DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY CLINICAL PRACTICE GUIDE

Interventions to improve physical function for children and young

people with cerebral palsy: international clinical practice
guideline
MICHELLE JACKMAN 1,2 | LEANNE SAKZEWSKI 1 | CATHERINE MORGAN 3 | ROSLYN N BOYD 1 |
SUE E BRENNAN 4 | KATHERINE LANGDON 5 | RACHEL A M TOOVEY 6 | SUSAN GREAVES 7 | MEGAN THORLEY 8 |
IONA NOVAK 3,9

1 Queensland Cerebral Palsy and Rehabilitation Research Centre, Faculty of Medicine, University of Queensland, Brisbane, Queensland; 2 John Hunter Children’s
Hospital, Newcastle, New South Wales; 3 Discipline of Child and Adolescent Health, Faculty of Medicine and Health, Cerebral Palsy Alliance Research Institute, The
University of Sydney, Sydney, New South Wales; 4 School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria; 5 Perth Children’s
Hospital, Perth, Western Australia; 6 Physiotherapy Department, University of Melbourne, Melbourne, Victoria; 7 Occupational Therapy Department, Royal Children’s
Hospital, Melbourne, Victoria; 8 Queensland Paediatric Rehabilitation Service, Brisbane, Queensland; 9 Faculty of Medicine and Health, The University of Sydney,
Sydney, New South Wales, Australia.
Correspondence to Michelle Jackman at Paediatric Occupational Therapy Department, John Hunter Children’s Hospital, Locked Bag 1, HRMC, NSW 2310, Australia. E-mail:
[email protected]

This clinical practice guide is commented by Saloojee on page 530 of this issue.

PUBLICATION DATA AIM To provide recommendations for interventions to improve physical function for children
Accepted for publication 18th August 2021. and young people with cerebral palsy.
Published online 21st September 2021. METHOD An expert panel prioritized questions and patient-important outcomes. Using
Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods,
ABBREVIATIONS the panel assessed the certainty of evidence and made recommendations, with international
CIMT Constraint-induced movement expert and consumer consultation.
therapy RESULTS The guideline comprises 13 recommendations (informed by three systematic
CO-OP Cognitive orientation to reviews, 30 randomized trials, and five before–after studies). To achieve functional goals, it is
occupational performance recommended that intervention includes client-chosen goals, whole-task practice within real-
GRADE Grading of Recommendations life settings, support to empower families, and a team approach. Age, ability, and
Assessment, Development and child/family preferences need to be considered. To improve walking ability, overground
Evaluation walking is recommended and can be supplemented with treadmill training. Various
HABIT-ILE Hand–arm bimanual intensive approaches can facilitate hand use goals: bimanual therapy, constraint-induced movement
training including lower therapy, goal-directed training, and cognitive approaches. For self-care, whole-task practice
extremity combined with assistive devices can increase independence and reduce caregiver burden.
ICF International Classification of Participation in leisure goals can combine whole-task practice with strategies to address
Functioning, Disability and environmental, personal, and social barriers.
Health INTERPRETATION Intervention to improve function for children and young people with
MACS Manual Ability Classification cerebral palsy needs to include client-chosen goals and whole-task practice of goals.
System Clinicians should consider child/family preferences, age, and ability when selecting specific
PICO Population, intervention, interventions.
comparison, outcome
RCT Randomized controlled trial

The estimated incidence of cerebral palsy (CP) ranges independence in activities of daily living, play, and partici-
from 1.4 to 1.8 in 1000 live births in industrialized coun- pation in education, social, and community activities.7
tries,1,2 with the prevalence being 2.95 to 3.4 per 1000 live Therapy interventions for children and young people
births in low- and middle-income countries.3,4 CP is an with CP have evolved considerably over the past 20 years,
umbrella term encompassing a heterogeneous group of in line with the World Health Organization’s International
permanent but not unchanging disorders of movement and Classification of Functioning, Disability and Health (ICF)
posture that is caused by damage to the developing brain.5 framework. This evolution has seen a change of focus from
In addition to movement difficulties, individuals may expe- primarily addressing underlying symptoms and impair-
rience challenges with communication, behaviour, vision, ments with the aspiration of improving function, to focus-
hearing, feeding, pain, and sleep.6 The impact of CP on an ing instead on training activities and real-life tasks that are
individual extends across the lifespan, influencing important to the person, plus directly targeting their full

