PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

2020, VOL. 40, NO. 1, 18–30

https://doi.org/10.1080/01942638.2019.1642287

Effect of Group-Task-Oriented Training on Gross and Fine

Motor Function, and Activities of Daily Living in Children
with Spastic Cerebral Palsy
Eun Jae Koa , In Young Sungb , Hye Jin Moonb, Jin Sook Yukc, Heung-Su Kimc,
and Nam Hyun Leec
a
Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan
College of Medicine, Ulsan, Republic of Korea; bDepartment of Rehabilitation Medicine, Asan Medical
Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; cDepartment of Rehabilitation
Medicine, Asan Medical Center, Seoul, Republic of Korea

ABSTRACT ARTICLE HISTORY

Aims: To determine the effects of group-task-oriented training Received 3 December 2018
(group-TOT) on gross and fine motor function, activities of daily living Accepted 6 July 2019
(ADL) and social function of children with spastic cerebral palsy (CP).
KEYWORDS
Methods: Eighteen children with spastic CP (4–7.5 years, gross motor
Cerebral palsy; children;
function classification system level I–III) were randomly assigned to group therapy;
the Group-TOT (9 children received group-TOT for 1 hour, twice a rehabilitation therapy;
week for 8 weeks) or the comparison group (9 children received indi- task oriented
vidualized traditional physical and occupational therapy). The Gross
Motor Function Measure (GMFM)-88, the Bruininks-Oseretsky Test of
Motor Proficiency 2nd edition (BOT-2), and the Pediatric Evaluation of
Disability Inventory (PEDI) were administered before and after the
intervention, and in the Group-TOT, 16 weeks after the intervention.
Results: Children in the Group-TOT showed significant improve-
ments in the GMFM-88 standing and walking/running/jumping sub-
scales, the BOT-2 manual dexterity subscale, and the PEDI social
function subscale (p < 0.05); changes were maintained 16 weeks after
the intervention ended. In contrast, the comparison group improved
in only the BOT-2 fine motor integration subscale (p < 0.05).
Conclusions: The findings provide evidence of effectiveness of
group-TOT in improving gross and fine motor function, and social
function in children with CP.

Cerebral palsy (CP) is described as a group of disorders attributed to the nonprogressive

disturbances that occur in the developing fetal or infant brain, which impact develop-
ment of movement and posture, causing activity limitations (Bax et al., 2005). The
prevalence has remained at 2–3.5 cases per 1,000 livebirths for the past 40 years despite
improvements in antenatal and perinatal care (Colver, Fairhurst, & Pharoah, 2014).
Affected individuals show muscle weakness, spasticity, lack of functional abilities,
reduced gross and fine motor abilities, and limitations in activities of daily liv-
ing (ADL).

CONTACT In Young Sung iysung@amc.seoul.kr Department of Rehabilitation Medicine, Asan Medical Center,
University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
This article has been republished with minor change. This change do not impact the academic content of the article.
ß 2019 Taylor & Francis Group, LLC
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 19

Many of the traditional neuro-rehabilitative approaches focus on the management of

