 .
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 .
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 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 .
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 .
spearman s correlation test was used to 
 assess the correlation between cp type and mental condition .
however , 15 patients were 
 excluded from the study and the results of only the remaining 28 patients were evaluated . 
 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 
 6.962.82  years ) , 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 2table 1 .
classification of our cp patients ( according to european cp follow - up 
 group)1sp type ( new classification)n%spastic bilateral2071.43spastic unilateral414.29dyskinetic27.14mixed27.1428100table
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 
 3table 3 .
identification of the problem and rehabilitation starting time in cp 
 patientsn%identification of the problem before 12 months of 
 age2071.4identification of the problem after 12 months of 
 age828.6starting rehabilitation before 12 months of age932.14starting rehabilitation after 12 months of age1967.86 ) . of the 28 patients ,
these were the most frequent findings , followed by 
 strabismus and optic disc paleness which is a retinal examination finding ( table 4table 4 .
diagnosis of cp patients after eye examinationdiagnosissub - group diagnosisnrefraction defecthypermetropia14myopia4astigmatism12strabismusesotropia4exotropia3pale optic disc6otheroptic nerve coloboma1traumatic optical atrophy1 ) .
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 .
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 ) .
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 5table 5 .
comparison of gmfm scoresgmfm total scoremeansdp valueadmission34.0228.950.002*discharge41.0828.55admission34.0228.950.001 * 1 month follow - up39.6226.50admission34.0228.950.001 * 3 month follow - up40.3527.02discharge41.0828.550.006 * 1 month follow - up39.6226.50discharge41.0828.550.007 * 3 month follow - up40.3527.021 month follow - up39.6226.500.0963 month follow - up40.3527.02*p<0.01 ) .
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 , walking  running  jumping 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 patient s mother , while the caregivers in 
 4 cases ( 14.29% ) were other relatives ( aunt , grandmother , stepmother ) .
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 problems 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 .
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 children s 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 ,
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 .
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 child s problem .
although 71.4% of the 
 patients were identified with problems in the first year of life , only 31.4% started 
 rehabilitation in the first year .
, 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 ,
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 .
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
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 incidence of mental retardation 
 was reported as 3050%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 involvement16,17,18,19 . 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 .
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 .
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 ,
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 .
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
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 .
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 literature contains other studies that included participants 
 with different gmfcs levels and different types of cp24 .
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 .
   [ 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 . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION