cerebral palsy ( cp ) is a nonprogressive disorder of movement due to brain injury in 
 childbirth or after birth1 . it leads to 
 limitations of activity , such as paresthesia , cognitive impairment , dysesthesia , and 
 behavioral disturbance2 . in addition , a 
 child with cp has no experience of various normal movement of the trunk , pelvis , and lower 
 extremities against gravity . even though a child with spastic diplegia is walk , child raises the upper limb high or 
 overextends the upper body to compensate for the lack of antigravity . the anterior tilt of 
 the pelvis is excessive due to improper control of muscles that are attached around the 
 pelvis . forward tilting of the pelvis leads to limitation of movement of the hip or knee 
 joint , such as adduction and flexion during gait . impaired posture control mechanism is a 
 major problem disturbing independent development of activity of daily living in 
 children3 . children with cp are treated over a long period of time , and achievement of independent 
 functional activity is very difficult . in addition , due to a shortage of skilled people to 
 provide specialized care , functional activity in children with cp is abnormal . in 
 particular , although a child with cp is able to walk independently , the gait is not 
 considered normal independent walking . the abnormal gait leads to deformity in the hip joint 
 or spine , as weight is supported asymmetrically by the legs due to asymmetry of the 
 bilateral pelvis . task - oriented training is used as a rehabilitation strategy to improve motor skill and as a 
 rehabilitation program for improvement of muscle strength or function4 , 5 . it should include 
 specific tasks to improve function as an effective treatment for functional improvement of 
 patients with disorders of the central nervous system6 , 7 . task - oriented training is a 
 neural rehabilitation approach to helping functional systematization , including not only an 
 intended result but also significant activity of a patient . it can be performed through 
 repeated training of activity tasks associated with daily activity . it is a training method that supports interesting tasks for children with cp and leads to 
 effectively functional movement7 . attention and adjustment processes need to 
 systemize subject accomplishment , communication , and coordinated social activity . therefore , 
 behavior is required for spatiotemporal adaptation of a child to the environment , and it is 
 organized with intentional repetitions8 . therefore , 
 treatment should include not only training with a child but also provide environmental 
 adaptation in order to stress a child 's functional behavior . the child is encouraged courage 
 and convinced of a positive reward starting with self - support , self - motivation , and 
 self - satisfaction8 . if a patient is not 
 interested in treatment , in other words , the effect of treatment is expected to be low , the 
 patient has poor prognosis9 . it does not 
 attract a patient 's interest . because it does not provide an accurate analysis or feedback 
 regarding a patient 's movement , the effect of training is decreased due to accumulated 
 errors made due to incorrect movements by the patient10 , 11 . this study applies a task - oriented training program to children with cp and then analyzes 
 impacts on the balance and effects of training on disability types , impaired part , and 
 transfer method . on the basis of evaluations of these analyses , the results of this study 
 suggest development of a proper child - centered task - oriented training program for 
 improvement of balance in children with cp . the subjects were 26 children with cp ( 14 boys and 12 girls , mean age , 11.8  3.54  years ; 
 mean height , 126.12  9.45  cm ; mean weight , 22.79  3.70  kg , iq70 , gmfcs i , ii , iii level ) 
 from an elementary school for physically disabled children in korea . the cp subjects had no 
 history of newly developed neurological problems , musculoskeletal disorders , or botulinum 
 toxin injections in the past six months . the study applied a child - centered task - oriented training program to 26 subjects during a 
 period of 15 weeks , providing two 40-minute sessions per week . during the training period , a 
 child was the starter of all activities , and the therapist was an observer or had a role as 
 a facilitator . when a child had no change in any activity over a period of two minutes , the 
 training program was applied to him or her . a child was able to choose various activities 
 during the child - centered task - oriented training program ; a therapist took on the role of an 
 assistant when a child wanted to perform an activity . however , a therapist provided verbal 
 cues and physical activity guidance when a child showed abnormal or compensatory movement 
 patterns during the training program . in addition , the task - oriented training program was 
 applied to integration of somatosensory and proprioceptive sensibility . therapists provided 
 feedback using a mirror to correct his or her posture as well . the child - centered 
 task - oriented training program used in this study the pbs , a 