impairments and normalization of the quality of movements by establishing and elicit-
ing normal patterns of movement through controlled sensorimotor experiences.
However, impairment improvements are not guaranteed for these children with disabil-
ities (Barbeau & Fung, 2001; Helders, Engelbert, Gulmans, & van der Net, 2001).
Modern concepts of motor learning focus on functionality and indicate that training
is most effective when the training task is specific for the intended outcome, as optimal
improvement in function involves the practice of task-specific activities (Bayona,
Bitensky, Salter, & Teasell, 2005; Blundell, Shepherd, Dean, Adams, & Cahill, 2003;
Schmidt & Timothy, 2005). Task-oriented training (TOT), which emerged in the early
1990s, emphasizes tasks that mimic the performance of functional activities, and focuses
on the role of the environment (M, 1999). Adaptation to changes in the environment,
exploration and selection of movements to find methods to perform tasks are important
features in TOT which is based on the active view of motor learning. People learn by
actively attempting to solve the problems related with functional tasks rather than prac-
ticing normal patterns of movement repetitively (Ketelaar, Vermeer, Hart, van Petegem-
van Beek, & Helders, 2001). Repetition alone, without usefulness or meaning in terms
of function, is not sufficient to produce increased motor cortical representations
(Bayona et al., 2005). In this approach, the task of the therapist is to provide an envir-
onment which leads the child to learn to perform self-initiated actions within natural
occurring restraints (RB, 1995).
Previous studies provided a form of TOT or functional therapy for children with CP.
Ketelaar et al., (2001) investigated the effects of 4 sessions (3 hours each) of a functional
therapy program for 28 children with mild or moderate CP. After establishment of
functional goals, repetitive practice of the problematic motor abilities in functional sit-
uations was performed at home, outdoors, or at clinics. They showed that this therapy
program, when contrasted to that of a comparison group of 28 children, significantly
improved the self-care and mobility subscales of the Pediatric Evaluation of Disability
Inventory (PEDI), but not the standing and walking/running/jumping domains of Gross
Motor Function Measure (GMFM)-88. Salem and Godwin, (2009) showed that TOT,
twice weekly for 5 weeks, resulted in the improvement of the mobility function in chil-
dren with CP in Gross Motor Function Classification System (GMFCS) level I–III, using
the GMFM and the Timed “Up and Go” (TUG) test. TOT in this study consisted of
activities which were similar to those children perform everyday such as sit-to-stand
transitions, walking, and stairs climbing, and it was performed at a clinic. Ahl,
Johansson, Granat, and Carlberg, (2005) examined the effects of a 5-month functional
training program in 14 children with CP (GMFCS level II–IV). The therapy goals were
discussed with parents, preschool assistants, and the children (for example, to stand up
from the toilet and walk to the bathroom sink), and the goal-directed functional therapy
was carried out at home and at preschool. The functional training significantly
improved GMFM scores and the ability to perform daily activities. Moon, Jung, Hahm
and Cho (2017) showed the effect of 20 minutes of TOT twice a week for 4 weeks in 6
children with spastic hemiplegic CP (GMFCS level I–II). The tasks were carried out at a
clinic and focused on improving upper limb functions: reaching, ring activity, and
stacking cups to catch the target using a paretic hand. After the intervention, the TOT
20 E. J. KO ET AL.

group showed a significant improvement of hand dexterity, but the comparison group
did not. Prior study limitations included: (1) focusing on gross motor function only
(Salem & Godwin, 2009), or gross motor function and ADL (Ahl et al., 2005; Ketelaar
et al., 2001), or fine motor function (Moon et al., 2017); (2) a study by Ahl et al. (2005)
did not have a control group; and (3) some studies (Ahl et al., 2005; Moon et al., 2017;
Salem & Godwin, 2009) did not have follow-up evaluations.
The introduction of group therapy to rehabilitation treatment appears to increase
motivation and exercise performance through aspects such as behavior modeling
(Barlow, Macey, & Struthers, 1993). Group therapy is believed to assist in social devel-
opment and problem solving through multiple relationships and feedback from others,
making therapy fun rather than laborious (Blundell et al., 2003). Furthermore, it allows
children to apply new skills in a social setting and allows therapists to assess children’s
abilities and evaluate challenges (A. LaForme Fiss, 2012). This valuable peer contact and
interaction has benefits in increased service accessibility and parents were satisfied with
group therapy (Camden, Tetreault, & Swaine, 2012). Furthermore, motor function
improvements were found in 8 weeks of group therapy in 12 children with developmen-
tal coordination disorders (Hung & Pang, 2010) and 10 weeks of group therapy in 5
children with Down syndrome (LaForme Fiss, Effgen, Page, & Shasby, 2009). Therefore,
if children with CP receive TOT in groups, it may be more effective and cost-efficient
compared to receiving individualized traditional rehabilitation therapy. A limited num-
ber of studies have previously discussed the effect of group-task-oriented training
(group-TOT) in children (Blundell et al., 2003; Crompton et al., 2007); however, these
lacked appropriate control groups.
The purpose of this study was to evaluate the effects of group-TOT on gross and fine
motor function, ADL, and social function, compared to the effects of individualized
traditional rehabilitation therapy in children with CP.

