cerebral palsy ( cp ) covers the broadest spectrum of childhood posture and movement 
 disorders . cp patients have static brain lesions and clinical manifestations that change 
 over time during growth and development of the affected individual . the wide range of 
 problems associated with cp poses difficulties in patient assessment and achieving 
 rehabilitation targets1 , 2 . the family and team of specialists should establish the most appropriate approach after 
 determining the treatment goal . although there are several treatment modalities , scientific 
 evidence regarding the basis for treatment decisions is limited . the heterogeneity of cp and 
 the absence of controls and results of disease specific measures are responsible for the 
 lack of evidence1 . the goal of rehabilitation of cp is to reduce secondary musculoskeletal deformity rather 
 than treating the primary central neurological deficit . medical management may also be 
 required in addition to physical , occupational , and speech therapy . most physical therapies are based on the principles of 
 neuroplasticity , patterning , postural balance , and muscle strengthening or stretching . in 
 addition , there are conductive education therapies , which include integrated education 
 programs3 , 4 . however , there is no scientific evidence for the superiority of one 
 treatment over another . healthcare providers often use these therapeutic approaches in 
 combination with functionally based therapies . the ideal duration and frequency of these 
 therapies the 
 superiority of intermittent high - frequency treatments has not yet been successfully 
 demonstrated in controlled studies5 , 6 . cp has a reported global prevalence of 23.5 per 1,000 live births7 , 8 and 4.4 per 1,000 
 live births in turkey9 . special education and rehabilitation centers exist in turkey for children with cp covered 
 by social security . these centers usually utilize a combination of therapeutic methods that 
 are tailored to the needs of each child . in this study , we aimed to review long - term 
 outcomes of rehabilitation in children undergoing such therapies . we conducted a retrospective review of medical records in 65 pediatric patients with cp who 
 were followed - up for 2  years from 2011 to 2013 at the cp outpatient clinic of istanbul 
 medeniyet university , goztepe training and research hospital , istanbul , turkey . the approval 
 to conduct this study was obtained from the the institutional board and local ethics 
 committee at istanbul medeniyet university , goztepe trainig and research hospital , istanbul , 
 turkey . written informed consent provided from the parents / guardian of the children prior to 
 enrolling in the study . eleven children with cp were excluded due to a change in address 
 leading to discontinuation of therapy ; 19 children met the study exclusion criteria ( i.e. , 
 priorly received botulinum toxin injection or had major surgery performed within the last 6 
 months ) . the study was completed by 35 cp patients who received continuous physical therapy 
 for 24 months and were followed - up by our team . all patients were diagnosed with cp by a 
 pediatric neurologist . at the time of treatment initiation , children were enrolled in treatment programs at 
 special rehabilitation centers after being examined by a physiatrist with expertise in cp 
 and a physiotherapist working at our clinic . patients received physiotherapy 3 times / week , 
 which included traditional physiotherapy approaches and neurodevelopmental therapy . 
 depending on individual needs , all children were reexamined at the end of the 2  year treatment program by the 
 same medical team . children with cp were classified according to the number of limbs affected as follows : 
 quadriplegic , an impairment of the trunk and 4 limbs ; diplegic , involvement of the lower 
 extremities ; and hemiplegic , only one side of the body was affected . patients were evaluated 
 using a locomotor system examination , gross motor function classification system ( gmfcs ) , 
 gross motor function measure-88 ( gmfm-88 ) , and wee functional independence measure 
 ( weefim ) . the gmfcs , commonly used in cerebral palsy studies , is a reliable and valid scale , which is 
 based on self - initiated movement with a particular emphasis on sitting ( truncal control ) and 
 walking10 . the gmfcs consists of 5 
 levels ; level 1 indicates independent mobility and level 5 indicates full dependency11 . have investigated changes in gross motor function during 6 months in 
 children with cp aged 38  years who were classified using the gmfcs as mild , moderate , or 
 severe13 . in the present study , we also 
 used the same classification for patient assessment . gmfcs level 3 patients walk with adaptive equipment assistance and were classified as 
 moderate ; level 4 and 5 patients who had no self - mobility were classified as severe . based 
 on this classification , the mild and moderate groups both contained 12 patients and the 
 severe group had 11 patients . the gmfm-88 is a valuable standardized test designed to examine the achievements and 
