Intermittent intensive
rehabilitation programs and the best training method or treat-
physiotherapy in
children with cerebral
palsy: a pilot study
Johanne Trahan MSc PT, Physiotherapist Institut de
réadaptation en déficience physique de Québec;
Francine Malouin* PhD PT, Professor, Department of
Rehabilitation, Faculty of Medicine, Laval University,
Quebec City, Canada.
*Correspondence to second author at Center for
Interdisciplinary Research in Rehabilitation and Social
Integration (CIRRIS), IRDPQ, B: 77, 525, boul. Wilfrid-Hamel,
Quebec City, PQ, Canada, G1M 2S8.
E-mail: Francine.Malouin@rea.ulaval.ca
The aims of the study were: (1) to determine the feasibility of
a rehabilitation program combining intensive therapy periods
(4 times/week for 4 weeks) with periods without therapy (8
weeks) over a 6-month period in severely impaired children
with cerebral palsy (CP); and (2) to measure changes in gross
motor function after intensive therapy periods (immediate
effects) and rest periods (retention). A convenient sample
included five children (two females, three males; mean age
22.6 months [SD 9.9]) with severe forms of CP with
impairment of four limbs and trunk (GMFCS levels IV and
V). A multiple-baseline design was used. Changes in motor
performance were assessed by a blind evaluator using the
Gross Motor Function Measure. Visual and statistical
analyses followed. Level of compliance during intensive
therapy was 93.1%. Children received a mean of 30
treatments over the 24 weeks of the experimental phase
compared with the 48 treatments they would have received
routinely. Increases in GMFM scores (mean 9.2%; range 3 to
15%) were significant in three children (p<0.05) and all
participants maintained their motor performance during the
two 8-week rest periods. Results showed that four treatments
per week over a 4-week period were well tolerated when
separated by rest periods. The intermittent program led to
improvements in motor function that were maintained over
the rest periods. Results underline the need to reconsider the
organization of physical rehabilitation programs. A regime
that is intensive enough without being tiring and one that
provides practice conditions for consolidating motor skills
learned during the intensive therapy period may best optimize
motor training.
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Over the last 15 years, reviews focusing on the effectiveness of
ment regime for promoting motor development for children
with cerebral palsy (CP) have been inconclusive (Parette and
Hourcade 1984, Ottenbacher et al. 1986, Campbell 1990,
Palisano 1991, Turnbull 1993). Turnbull (1993), for example,
in a review of 15 studies concluded that neither a quantita-
tive nor a qualitative analysis had provided evidence for the
effectiveness of early intervention in children with, or at risk
of developing CP. Methodological bias or limitations such as
small samples, inappropriate outcome measures, improper
study design, or lack of standardization of experimental pro-
cedures have been cited to explain the inconclusive results
reported in these studies (Campbell 1990, Palisano 1991,
Turnbull 1993).
Other researchers have suggested that the focus should be
on research questions pertaining to the conditions under
which different interventions are effective (Innocenti and
White 1993) rather than on the types of intervention per se.
It was suggested that the intensity of treatments could be a
key variable in studies examining the efficacy of early inter-
vention. To date, however, experimental studies in which
therapy was provided in variable intensities to groups of chil-
dren have not provided conclusive evidence. While some
studies demonstrated that programs providing a higher fre-
quency of treatments yielded better results (Mayo 1991,
Bower and McLellan 1992, Bower et al. 1996, Richards et al.
1997), others did not (Bower et al. 2001). For instance, it was
reported that children with delayed motor function who
were treated four times a month improved more than chil-
dren treated once a month (Mayo 1991). Conversely, no sig-
nificant differences were found in the gross motor function
scores of children who were treated five times a week over a
6-month period, instead of twice a week (Bower et al. 2001).
Reddihough and coworkers (1991) were unable to measure
any improvement in upper-limb function in a group of 10