 modified version of the berg balance scale ( bbs ) used for assessment of the balance ability 
 of adults , is a tool for evaluation of infants12,13,14 . the pbs , which has been widely used in assessment of balance 
 performance , has strong internal consistency and high intrarater reliability and interrater 
 reliability ( icc=0.980.99)15 . the scale 
 consists of measurement of a subject 's ability to perform 14 activities , such as stair 
 climbing , or donning pants in a standing position , requiring balance and reflecting of 
 functional activities . the score for each of the 14 test items ranges from 0 to 4 points . higher scores indicate greater balance 
 ability and functional independence with respect to the activities tested16 . the shapiro - wilk test was used for 
 determination of the general properties and variables of the subjects . the paired t - test was 
 used for comparison of pretest and posttest results within each group , and one - way anova was 
 performed for analysis of changes between groups of dependent variables . a post - hoc test 
 using the scheffe method was employed for comparison of each group . number ( % ) . mean ( sd ) values are means ( sd ) . * statistically significant difference between pre- and 
 post - test values ( p<0.05 ) . a , statistically significant difference between the 
 independent walk group with wheelchair use group ( p<0.05 ) . b , statistically 
 significant difference between the independent walk group with walker use group 
 ( p<0.05 ) . c , statistically significant difference between the walker use group and 
 the independent walk and wheelchair use groups ( p<0.05 ) . baseline characteristics for the 26 participants who completed the study are shown in table 2 . the pbs score of the group younger 
 than nine years of old was significantly changed , increasing by 4.18 points , from 19.55 
 points to 23.73 points , after the intervention ( p<0.05 ) . the group between 10 and 
 12  years old showed a significant difference , increasing by 5.40 points from 19.60 points to 
 25.00 points . the group older than 13  years old also showed a significant change , increasing 
 by 3.70 points from 26.30 points to 30.00 points after the intervention ( p<0.05 ) . the pbs score 
 in the spastic type showed a statistically significant difference , increasing by 4.41 points 
 from 21.71 points to 26.12 points ( p<0.05 ) . the atheotid type also showed a significant change , increasing by 4.50 points after the 
 intervention ( p<0.05 ) . the mixed type did not show a significant change , increasing by 
 2.67 points from 25.67 points to 28.33 points . the pbs score in diplegia showed a significant change , increasing by 4.75 points from 23.42 
 points to 28.17 points after the intervention ( p<0.05 ) . that for quadriplegia showed a 
 statistically significant change , increasing by 3.77 points from 19.85 points to 23.63 
 points ( p<0.05 ) . the pbs score in the independent walking group showed a significant difference , increasing 
 by 3.20 points from 33.60 points to 36.80 points ( p<0.05 ) . an increased pbs score was 
 observed in the group of subjects who used walkers , with the score increasing by 6.10 points 
 from 23.40 points to 29.50 points ( p<0.05 ) . there was a significant change in the wheelchair use group after the intervention , with the 
 score increasing by 3.00 points from 15.81 points to18.82 points ( p<0.05 ) . in addition , a 
 statistically significant difference in pre- and post- intervention values was observed 
 between the independent walking group and the wheelchair group ( p<0.05 ) . a significant 
 difference change in value was observed between the walker group and wheelchair group 
 ( p<0.05 ) . rehabilitation of central nervous system disease has changed from neuromuscular 
 facilitation based on facilitation - inhibition techniques to a task - oriented approach with 
 functional activities16 . the 
 task - oriented approach is based on motor learning and involves repeat training with 
 task - oriented activities . it is effective for improvement of the functional performance of a 
 child with cp . in addition , it is a training method for encouraging functional movement 
 while providing children with an interesting task7 . in our study of a child - centered task - oriented training program designed to affect the 
 balance of a child with cp used in this study , balance ability was significantly changed 
 after the intervention in the spastic type , athetoid type , diplegia , and quadriplegia . to be 
 included , patients met the following criteria : subjects had an intelligence quotient ( iq ) 
 score of more than 70 with the ability to understand and follow instructions or make their 
 own choices as self - determination balance is a neurophysiological process 
 for maintenance of the stability of the body within the base of support with the least 
 sway17 . the balance control ability of 
 a child with cp is very important in the clinic , especially in the standing and sitting 
 positions . according to the results of this study , in children with diplegia and quadriplegia a large 