Methods
Study Design
This study was approved by the Ethical Committee of Asan Medical Center (reference
number: 2008-0234), and the trial has been registered at the Clinical Research
Information Service (reference number: KCT0003550). Written informed consent was
provided for all participants before data collection began.
Children who visited the outpatient clinic of the Pediatric Rehabilitation Medicine
Division at Asan Medical Center from February 2009 to December 2009 were assessed
for inclusion in the study according to the following criteria: (1) a diagnosis by a pedi-
atric physiatrist of spastic CP; (2) between 4 and 7.5 years of age; (3) classified as
GMFCS (Palisano et al., 1997) I–III; (4) understand Korean and were able to follow 1-
step verbal instruction; (5) previously participated in a traditional rehabilitation pro-
gram; and (6) a caregiver provided written informed consent. Exclusion criteria were as
follows: (1) poor medical conditions preventing participation in the group-TOT; and (2)
surgical procedures or chemical nerve block therapy performed in the year prior to
the study.
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 21

Randomization and Blinding

Children were randomly assigned to the Group-TOT or comparison groups by a differ-
ent person from the one doing the recruitment and physical therapy treatments. All
children were aware of their treatment allocation. However, one physical therapist and
one occupational therapist involved in the evaluation and the two investigators who
conducted the study were blinded to the treatment allocation.

Participants
Eighteen children who met the inclusion criteria were randomized to the Group-TOT
and comparison groups. All the children attended all sessions, and there were no absen-
ces. Baseline characteristics of the children in the Group-TOT and comparison groups
are given in Table 1. The mean age of the Group-TOT group was 4.9 ± 1.1 years, and
there were five males and four females. The Group-TOT group consisted of one child
with unilateral and eight with bilateral spastic CP; one child was classified as GMFCS
level I, six as GMFCS level II, and two as GMFCS level III. The mean age of the com-
parison group was 5.1 ± 1.5 years, and there were four males and five females. The com-
parison group consisted of four children with unilateral and five with bilateral spastic
CP; three children were classified as GMFCS level I, four as GMFCS level II, and two as
GMFCS level III. When comparing the above baseline characteristics, there was no stat-
istically significant difference between the two groups; however, there were more chil-
dren classified as GMFCS level II in the Group-TOT group than in the comparison
group (6 vs. 4), and less children classified as GMFCS level I in the Group-TOT group
than in the comparison group (1 vs. 3).

Outcome Measurements
Children were evaluated by experienced physical and occupational therapists at baseline
(pretreatment, period A) and immediately following the 8 weeks of Group-TOT (post-
treatment, period B) in both groups. An additional evaluation was conducted at follow-
up (16 weeks after the Group-TOT ended, period C) only in the Group-TOT group.
The outcomes were assessed using the GMFM-88 (Bjornson, Graubert, &
McLaughlin, 2000; Russell et al., 2000) for gross motor function; the Bruininks-
Oseretsky Test of Motor Proficiency 2nd edition (BOT-2) (Robert, Bruininks, Brett, &
Bruininks, , 2005) for fine motor function; and the PEDI (Haley SM, 1992) for ADL.
The GMFM-88 (Bjornson et al., 2000; Russell et al., 2000) (scored as 0– 100) is a

Table 1. Baseline characteristics of the Group-TOT and comparison groups.

Group-TOT group (n ¼ 9) Comparison group (n ¼ 9)
Age (years) 4.9 ± 1.1 5.1 ± 1.5
Male: Female 5:4 4:5
Unilateral CP: Bilateral CP 1:8 4:5
GMFCS I: II: III 1:6:2 3:4:2
Values are presented as mean ± standard deviation or number. CP: Cerebral palsy; GMFCS: Gross motor function classifi-
cation system.
None of the baseline characteristics were significantly different between the Group-TOT and the comparison groups
(p > 0.05 by the Mann-Whitney U test or the Fisher’s exact test).
22 E. J. KO ET AL.