536 DOI: 10.1111/dmcn.15055 © 2021 Mac Keith Press

participation within the community.8 Client-centred goals, What this paper adds
direct active practice of the individual’s goal and adaptation • To improve physical function, intervention should focus on active practice of
of the task and environment to suit the individual align the client’s goals.
both with personal and environmental factors of the ICF • Best practice includes client-chosen goals and whole-task practice.
and tap into personal factors including motivation and • Education and support need to be provided to empower families in decision-
making.
individual interests. This holistic approach to targeting all • Child/family preferences, age, and ability need to inform choice of interven-
modifiable factors that might influence outcomes is also tions.
aligned with the ‘F words’ for child development: function,
family, fitness, fun, friends, and future.9 complete the whole task, part-task practice could be con-
Interventions that aim to improve function are therapeu- ducted, followed by whole-task practice.
tic approaches in which the child actively practises the goal The aim of this guideline is to provide equitable and rele-
or task they wish to achieve (known as ‘goal-directed’, vant recommendations based on the best available evidence
‘task-based’, or ‘whole-task practice’ approaches). These to guide clinicians and inform families about the most
interventions encompass similar principles in which indi- appropriate interventions to improve function for children
vidual goals are set, and the goal or task is actively prac- and young people with CP. This guideline places an empha-
tised by the individual until the goal or desired ‘functional’ sis on physical strategies because CP is a physical disability
outcome is achieved in a holistic way. Examples of specific and most of the evidence has researched physical function.
named interventions that are ‘goal-based’ include While cognitive, communication, and social functions are
cognitive orientation to occupational performance (CO- important, these are not the focus of this guideline.
OP), goal-directed training, goal-directed motor coaching,
goal-directed home programmes, and hand–arm bimanual METHOD
intensive training including lower extremity (HABIT-ILE). The Grading of Recommendations Assessment, Develop-
Examples of specific named interventions that are ‘task- ment and Evaluation (GRADE)12 approach underpinned
based’ include bimanual training, constraint-induced the guideline development. A technical panel comprising
movement therapy (CIMT), context therapy, hand–arm clinician-researchers and methodologists trained in
bimanual intensive training (HABIT), partial bodyweight- Cochrane and GRADE approaches (Appendix S4, online
supported treadmill training (part-task), sit-to-stand train- supporting information) had oversight of the technical pro-
ing, task-orientated functional exercise, and treadmill cess of development (Appendix S5, online supporting
training (part-task). Examples of specific named interven- information).
tions that are ‘whole-task practice’ include overground Wide international consultation was conducted at every
walking. Interventions that improve function encompass stage of the guideline development with key stakeholders.
goals within the ‘activity’ and ‘participation’ domains of Stakeholders included parents and consumers, specialist
the ICF, rather than addressing underlying impairments or clinicians and researchers (n>600) in three continents, and
goals within the ‘body functions and structure’ domain of an international panel from high-, middle-, and low-
the ICF (such as ‘fitness’). For example, interventions that income contexts. The guideline topic was nominated and
improve function do not aim to improve muscle tone, mus- prioritized by parents of children and young people with
cle strength, or joint range of motion; and while addressing CP, researchers, and clinicians during a formal consulta-
these may be important for a child with CP, they are not tion process conducted by the International Alliance of
the focus of this guideline (see Appendices S1–S3, online Academies of Childhood Disability guidelines group in
supporting information). Vienna in 2014, San Diego in 2014, and an e-consumer
When aiming to improve functional goals, evidence sug- survey in 2015. Parents rated improving function as their
gests that the whole goal needs to be practised, ideally third highest priority for clinical guideline development
within a ‘real world’ context for skills to be effectively (after early diagnosis and early intervention, which were
transferred to an individual’s everyday life.10,11 For exam- addressed in separate publications). For each clinical ques-
ple, a child’s goal of improving handwriting legibility tion, the technical panel members conducted the search,
would not focus on finger strength and pincer grasp. critical appraisal, and summarized findings of the system-
Instead, intervention to improve function would involve atic review and the certainty of the evidence in GRADE
actual practice of handwriting, and take into consideration Evidence Profiles.12 Using the GRADE Evidence to Deci-
other factors that may be affecting the child’s ability to sion framework,13,14 recommendations were made by a
produce written work at home and school (e.g. the pen or multidisciplinary panel that included consumers and clini-
pencil the child is using, the chair or table they are seated cians. The resulting draft guideline was reviewed by a 20-
at for writing, where the child is positioned within the member international panel for feasibility, acceptability,
classroom, literacy skills, as well as the child’s motivation affordability, and cultural sensitivity globally. The guide-
or the levels of ‘fun’). In this way, intervention is not solely line development methods are reported in full in Appen-
focused on the motor skill, but also takes into considera- dices S4 to S6, Tables S1 to S3, and Figure S1 (online
tion the ICF personal and environmental factors that may supporting information). A flow diagram of the develop-
be affecting achievement of the goal. If the child cannot ment and consultation process is also provided (Fig. 1).