 percentage of the children with cp showed remarkable progress in balance ability . improvement of balance ability might have resulted from facilitation of proprioceptive 
 sense , leading to change in various supports . in particular , equine gait which results from 
 weakness of the peroneal and anterior tibia ankle stability is required to treat instability in standing or walking and can be improved 
 with extension of calf muscles . ankle stability in this study might have been improved by 
 the following activities : ( 1 ) sitting on a physioball with the feet on the floor and 
 bouncing up and down on the ball , ( 2 ) weight bearing activities for the ankle joint while 
 going up and down stairs , and ( 3 ) activities for proprioceptive sensibility . in the future , 
 a follow - up study of the child - centered task - oriented training program for stability of the 
 ankle joint will be conducted . the stability of the body appears to be higher when pressure is on the rear foot , compared 
 with the forefoot . therefore , the relative increase in pressure on the rear foot is one of 
 the important factors in controlling the stability of the body19 . this study found on improvement of the ability of the 
 body of a child with cp to provide support and balance ability . in a child with cp , walking 
 is deeply associated with improvement of stability in the standing position . in a study of 
 the relation between standing balance and walking , liao et al.15 reported that slow walking speed reflects the decrease in 
 balance ability , loss of muscular strength , and asymmetry of injured vital dynamics . flynn , 
 palma , and bender11 reported that fast 
 movement with a stable condition on the base of support leads to a new base of support and 
 changes from the control of static balance to that of dynamic balance . the present study showed a statistically significant 
 difference between the independent walk group with wheelchair use group . the pre - post 
 difference was significant in the independent walking group and the walker group . therefore , the method of transport for a child with cp is able to affect balance ability . in particular , the independent walking group showed better balance ability than the walker 
 group , and the wheelchair group , however , the features of the pbs led to a celling effect . therefore , statistically significant improvement was observed after application of a 
 child - centered task - oriented training program , but the changes in values did not show 
 significant improvement , compared with the other groups . on the other hand , the walker use 
 group showed greater improvement in balance ability compared with the independent walking 
 group and the wheelchair group according to the post - hoc results . balance ability with 
 regard to standing balance might have been more improved in the walker use group by the 
 following exercises : use of a phyioball , and activities in a standing position . in the 
 future , we plan to consider performance of a follow - up study for endurance and walking 
 ability in children with cp using a child - centered task - oriented training program . the 
 present study has some limitations , such as the small number of subjects with cerebral palsy 
 and unequal numbers of cp types . even though the special education school did not use other 
 physical or occupational therapies in addition to child - centered task - oriented training , it 
 could not control outpatient treatment . in addition , the inclusion criteria of subjects have 
 iq score of more than 70 with the ability to understand and follow instructions or make 
 their own choices might have positively affected the results of this study . however , 
 elimination of the above criteria would necessitate use of therapist - centered training 
 rather than child - centered task - oriented training according to the cognitive capability of a 
 child with cp .
[ purpose ] this study was conducted in order to investigate the effects of child - centered 
 task - oriented training on balance ability in patients with cerebral palsy . 
 [ subjects ] 
 twenty - six subjects with cerebral palsy were recruited . 
 [ methods ] this study applied a 
 child - centered task - oriented training program to 26 subjects during a period of 15 weeks , 
 with two 40-minute sessions per week . the pediatric berg balance scale ( pbs ) was used for 
 measurement of the effect of child - centered task - oriented training . 
 [ results ] balance 
 ability showed a significant change after the intervention in age groups younger than 
 nine , between 10 and 12 , and older than 13 . 
 in addition , a significant difference in 
 balance ability was observed in the spastic type , athetoid type , diplegia , and 
 quadriplegia transport groups , including an independent walking group , a group of subjects 
 who used walkers , and a group of subjects who used wheelchairs . 
 [ conclusion ] although we 
 suggest conduct of a follow - up study on child - centered task - oriented training , the results 
 of this study showed improved balance ability in patients with cerebral palsy . therefore , 
 these results recommend a variety of applications in clinical trials of conservative 
 therapeutic methods .