standardized observational instrument designed and validated to measure changes in

gross motor function over time in children with CP. It consisted of 88 items grouped
into 5 subscales: (1) lying and rolling; (2) sitting; (3) crawling and kneeling; (4) stand-
ing; and (5) walking, running, and jumping. BOT-2 (Robert et al., 2005) is a compre-
hensive, judgement-based, standardized instrument measuring gross and fine motor
skills in patients between 4 and 21 years of age, which has good internal consistency
and excellent test-retest reliability. To evaluate fine motor control, only some subscales
of the BOT-2 were used: (1) fine motor precision (7 items, scored as 0–41); (2) fine
motor integration (8 items, scored as 0–40); and (3) manual dexterity (5 items, scored
as 0–45). The PEDI (Haley, Ludlow, Haltiwanger, & Andrellos, 1992) measures the
functional capacity and performance of children between 6 months and 7.5 years of age
in three subscales: (1) self-care; (2) mobility; and (3) social function. It has evidence of
very good reliability, validity, and responsiveness (Berg, Jahnsen, Froslie, & Hussain,
2004; Vos-Vromans, Ketelaar, & Gorter, 2005; Wright, Boschen, & Jutai, 2005). In add-
ition, data on age, sex, type of CP (unilateral spastic or bilateral spastic), and GMFCS
levels (Palisano et al., 1997) were collected.

Intervention
The experimental group consisted of 2–4 children, and therapy included 1-hour sessions
twice a week over a period of 8 weeks in a clinic under the supervision of both a pediat-
ric physical therapist and a pediatric occupational therapist. The group-TOT was based
on the following principles: 1) functional goal-directed training, implying a focus on
practicing specific activities of importance to the child during daily activities (Ketelaar
et al., 2001; Valvano, 2004); 2) cooperation between the group members; 3) planning
activity-focused interventions by adapting recent knowledge of motor learning to the
child’s individual learning strengths and needs (Valvano, 2004); and 4) allowing for the
interest and participation of the children.
Because children had different problems in performing functional performances,
functional goals were discussed with children and their caregivers. For example, chil-
dren had different problems, such as jumping over lines, picking up and throwing balls,
playing with balloons, reaching in different directions, picking up coins, playing with
beads, closing the button and the zip of a jacket, cutting paper with scissors, standing
up from a chair, walking forward, backward, and sideways, or turning around in circles.
They wanted to achieve different goals. Therefore, after establishing individual goals
and objectives for each child, children with similar goals and objectives were grouped as
one group according to their activity levels. When doing the activities, children helped
each other to achieve the goals, and they interacted verbally. To imitate natural situa-
tions outside the clinic, goals were practiced in various settings and children were
encouraged to accomplish the tasks. When the children had difficulty completing tasks,
the pediatric physical therapist and the pediatric occupational therapist, who were
highly experienced in managing children with CP, assisted them and gave
them feedback.
The comparison group received individualized traditional rehabilitation therapy, and
it was based on the principle of normalization of the quality of movement, rather than
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 23

function. It consisted of 30 minutes of physical therapy and 30 minutes of occupational

therapy consecutively, on the same day. The total number of sessions and the duration
of the treatment sessions with the children were the same in both groups. During the
study, children in the Group-TOT and comparison groups did not change their sched-
ule of school and community activities.

Data Analysis
Data were analyzed using SPSS for Windows version 18.0 (SPSS Inc, Chicago, IL, USA),
and mean and standard deviations were obtained with a threshold for statistical signifi-
cance set at p < 0.05. To compare the baseline characteristics of the two groups, the
Mann-Whitney U test and Fisher’s exact test were used. The Wilcoxon signed rank test
was used to compare the pre- and post-treatment measurements of the two groups, and
the effect size (r) was calculated using an equation: r ¼ pZffiffiffi
N
(r: effect size, Z: Z-value, N:
total number of observations) (Grande, 2015). r ¼ 0.10 is considered a small effect size,
0.30 represents a medium effect size, and 0.50 a large effect size. The Mann-Whitney U
test was used to compare changes in measurements between the two groups.

Results
Comparison of Outcome Measurements within and between the Group-TOT and
Comparison Groups
The two groups were not significantly different in their GMFM-88, BOT-2, and PEDI
scores before the Group-TOT. After 8 weeks of group-TOT, the Group-TOT children
showed significant improvements (p < 0.05) in the standing (r ¼ 0.56) and walking/run-
ning/jumping subscales (r ¼ 0.63) of the GMFM-88, the manual dexterity subscale of
the BOT-2 (r ¼ 0.58), and the social function subscale of the PEDI (r ¼ 0.47) (Table 2).
In contrast, the comparison group showed significant improvements only in the fine
motor integration subscale of the BOT-2 (p < 0.05, r ¼ 0.71). However, when comparing