Clinical Practice Guide Michelle Jackman et al. 537

 Problem Identified PICO Question Systematic Search
Formulated for Evidence

Consumers & Key Stakeholders Technical Panel Technical Panel

Appraise Evidence Overarching

YES Systematic Reviews?
Quality [GRADE/ROB]

Search for
Extra RCTs NO
Technical Panel Technical Panel Technical Panel

Evidence to Decision Framework Make

Recommendations
Research Additional Panel
GRADE Criteria Judgements
Evidence Considerations

Priority of the problem

Multidisciplinary Panel
Benefits & Harms

Certainty of the Evidence Assess Global

Applicability
Outcome Importance

Balance

Resource Use
International Panel

Equity

Feasibility Publish Guideline

Acceptability

Multidisciplinary Panel Technical Panel

LEGEND

CONSUMERS = People with Cerebral Palsy & Parents

KEY STAKEHOLDERS = International Alliance of Academies of Childhood Disability [Inc Parents, Clinicians & Researchers]

TECHNICAL PANEL = GRADE & Cochrane Trained Clinician Researchers

MULTIDISCIPLINARY PANEL = Consumers + Key Stakeholders + Technical Panel

INTERNATIONAL PANEL = 20 Expert Clinician Researchers in Low-, Middle- & High-Income Countries

Figure 1: The guideline process. PICO, population, intervention, comparison, outcome; GRADE, Grading of Recommendations Assessment, Development
and Evaluation; ROB, risk of bias; RCT, randomized controlled trial.