children who received four times the amount of therapy nor-
mally provided. Most of these studies raised questions about
the specificity of the effects observed, either because of a lack
of information about the therapy provided (Bower and
McLellan 1992, Bower et al. 1996) or because of methodologi-
cal concerns relative to the outcome measures, the duration of
therapy (Mayo 1991, Reddihough et al. 1991), and the compli-
ance with treatments (Bower et al. 2001).
There is, thus, a need to examine further the conditions of
service delivery. Results from a recent study suggest that an
increase in intensity can have pitfalls and that a higher frequen-
cy of therapy is not necessarily better (Bower et al. 2001).
Children treated five times a week for 6 months showed low
compliance and therapy was considered tiring and stressful by
many participants (Bower et al. 2001). Increasing the frequen-
cy of weekly treatments over a long period is very demanding
for the children and their families and as such, could jeopar-
dize the efficacy of intensive therapy. Thus, a treatment regime
including short periods of enhanced therapy separated by rest
periods could represent a good compromise, especially for
younger children or those with more severe impairments and
low resistance to physical exertion.
This pilot study was designed to: (1) determine the feasibil-
ity of a rehabilitation program combining intensive therapy
periods (4 times/week for 4 weeks) separated by periods
without therapy (8 weeks) over a 6-month period in young
Developmental Medicine & Child Neurology 2002, 44: 233–239 233
 and severely impaired children with CP; and (2) measure the
changes in gross motor function after enhanced therapy peri-
ods (immediate effects) and rest periods (retention).
Method
STUDY DESIGN
A multiple-baseline design was used (Gonnella 1989). With
this design, the duration of the baseline phase varies across par-
ticipants and as such, it provides a clear demonstration that
performance changes when the intervention is introduced.
The design, thus, provided a between-patient control (stag-
gered duration of the baseline) and a within-patient control
(from phase A to B). During phase A (baseline), the children
underwent conventional physical therapy (twice a week). The
duration of phase A ranged from 8 to 20 weeks (staggered base-
line). In phase B (experimental), intensive physical therapy (4
times a week) was provided over a 4-week period (phase Bt)
followed by an 8-week rest period without any treatment
(phase Br). This first sequence of 12 weeks’ duration (Bt1: 4
weeks; Br1: 8 weeks) was repeated (Bt2: 4 weeks; Br2: 8 weeks)
for a total experimental phase duration of 24 weeks (Fig. 1).
Table I: Characteristics of children
Participant Sex Age Diagnosis GMFCS
(mo) levela
PARTICIPANTS
To be included in the study children had to: (1) be enrolled
in a rehabilitation program at the Institut de réadaptation en
déficience physique de Québec, Canada; (2) have a diagnosis
of CP (as defined by Bax, 1964: ‘a neurodevelopmental
impairment caused by a non-progressive defect or lesion in
single or multiple locations in the immature brain’ p 295) of
either spastic, athetoid, spastic–athetoid, or ataxic form con-
firmed by a neurologist; and (3) have a severe form of CP
with impairment of the four limbs and trunk. We excluded
children who were candidates for surgery or with any other
conditions that could potentially modify the rehabilitation
program. These criteria were chosen to produce a homoge-
neous sample of children with severe impairment. Parents of
the participants signed an informed consent form approved
by the ethics committee of the rehabilitation center.
Three males and two females (mean age 22.6 months, SD
9.9) participated in the study. Characteristics of the children
at baseline are given in Table I. Three children had a diagnosis
of quadriplegia while two were classified as having double
hemiplegia. Initial GMFM total scores ranged from 9.4 to
39.2% indicating severe motor impairment. Except for child 2
(level V), all children were able to roll from prone to supine
and vice versa (level IV). All children, however, were able to
hold the sitting position on the floor when supported at the
thorax by the therapist. Only three children (1, 4, and 5)
Baseline total could crawl 1.8 m. None was able to stand, even with support.
GMFMb score
(%)c TYPE OF THERAPY