Table 2. Comparison of outcome measurements before and after treatment within the two groups.
Group-TOT group (n ¼ 9) Comparison group (n ¼ 9)
Pre-treatment Post-treatment p-value Pre-treatment Post-treatment p-value
GMFM-88
Lying & rolling 100.0 ± 0.0 100.0 ± 0.0 1.00 98.9 ± 0.0 98.9 ± 0.0 1.00
Sitting 99.1 ± 4.8 99.3 ± 4.7 0.32 98.3 ± 5.0 99.3 ± 4.7 0.09
Crawling & kneeling 90.7 ± 9.3 92.6 ± 10.3 0.07 91.0 ± 8.8 91.8 ± 9.2 0.32
Standing 74.4 ± 16.1 77.8 ± 14.7 0.03 73.1 ± 17.7 74.5 ± 16.0 0.18
Walking/running/jumping 54.6 ± 15.0 59.4 ± 16.5 0.02 54.1 ± 14.9 57.2 ± 15.5 0.18
BOT-2
FM precision 14.4 ± 8.8 16.8 ± 7.9 0.12 15.3 ± 6.6 16.8 ± 6.8 0.27
FM integration 11.6 ± 6.2 13.1 ± 6.0 0.18 12.4 ± 6.5 15.9 ± 6.6 0.03
Manual dexterity 8.7 ± 5.3 11.1 ± 7.2 0.04 9.0 ± 6.2 10.8 ± 7.4 0.26
PEDI
Self-care 57.8 ± 10.7 58.9 ± 10.1 0.18 57.6 ± 8.7 58.6 ± 11.4 0.13
Social function 45.8 ± 8.2 48.4 ± 4.9 0.04 44.8 ± 10.1 45.3 ± 9.3 0.10
Mobility 47.1 ± 7.7 50.9 ± 8.5 0.07 47.4 ± 8.4 49.9 ± 8.7 0.26
Values are presented as mean ± standard deviation. GMFM: Gross Motor Function Measure; BOT-2: Bruininks-Oseretsky
Test of motor proficiency, 2nd edition; FM: Fine motor; PEDI: Pediatric Evaluation of Disability Inventory.
indicates p < 0.05 by the Wilcoxon signed rank test.
24 E. J. KO ET AL.

the change in values before and after the intervention between the two groups, there
were no statistically significant differences.

Maintenance of the Effects of Group-Task-oriented Training

When evaluated 16 weeks (period C) after the cessation of the group-TOT, most of the
Group-TOT children showed improvement in the subscales of the GMFM-88, the BOT-
2, and the PEDI, but these values were not statistically significant compared to those of
the post-treatment evaluation (period B) (Figure 1). However, the children’s scores for
the standing and walking/running/jumping subscales of the GMFM-88, the manual dex-
terity subscale of the BOT-2, and the social function subscale of the PEDI, evaluated at
period C, showed significant improvements compared to the pretreatment evaluation
scores (period A), demonstrating that the improvements in these functions were main-
tained even after the cessation of the group-TOT.

Discussion
The results of this study indicated that group-TOT for 60 minutes per session, twice a
week, over a period of 8 weeks significantly improved the scores of the standing and
walking/running/jumping subscales of the GMFM-88, the manual dexterity subscale of
the BOT-2, and the social function subscale of the PEDI in children with spastic CP.
However, the fine motor integration subscale of the BOT-2 showed significant improve-
ment in the comparison group, but not in the Group-TOT group. The manual dexterity
subscale in the BOT-2 tests goal-directed activities that involve reaching, grasping, and
bimanual coordination, therefore the Group-TOT group likely improved the scores on
this subscale by performing TOT. On the other hand, the fine motor integration sub-
scale of the BOT-2 requires precise control of finger and hand movements. Less concen-
tration in fine movements due to therapy in a group situation probably led to lesser
improvements in the BOT-2 fine motor integration subscale in the Group-TOT group
compared to that of the comparison group. Furthermore, improvements in the standing
and walking/running/jumping subscales in GMFM-88 might have resulted from chil-
dren being competitive and imitating other children who controlled their lower limbs
well and who had good balance and coordination during group therapy.
Improvement of the social function subscale in PEDI might have resulted from the
interaction among the children in group therapy. There were more improvements in
the crawling and kneeling subscale in GMFM-88, fine motor precision subscale in BOT-
2, and self-care and mobility subscales in PEDI in the Group-TOT group compared to
those of the comparison group, but they were not statistically significant; probably due
to the small number of children involved in this study. Furthermore, lying, rolling, and
sitting subscales in GMFM-88 in the Group-TOT group were not significantly different
to those of the comparison group, and these were probably due to the ceiling effect of
the children’s measurements as they were initially functioning at a high level on
the tests.
Follow-up measurements showed that the improvements were maintained for
16 weeks. All children in the Group-TOT group received traditional rehabilitation
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 25