 limitations of gross motor function in children with cp , monitor progress of the individual 
 child , and evaluate the treatment outcomes of programs for this population14 . the gmfm-88 is very reliable for 
 assessing the mobility and functional ability of children with cp15 . gmfm-88 consists of 88 items , which are scored as 03 
 points based on how well each of the following 5 activities are performed : lying and rolling 
 ( a ) , sitting ( b ) , crawling and kneeling ( c ) , standing ( d ) , and walking , running , and jumping 
 ( e ) . the weefim was used to evaluate the health of the patients , their developmental condition , 
 educational level , and degree of local sociality . items of the weefim are scored as 17 , 
 where 1 indicates total assistance and 7 indicates complete independence . the lowest and 
 highest possible score is 18 and 126 , respectively16 . the reliability and validity of the turkish version of the weefim 
 for assessing the functional status in turkish children with cp have been demonstrated17 , 18 . statistical package for social sciences ( spss ) for windows 19.0 software package ( ibm , new 
 york , usa ) was used for statistical analyses of study findings . study data were analyzed 
 using statistical methods ( i.e. , median and minimum - maximum ) and wilcoxon signed rank test 
 was used for intragroup comparisons of quantitative parameters that did not follow a normal 
 distribution . results were reported with 95% confidence intervals and a 
 p - value < 0.05 was considered significant . the age range of the 35 children with cp was 315  years ( median , 6  years ) . all cp patients 
 had spastic type cp and most of them were boys with a diplegic predominance . two children 
 with athetoid form of cp and 4-limb involvement were included in the quadriplegic group . the 
 characteristics of the study participants are illustrated in table 1table 1.characteristics of the study participantscharacteristic valueage ( years)315 ( median 6)treatment course ( sessions)312duration of treatment ( months)24 gendermale23 ( 65.7%)female12 ( 34.3%)type of involvementdiplegic19 ( 54.3%)hemiplegic4 ( 11.4%)quadriplegic12 ( 34.3% ) . a highly significant increase in gmfm-88 scores was observed after 24 months 
 of treatment compared to baseline when all children were evaluated together ( n = 35 ; p = 
 0.000 ) . in addition , a highly statistically significant increase in weefim values of the 
 whole group was observed at the end of 24 months ( p = 0.000 ; table 2table 2.gross motor function measure-88 and wee functional independence measure results 
 of patients with cerebral palsy ( n = 35)initial ( median ) final ( median)gmfm-88125176*weefim4671**p < 0.001 , wilcoxon signed rank test ; gmfm-88 : gross motor function measure-88 ; 
 weefim : wee functional independence measure ) . * p < 0.001 , wilcoxon signed rank test ; gmfm-88 : gross motor function measure-88 ; 
 weefim : wee functional independence measure significant increases were observed in gross motor function ( table 3table 3.changes in the gross motor function measure-88 scores 
 ( pre - treatment  post - treatment)ninitial ( median ) final ( median)mild12218.5247.5**moderate12123175**severe112515**p < 0.01 , wilcoxon signed rank test ) and functional measure scores ( table 
 4table 4.changes in the wee functional independence measure scores ( pre - treatment  
 post - treatment)ninitial ( median)final ( median)mild1279112***moderate1247.568**severe111819**p > 0.05 , * * p < 0.05 , * * * p < 0.01 , wilcoxon signed rank test ) following treatment among patients with mild and moderate disease . however , 
 the reduction in gmfm-88 scores observed among the severe group was not statistically 
 significance . in addition , post - treatment changes in weefim scores were not statistically 
 significant in patients in the severe groups . * * p < 0.01 , wilcoxon signed rank test * p > 0.05 , * * p < 0.05 , * * * p < 0.01 , wilcoxon signed rank test an increase , decrease , and no change in gmfm scores was observed in 26 , 8 , and 1 
 patient(s ) , respectively , according to the gmfm-88 evaluation after 24 months of treatment 
 ( table 5table 5.changes observed in gross motor function measure-88 and wee functional 
 independence measure scores at the end of 2  yearsincreaseddecreasedno changegmfm-882681weefim2654gmfm-88 : gross motor function measure-88 , weefim : wee functional independence 
 measure ) . however , weefim scores were increased , decreased , and unchanged in 26 , 5 , 
 and 4 patients , respectively ( table 5 ) . there 
 was a significant correlation between baseline gmfm-88 and weefim scores and post - treatment 
 gmfm-88 and weefim scores ( p = 0.000 ) . significant improvements in gross motor function were found when all ( n = 35 ) pediatric cp 
 patients were assessed together after 2  years . individual evaluation of groups showed 
 significant increases in both gmfm-88 and weefim scores for mild and moderate groups . yi et 
 al . observed a marked improvement in gross motor function in 45 children with cp after 6 
 months of rehabilitation and attributed this improvement to a longer treatment duration , 