1 M 18 Quadriplegia IV 22.2 Physical therapy (PT) (in phases A, Bt1, and Bt2) consisted of an
2 F 24 Quadriplegia V 9.4 individual session of 45 minutes. PT administered throughout
3 M 10 Quadriplegia IV 21.9 the study by the children’s treating physiotherapist, was the
4 F 37 Double hemiplegia IV 34 regular therapy based on the neurodevelopmental approach
5 M 24 Double hemiplegia IV 39.2 described by Mayston (1992). This approach uses techniques
Mean 22.6 25.3 of handling to guide the child’s movements with carefully
SD 9.9 11.6 graded stimulation. The rehabilitation program of all chil-
a Gross Motor Function Classification System (Palisano et al. 1997). dren also included occupational therapy (OT), which focused
b Gross Motor Function Measure (Russell et al. 1989). c Mean baseline on the upper-extremity function (manipulation, prehen-
evaluation scores. sion), hand–eye coordination tasks, and perceptual training.

Figure 1: Study design.

Phase A Phase B Phase A, staggered
baseline; Phase B,
Treatments Treatments treatment and rest.
Bt1 Br1 Bt2 Br2 Bt1, first treatment
2x/wk phase; Br1, first rest
4x/wk 0x/wk 4x/wk 0x/wk
phase; Bt2, second
8 treatment phase; Br2,
4 8 4 8 second rest phase.
12

16

20 12 12

Weeks Weeks
Baseline Experimental

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 OT treatments followed a schedule similar to that set for the used transportation services provided by the center. During
PT treatments. During the therapy periods, treatments were phase Br, when all treatments (PT and OT) were discontin-
carried out at the rehabilitation center and children generally ued, the children did not come to the center and parents

Child 1 Child 2
40 20
35

30 15
35
GMFM (%)

GMFM (%)
20 10
15

10 5
5

0 0
0 4 8 4 8 12 16 20 24 0 4 8 12 16 4 8 12 16 20 24
Phase A Phase B Phase A Phase B
Weeks Weeks

Child 3 Child 4

40 40

35 35

30 30

35
GMFM (%)

35
GMFM (%)

20 20

15 15

10 10

5 5

0 0
0 4 8 12 4 8 12 16 20 24 0 4 8 12 16 20 4 8 12 16 20 24
Phase A Phase B Phase A Phase B
Weeks Weeks

Child 5
60
Figure 2: Individual GMFM scores for Phases A
50
and B. ■, treatment 2x/week; ●, treatment
4x/week; !, no treatment each week.
40
Each data point represents total GMFM value
recorded at each assessment over course of
GMFM (%)

30
study. Horizontal dashed lines represent ±2SD
from mean (continuous line) baseline values. A
20
statistically significant (p<0.05) change has
occurred when two successive observations
10
(data points) during experimental phase fall
outside 2SD band.
0
0 4 8 12 4 8 12 16 20 24
Phase A Phase B
Weeks