Figure 1. Maintenance effects of group task-oriented training in: (A) Gross Motor Function Measure
(GMFM)-88; (B) Bruininks-Oseretsky test of motor proficiency, 2nd edition (BOT-2); and (C) Pediatric
evaluation of disability inventory (PEDI).
indicates p < 0.05 by Wilcoxon signed rank test between period (A) and (B).
†
indicates p < 0.05 by Wilcoxon signed rank test between period (A) and (C).
26 E. J. KO ET AL.

therapy for 16 weeks after the cessation of the group-TOT, because stopping rehabilita-
tion treatment would have been unethical. Figure 1 shows that there were improve-
ments in the measurements between the post-treatment and follow-up periods, but
these were not statistically significant. However, significant improvements were seen
between the pretreatment (period A) and the post-treatment periods (period B), and the
pretreatment (period A) and follow-up periods (period C). Taken together, it could be
concluded that the improved functions were maintained even after the cessation of the
group-TOT.
Our findings are in agreement with previous studies (Ahl et al., 2005; Ketelaar et al.,
2001; Moon et al., 2017; Salem & Godwin, 2009) which discussed the effect of TOT in
children with CP. However, there are some differences between this current study and
previous studies: 1) this study focused on gross and fine motor functions, and ADL,
while previous studies focused on gross motor function only (Salem & Godwin, 2009),
gross motor function and ADL (Ahl et al., 2005; Ketelaar et al., 2001), or fine motor
function and grip strength (Moon et al., 2017); 2) this study had a control group,
whereas the study conducted by Ahl et al. (2005) did not; 3) TOT was provided in a
group environment in this study, compared to individual environments in previous
studies (Ahl et al., 2005; Ketelaar et al., 2001; Moon et al., 2017; Salem & Godwin,
2009); and 4) this study had a 16 week follow-up evaluation, while previous studies (Ahl
et al., 2005; Moon et al., 2017; Salem & Godwin, 2009) did not.
TOT has many advantages: it is more purposeful and is more structured, the aim of
the therapy is clearer for both children and therapists, and it promotes better participa-
tion and motivation of the children. However, a major challenge in the management of
children with CP is enhancing their motivation to practice. Motivation to participate in
activities is closely linked to improvement in the acquisition of motor abilities (Bartlett
& Palisano, 2002); therefore, a method of group-TOT was employed in this study. The
dynamics of the group appeared to provide the ‘healthy competition’, which has been
previously shown by Blundell et al. (2003), to motivate the children, and to enhance
their participation in the training programs. When children serve as peer models, they
will learn the skills and tasks more naturally in group activities. Furthermore, it will
play a major role in the socialization of each child, which provides additional learning
regarding other practices. Potential limitations of a group setting are that tasks may not
always be sufficiently challenging or meet the specific needs of each child. Therefore,
children with similar goals and objectives were grouped as one group according to their
activity level, and the relatively small group sizes (2–4 children in a group) facilitated
each child’s involvement in the tasks at an appropriate level in this study.
Some studies have discussed the effect of group therapy on resistance training
(Aviram, Harries, Namourah, Amro, & Bar-Haim, 2017), constraint-induced movement
therapy (Wu, Hung, Tseng, & Huang, 2013), and aquatic training (Ballaz, Plamondon,
& Lemay, 2011); however, there are only two previous studies discussing the effect of
group-TOT in children with CP. Blundell et al. (2003) showed that 4 weeks of group
circuit training focusing on lower limb strength using functional activities resulted in
improved lower limb strength (by dynamometry and Lateral Step-up Tests) and func-
tional performance (by the Sit-to-Stand test in the Motor Assessment Scale, minimum
chair height test, stride length, and 10-minute walk test) in eight children with CP
 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS 27