 baseline gmfm-88 scores , and absence of a concomitant disorder . gmfm-88 scores were 
 increased in both groups in this previous study , including diplegic and quadriplegic 
 patients . a greater improvement was observed in diplegic patients compared to severely 
 affected patients , albeit not statistically significant19 . in contrast , a statistically significant change was not observed 
 in gmfm-88 scores among our severely affected patients . treatment was provided twice daily 
 for 5 days / week in the study by tae et al . , which was different compared to our study . improvements in gmfm-88 scores were observed in all 3 groups ( i.e. , hemiplegic , diplegic , 
 and quadriplegic ) in a study with different types of cp patients after 8 months of 
 treatment . according to that study , although a substantial improvement in motor performance 
 was detected during the first 4 months in hemiplegic and quadriplegic children , the trend 
 was not maintained in the succeeding 4 months . average gmfc scores of quadriplegic children 
 were found to be lower compared to those of other groups20 . in a retrospective study by harries et al . , 106 children with cp were evaluated after 
 7  years of follow - up using gmfm-88 , and an increase in gmfm-88 scores was observed among 
 mild , moderate and severe cp groups . while the speed of improvement varied according to the 
 severity of motor disability , both mild and severe groups reached their maximum gross motor 
 function within the 7  year follow - up13 . the developmental patterns of children with spastic diplegic ( sd ) and spastic quadriplegic 
 ( sq ) cp were compared in the study by chen et al . in that study , it was observed that 
 children with sq had lower development quotients in all developmental functions compared to 
 sd children21 . in a similar study , gross 
 motor functions and developmental patterns improved with age and were correlated with the 
 degree of ambulatory function in diplegic children ; however , these results were not observed 
 among sq children22 . these findings 
 corroborate our results of quadriplegic patients ( i.e. , severe group ) . we found that the gross motor function and weefim scores of children were correlated prior 
 to treatment and following 24 months of rehabilitation . in our study , children with mild and 
 moderate cp had higher post - treatment weefim scores compared to baseline , which were 
 consistent with their improved gross motor function , but there was no significant change in 
 children with severe cp . in a study by damiano and abel , children with cp who achieved 
 highest functional ambulation scores had higher gmfm-88 scores23 . beckung and hagberg have stated that gross motor 
 functions of children with cp are crucial for their physical independence and mobility24 . the pre - treatment and post - treatment 
 gmfm-88 and weefim scores were determined to be correlated in a study involving children 
 with cp after 1  year rehabilitation25 . however , no correlation was found between gmfm-88 and weefim scores of children with cp in a 
 contrasting study26 . major limitations of our study included the fact that patients were treated at different 
 centers and a small sample size . while a non - intensive ( i.e. , 3 times / week ) rehabilitation 
 program provided marked motor improvement and increased functional capacity at the end of 
 2  years in children with mild and moderate cp , which helped them reach their full potential , 
 there was no such improvement in patients with severe cp . identification and anticipation of problems 
 experienced by children with severe disability would help patients and their families 
 prepare better for the future .
[ purpose ] to observe motor and functional progress of children with cerebral palsy during 
 2  years . 
 [ subjects and methods ] pediatric cerebral palsy patients aged 315  years ( n = 
 35/69 ) with 24-month follow - up at our outpatient cerebral palsy clinic were evaluated 
 retrospectively . 
 the distribution of cerebral palsy types was as follows : diplegia ( n = 
 19 ) , hemiplegia ( n = 4 ) , and quadriplegia ( n = 12 ) . 
 participants were divided into 3 
 groups according to their gross motor functional classification system scores ( i.e. , mild , 
 moderate , and severe ) . 
 all participants were evaluated initially and at the final 
 assessment 2  years later . during this time , patients were treated 3 times / week . 
 changes in 
 motor and functional abilities were assessed based on gross motor function measure-88 and 
 wee functional independence measure . 
 [ results ] significant improvements were observed in 
 gross motor function measure-88 and wee functional independence measure results in all 35 
 patients at the end of 2  years . 
 the gross motor function measure-88 scores correlated with 
 wee functional independence measure scores . marked increases in motor and functional 
 capabilities in mild and moderate cerebral palsy patients were observed in the subgroup 
 assessments , but not in those with severe cerebral palsy . 
 [ conclusion ] rehabilitation may 
 greatly help mild and moderate cerebral palsy patients achieve their full potential .