Intermittent Physiotherapy in CP Johanne Trahan and Francine Malouin 235

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 were given general advice without a specific home program.
Children who used a special positioning device (e.g. for the
wheelchair) continued to use it. Parents were instructed to
contact the treating physical therapist if the child’s condi-
tion showed any signs of deterioration. Parents were also
asked to refrain from initiating any replacement therapy
(such as hydrotherapy) during the rest phase.
OUTCOME MEASURE
The main outcome measure was the GMFM: a test designed to
measure the gross motor function of children under 5 years of
age. This test includes 88 items grouped in five dimensions: (A)
Lying and Rolling; (B) Sitting; (C) Crawling and Kneeling; (D)
Standing, and (E) Walking, Running, and Jumping. Each item
of the test is scored on a 4-point Likert scale and a percentage
score is calculated for each dimension. The total score is
obtained by calculating the mean of the five dimension scores.
The total GMFM score and dimension scores collected at each
evaluation were used in the analysis. The children’s motor
functional status was also classified according to the Gross
Motor Function Classification System for Cerebral Palsy
(Palisano et al. 1997).
The same physical therapist, trained in the use of the GMFM
test procedure, assessed the children every 4 weeks. The thera-
pist did not know the children, was unaware of the aims of the
study, and was not provided with the scores from previous
assessments. Assessments took place at the rehabilitation cen-
ter in the usual treatment room and always at the same period
of the day. Testing conditions were standardized according to
the protocol developed by Russell and coworkers (1989).
Variables such as age and sex were collected at baseline.
DATA AND STATISTICAL ANALYSES
A two-component (stability level and trend) visual analysis
followed by a statistical analysis were performed. Stability
level refers to the amount of variability or to the range of
data-point values in phase A. Data points were said to be sta-
ble if 80% fell within a 20% range of the mean level of all data
point values in phase A. Trend refers to the direction of the
data points and a freehand method was used to estimate if
the data path indicated improvement or worsening of the
performance (Tawney and Gast 1984). Statistical significance
was established with the standard deviation band method
(Gottman and Leiblum 1974, Ottenbacher and York 1984).
This method consists of computing the mean and 2 standard
deviation values of baseline data (phase A). Then, a horizon-
tal band representing ±2SD from the mean baseline and
extending into the experimental phase (phase Bt and Br) is
traced. If at least two successive observations (data points)
during the experimental phase fall outside the band, then a
statistically significant change has occurred. The chance of a
data point occurring outside the 2SD band without real
change taking place is less than 5% (p<0.05).
Results
BASELINE PHASE
Figure 2 illustrates the total GMFM scores for each child
recorded at each evaluation during phase A and phase B. The
total number of treatments received during the multiple base-
line in phase A, ranged from 15 to 36 and the treatment com-
pliance during the baseline phase (Table IIa) ranged from
93.8% (child 1) to 70.8% (child 5). As can be seen from the
data points in Figure 2, the motor performances of three chil-

Table IIa: Number and % of treatments and compliance Table IIb: Mean number of
weekly treatments
Participant Phase A Phase Bt1 Phase Bt2 Mean B1&2
Duration Treatments Compliance Compliance Compliance Compliance Participant Phase A Phase B
(wk) R E % % n % n % (Bt and Br)

1 8 15 16 93.8 100 16 93.7 15 96.9 1 1.88 1.29

2 16 26 32 81.3 87.5 14 93.7 15 90.6 2 1.63 1.21
3 12 19 24 79.2 100 16 100 16 100 3 1.58 1.33
4 20 36 40 90 93.7 15 93.7 15 93.7 4 1.80 1.25
5 12 17 24 70.8 93.7 15 75 12 84.4 5 1.42 1.13
Mean 13.5 22.6 27.2 83 95 15.2 91.2 14.6 93.1 Mean 1.66 1.24
SD 4.6 8.6 9.1 9.1 6.5 0.84 6.5 1.5 6 SD 0.18 0.08

R, received; E, expected; Bt1, first treatment phase; Bt2, second treatment phase. Bt, treatment phase; Br rest phase.

Table III: Mean total GMFM scores (%) during phases A and B

Participant Phase Aa Phase Bt1 Phasea Br1 Phase Bt2 Phasea Br2 Maximal increase

1 22.2 (1.3) 27 29.3 31.9 30.7 9.7

2 9.4 (2) 9.3 10.3 12.4 12.3 3
3 21.9 (4.4) 28.7 29.8 37.5 36.9 15.6
4 34 (2.3) 39.4 36.8 37.1 37.7 3.7
5 39.2 (5.2) 50.4 49.8 53.3 51.9 14.1
Mean 25.3 31 31.2 34.4 33.9 9.2
SD 11.6 15.3 14.3 14.7 14.4 14.4
a Mean (1SD) scores; Bt1, first treatment phase; Br1, first rest phase; Bt2, second treatment phase; Br2, second rest phase.