(seven with spastic diplegia and one with quadriplegia, GMFCS level I–III), and these
improvements were maintained for 2 months. The group-TOT developed by Blundell
et al. was similar to that used in the current study; however, it did not have a control
group and focused only on lower limb strength and functional performance. The
improvement of the gross motor function in this study is similar with the previous
study (Blundell et al., 2003); however, an advantage of our study is that children were
randomized to the experimental and comparison groups. Furthermore, our study inves-
tigated outcomes of not only gross and fine motor functions, but also ADL.Crompton
et al. (2007) discussed the feasibility of a 6-week group-based TOT in children aged
6–14 years with spastic diplegia. Children participated in TOT focusing on either the
lower or upper limbs. Children in the lower limb training program served as controls
for children in the upper limb training program and vice versa. Eight children were
randomized to the lower limb TOT and their TUG test scores were not significantly dif-
ferent to those of the children randomized to the upper limb TOT. This was different
from our study which showed the improvement of the gross motor function, and it was
probably due to the ceiling effect of the children’s measurements in the study by
Crompton et al., as they were initially functioning at a high level on the tests. Seven
children were randomized to the upper limb TOT and they demonstrated greater
improvements in measures of manual dexterity (as assessed by the Bruininks-Oseretsky
Test of Motor Proficiency and NK Dexterity Board) compared to children randomized
to the lower limb TOT, and the result was consistent with this current study. However,
as previously stated our study had a comparison group, included ADL as an outcome,
and there was a 16 week follow-up. Furthermore, group-TOT in this study was per-
formed with 2–4 children in a group; however, group-TOT in the above studies
(Blundell et al., 2003; Crompton et al., 2007) were performed with 7–8 children in a
group, which could mean that children had more supervision in this study.
In interpreting the results of this study, several limitations must be considered. First,
a small number of children from only one organization were included. Second, follow-
up outcome measurements of the comparison group were not evaluated. Third,
although PEDI is an instrument that measures independence in daily living, it is limited
in its ability to evaluate daily activities in real life. Fourth, since the goals of the children
were different, the Goal Attainment Scale might have been an appropriate measurement
for this study, which is a criterion-referenced measure of an individual’s goal achieve-
ment. Fifth, although the Group-TOT group showed more improvements than the com-
parison group, it is probably not solely a result of group-TOT because children also
participated in school and community activities. However, to minimize this effect, chil-
dren did not change their activity schedules. Finally, the results of this study cannot be
generalized to all children with CP, because the children included in this study had rela-
tively mild forms of CP. Further testing with a larger cohort is needed.

Conclusion
This study supports the effectiveness of group-TOT for improving gross and fine motor
function, and social function in children with CP. Additionally, improvements were
maintained 16 weeks post-intervention. Since group therapy can provide a time-efficient,
28 E. J. KO ET AL.

economical, and effective form of therapy, the clinicians working with children with CP
may consider group-TOT for improving gross and fine motor function and
social function.

Acknowledgements
The authors thank the children who participated in this study.

Disclosure Statement
The authors report no conflicts of interest.

Notes on contributors
Eun Jae Ko, M.D., Ph.D., is a clinical assistant professor in Department of Physical Medicine
and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan,
Republic of Korea.
In Young Sung, M.D., Ph.D., is a professor in Department of Rehabilitation Medicine, Division
Chief of Pediatric Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of
Medicine, Seoul, Republic of Korea.
Hye Jin Moon, M.D., is a doctor in Department of Rehabilitation Medicine, Asan Medical
Center, Seoul, Republic of Korea.
Jin Sook Yuk, M.P.H., O.T., is an occupational therapist in Department of Rehabilitation
Medicine, Division of Pediatric Rehabilitation Medicine, Asan Medical Center, Seoul, Republic
of Korea.
Heung-Su Kim, O.T., is an occupational therapist in Department of Rehabilitation Medicine,
Asan Medical Center, Seoul, Republic of Korea.
Nam Hyun Lee, P.T., is a physical therapist in Department of Rehabilitation Medicine, Division
of Pediatric Rehabilitation Medicine, Asan Medical Center, Seoul, Republic of Korea.

ORCID
Eun Jae Ko http://orcid.org/0000-0001-7198-5407
In Young Sung http://orcid.org/0000-0001-6545-6744

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