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 dren (1, 4, and 5) were considered stable as 80% of their four treatments a week over a 4-week period can be very well
baseline data points fell within 20% of the mean value. The tolerated. Second, increases in the GMFM scores ranging from
motor performance of child 2 was considered variable when 3 to 15% indicate that children with severe motor impairment
all data points were included, but not when the first data can improve their gross motor function. Third, a very com-
point was left out, indicating a stabilization trend over time. pelling finding was the maintenance of improved motor per-
The more variable motor performance of child 3 also tended formance during the two 8-week rest periods.
to decrease with time.
FEASIBILITY
EXPERIMENTAL PHASE This pilot study provides evidence that increasing the number
Mean (SD) number of treatments received during the experi- of treatments from two to four times a week over per 4-week
mental phase was 30 (SD 1.9). This value corresponds to a period is well tolerated by young children with CP who have
compliance level of 93.1% during intensive therapy with the severe impairment. In fact, the level of compliance increased
majority of children (n=3) attending at least 30 of the expected from 83 to 93.1% when children received twice as many treat-
32 therapy sessions (Table IIa). During the 24 weeks of the ments weekly and reasons for missing treatments were inde-
experimental phase, the children received a mean of 1.2 week- pendent of the child (e.g. transportation problems or absence
ly treatments (Table IIb), which is less compared with the base- of therapist); only child 5 missed one treatment for health rea-
line phase with a mean of 1.7 treatments. Had they followed sons. According to the parents, intensive therapy periods were
the usual therapy program, children would have received 48
treatments (24 weeks × 2/week) over a 24-week period.
All children showed some increase in their total GMFM
Table IV: Change in motor performance in each GMFM
scores at the end of the experimental phase (see Fig. 2 and
dimension score
Table III) but improvement of performance was significant
(p<0.05) in only three (children 1, 3, and 5). The two other Child Dimensions
children showed very little improvement, with total GMFM A B C D E
scores remaining usually below the 2SD line. No child
showed a deteriorating trend during the experimental 1 = ∨ ∨ ∨ ∨
phase. A closer examination of the motor performance (see 2 = = = = ∨
Table III and Fig. 3) after the first intensive therapy period 3 = ∨ ∨ = ∨
(Bt1) indicates that increases in the total GMFM scores 4 = = = = ∨
ranged from 4.8 to 11.2% in four (children 1, 3, 4, 5) with 5 = ∨ ∨ ∨ ∨
only one (child 2) without any change. Note that after the
first rest period (Br1), the total GMFM scores from three =, GMFM dimension score did not change significantly; ∨, GMFM
(children 1, 2, and 3) continued to slightly increase (1 to dimension score increased significantly (>2SD line or p<0.05).
A, Lying and Rolling; B, Sitting; C, Crawling and Kneeling; D, Standing;
2.2%) while in the other two (children 4 and 5) it slightly
E, Walking, Running, and Jumping.
decreased (2.6% and 0.6%). The changes after the period
without therapy were not significant, indicating that the
motor performance had not deteriorated nor continued to
significantly improve after the first rest period. Motor per-
formance during the second period of intensive physical 16
therapy (Bt2) continued to improve with changes in the total
14
GMFM scores (from baseline) ranging from 3 to 15.6%.
When treatments were suspended a second time (Br2) the 12
GMFM scores (%)

total GMFM scores again remained generally stable; they

slightly decreased in four children (range from 0.1 to 1.4%) 10
and increased 0.6% in another (child 4) indicating again that
8
the improved motor performance was maintained during
the second rest period. Over the 24-week period the maxi- 6
mal increase in total GMFM scores ranged from 3 to 15.6%
4
(see Fig. 3 and Table III).
Table IV gives a summary of individual changes for each 2
dimension of the GMFM at the end of the experimental phase.
0
Note that significant improvement of performance was found
Bt1 Br1 Bt2 Br2
in all children in the walking with support task of dimension E,
conversely, the performance remained unchanged for dimen-
sion A. Significant changes were found in two children for Figure 3: Changes in total GMFM scores during
dimension D and in three for dimensions B and C. experimental phase for children 1 to 5. Mean baseline
values were used in calculation of change score. Bt1&2 :
Discussion represent changes after 4 weeks of intensive therapy
Results of this study confirm the feasibility a rehabilitation (4/week) and Br1&2 : represent scores after 2 months
program comprised of short intensive therapy periods fol- without therapy. , child 1; ■, child 2; !, child 3; , child
lowed by longer rest periods. First, the high level of compliance 4; , child 5. Bt1, first treatment phase; Br1, first rest phase;
during both intensive treatment periods demonstrates that Bt2, second treatment phase; Br 2, second rest phase.

Intermittent Physiotherapy in CP Johanne Trahan and Francine Malouin 237

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 generally well tolerated by the children. The parents of child 1
and child 2 (with the most severe disabilities), admitted that
their child needed more rest by the end of the experimental
phase, but it did not reduce their collaboration, nor interfere
with their compliance which remained over 90%. These obser-
vations, however, suggest that intensive therapy should proba-
bly not be prolonged for periods longer than 4-weeks at a time
in children with more severe disabilities. The low level of com-
pliance (median of 73%) and complaints of fatigue and stress
by the participants when intensive therapy (5/week) was pro-
vided over a 6-month period (Bower et al. 2001) further sup-
port the idea that intensive therapy for a very long period is not
necessarily better than routine therapy.
MOTOR PERFORMANCE
Increasing the frequency of treatments, from twice a week to
four times a week, improved the level of motor performance
as measured with the total GMFM scores. Such findings sup-
port the idea that more intensive therapy can accelerate motor
skill acquisition of severely impaired children with CP. Present
results are in agreement with findings from others (Mayo
1991, Bower and McLellan 1992, Bower et al. 1996) who also
observed more gains with a higher treatment frequency.
Earlier, we observed a mean GMFM gain of 6.2% (SD 7.5%)
over an 8-month (32-week) period in a group of 24 children
with quadriplegia who were treated twice a week (Trahan and
Malouin 1999) for a total of 64 treatments. In comparison,
children in the present study had a mean gain of 9.2% (SD
5.8%) over a 6-month period with half the number of treat-
ments suggesting that combining enhanced therapy periods
with rest periods can optimize the effects of therapy.
The rate and magnitude of gains, however, varied markedly
across children, with the best gains in children 1, 3, and 5 (9%,
13%, and 15%, respectively) and smallest (3%) in the two oth-
ers. Poor collaboration and severity of impairment are two fac-
tors that, in part, explain the small changes in children 2 and 4.
Child 2 had the most severe impairments (mean baseline
GMFM 9.4%), supporting the slower rate of change in gross
motor function (Russell et al. 1990). With child 4, although
the oldest, there were problems in keeping her focused and
maintaining her collaboration during therapy throughout
the study.
RETENTION OF GAINS
All the children increased their total GMFM score and none of
the children had a score lower than their mean baseline score
during the whole experimental phase (Fig. 3). Such findings
indicate that the motor performance did not deteriorate
despite the two 8-week rest periods even without a home ther-
apy program. Unlike other studies (Bower and McLellan 1992,
Bower et al. 2001) which reported some deterioration with
therapy cessation or reduction, the level of performance never
markedly decreased. On the contrary, in most children the total
GMFM scores continued to increase. Such results raise the pos-
sibility that the child’s daily activities in their natural environ-
ment provided practice conditions that contributed to the
development of motor skills and promoted the consolida-
tion of skills learned during therapy sessions. Such findings
are consistent with increasing evidence to the effect that
repetition of meaningful tasks (Dean and Shepherd 1997, Carr
and Shepherd 1998) and variable practice (Gentile 1987,
Schmidt 1988) can promote retention.
238 Developmental Medicine & Child Neurology 2002, 44: 233–239
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ADVANTAGES AND DISADVANTAGES OF INTERMITTENT THERAPY
Varying the frequency of treatment delivery with blocks of
intensive therapy alternating with rest periods provided advan-
tages of a different nature. The main advantage reported by the
therapists was that seeing the child almost daily during the
intensive therapy phase had positive effects on the interaction
and communication with the child and family. They felt that it
was easier to develop and maintain a good relationship with
the child. Moreover, as the child made progress, short-term
goals could be adapted regularly on a day-to-day basis. Such
observations suggest that therapy on a more regular basis
helped in establishing a stronger child–therapist interaction,
which by increasing the quality of the time spent with the child,
may have contributed to the optimization of the treatment.
Another advantage reported by both parents and therapists
was the beneficial effect of the rest periods. At the beginning of
the study, the parents and the therapists were concerned that 8
weeks without therapy would result in a deterioration of the
child’s motor performance. Once they realised that such was
not the case, they felt more confident and parents were able to
take advantage of the periods without therapy to enjoy a less
stressful and more normal family lifestyle.
The third advantage was economic in nature. Present results
showed that the motor performance of all children increased
from phase A to B even with a lower mean number of weekly
treatments in the experimental phase (Bt and Br) indicating
the rate of treatment delivery to be more critical than the num-
ber of treatments. This is a most crucial finding given the limit-
ed human and financial resources in most health systems. In
the present economic context, wherein treatment benefits ver-
sus costs are questioned and where therapists have to provide
optimum therapy with less resources, the proposed regime of
care delivery deserves further consideration.
The main disadvantage with the proposed treatment regime
was organizational. The scheduling of treatments was more
difficult when children had appointments in other services.
Increasing the frequency of treatments over a given period and
cancelling them for the next period also required much collab-
oration from the persons involved with the transportation.
LIMITATIONS
Although the multiple-baseline design provided an interest-
ing means of monitoring the progress on an individual basis,
changes observed cannot be attributed solely to the treat-
ment regime under study. Without a control group, the natur-
al variation of the motor performance cannot be controlled,
however, the multiple-baseline design provided a way to
monitor the stability of the measures before the experimental
phase and the variations of measures during the baseline
period were taken into account in the data analysis. Within
these limitations, it was shown that three children demon-
strated significant improvement, but two did not. Severe
motor impairment could be responsible for the lack of signif-
icant improvement in these children and observations over a
longer period may be needed to detect significant changes in
children with more severe impairment. The small sample size
and the homogeneity of the group must be taken into consid-
eration and present results need to be replicated in a larger
sample of children. The actual treatment regime may be well
tolerated by children with less severe impairment and it would
be of interest to measure the benefits of intermittent physio-
therapy on the development of their motor performance.
 Last, results indicate that when PT and OT treatments were
discontinued, the performance of the children did not deteri-
orate. Although parents were not given a specific home pro-
gram, there is always the possibility that parents spent more
time playing and interacting with their child during the off-
treatment periods. Thus, in future studies, daily activities of
the children should be monitored (for example, using a log
book) during the periods with and without PT and OT treat-
ments. Such information would indicate if the parents tend
to replace formal treatments by modifying daily activities dur-
ing the off-treatment periods.
Conclusions
In conclusion, this pilot study showed that children with severe
impairments who had quadriplegia improved their motor per-
formance when short periods of high treatment frequency
alternated with longer periods of rest. The short periods of
intense therapy were well tolerated and the motor perfor-
mance of the children did not deteriorate during the rest peri-
ods without therapy. This pilot study highlights the need to
reconsider the way physical rehabilitation programs are orga-
nized, as more does not seem better than less. Sequences of
short intensive therapy periods alternating with longer rest
periods seem to optimize the effects of motor training. Thus,
the best treatment regime may be a program that is intensive
enough without being tiring and that can provide the child
with practice conditions for consolidating the motor skills
learned during intensive therapy.
Accepted for publication 28th September 2001.
Acknowledgements
The authors wish to thank the clinicians, the participants, and their
families. We extend our thanks to Dr CL Richards for the critical
reading of the manuscript and Mr Daniel Tardif for the preparation
of the figures. This work was supported by the Consortium de
recherche en réadaptation de l’est du Québec from the Fonds de
recherche en santé du Québec (FRSQ).
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