538 Developmental Medicine & Child Neurology 2022, 64: 536–549

PICO Data synthesis
Our population, intervention, comparison, outcome Selection of evidence was based on alignment of the study
(PICO) question was as follows. For children and young with the PICO questions, how up to date the systematic
people with CP (P), which interventions to improve func- review (which included RCTs) was, and the methodologi-
tion (as defined in the introduction) (I), compared with cal quality. Characteristics of included studies and risk-of-
alternative interventions or no intervention (C), improve bias assessment were tabulated (primary evidence
outcomes in the activities or participation domains of the [Table S1]; other included studies [Table S2]; excluded
ICF (O)? studies [Table S3]). Certainty of evidence was assessed and
tabulated in GRADE evidence profiles (Appendices S7–
Eligibility criteria S10, online supporting information). If randomized trials
Inclusion criteria for systematic reviews (which included had sufficiently similar characteristics, meta-analyses were
randomized trials) and randomized trials were the follow- performed.
ing: (1) at least 80% of participants had CP; (2) at least
80% were aged between 2 and 18 years; (3) they evaluated Evidence-based recommendations
interventions that aimed to improve physical function; (4) The GRADE Evidence to Decision framework was used to
outcomes were measured using valid, reliable, and respon- develop recommendations, considering the balance of bene-
sive measures at the activities and participation domains of fits and harms, certainty of evidence, patients’ values and pref-
the ICF. erences, resources, equity, acceptability, and feasibility. The
Inclusion criteria for supplementary searches (if no rele- guideline multidisciplinary panel, which included consumers,
vant systematic reviews or randomized trials existed) clinicians, and technical methodologists, considered evidence
included the following: (1) participants included children and other information in relation to each of these Evidence to
and young people with CP aged 2 to 18 years; (2) reliable Decision criteria to decide on the direction (for or against an
research methods were evident; (3) studies evaluated inter- intervention) and the strength (strong or conditional) of each
ventions that aimed to improve physical function. recommendation.18,19 For each area of function, the panel
Where duplicate or similar systematic reviews existed, made recommendations at two levels. First, the panel made a
we selected one systematic review that best answered our general recommendation considering the totality of evidence
PICO. A review was deemed to be superseded if there was across interventions that aim to improve function versus no
a newer review that included the same randomized con- intervention (e.g. for or against mobility training). Second,
trolled trials (RCTs) or was more comprehensive. When specific recommendations were made for each of the inter-
an RCT was missing from an overarching systematic ventions for which there was evidence (overground walking,
review but was included in other reviews, these extra RCTs treadmill training, etc.). The evidence, information, and
were extracted and added to the body of evidence under panel’s judgements are summarized in a single Evidence to
examination. See Appendix S5 for further detail. Decision framework for each function (shown in Appendices
S7–S10). Strong recommendations are made for interven-
Search tions where the benefits clearly outweigh the harms (includ-
We systematically searched the Cochrane Library, ing high or moderate certainty evidence, and for which most
CINAHL, Embase, and MEDLINE up to November individuals [children/young people and families] would place
2018 to capture existing guidelines, systematic reviews similar values on the outcomes of the intervention), and
(including RCTs), and RCTs that answered our PICO where other factors favour the use of the intervention. In
question. Supplementary searches were done where higher- essence, a strong recommendation in GRADE means that
quality evidence was unavailable or the systematic review most health professionals should follow the recommendation
did not fully answer our PICO question. Search terms are and most individuals would want the recommended action:
available in Appendix S6. An updated search of systematic the intervention is considered essential. Conditional recom-
reviews and randomized trials only was done in May 2021. mendations are those for which there is a closer balance
between the benefits and harms (including lower certainty of
Study selection and data extraction evidence, variability, or uncertainty about the value individu-
Two reviewers independently performed study selection, als place on the outcomes of the intervention), where there
data extraction, and risk-of-bias ratings. The methodolog- may be cost implications, and shared decision-making is
ical quality of studies chosen as primary evidence was essential because different choices of interventions may be
assessed (Table S1): overarching systematic reviews (which appropriate for individuals (children/young people and fami-
included primary RCTs) using the revised A MeaSure- lies).
ment Tool to Assess systematic Reviews (AMSTAR 2);15
randomized trials using the Cochrane Risk of Bias-2 Good practice recommendations
(RoB 2);16 and non-randomized studies using the Risk Of The multidisciplinary panel drafted good practice recom-
Bias In Non-randomized Studies of Interventions mendations for questions outside the scope of the system-
(ROBINS-I).17 atic review, following the GRADE approach for ungraded

Clinical Practice Guide Michelle Jackman et al. 539

recommendations.20 The panel based these recommenda- intervention options. Recommendations are summarized in
tions on their consensus views of currently accepted ethical Tables 1 and 2.
and healthcare standards for children and young people
with CP. These were reported separately. GOOD PRACTICE RECOMMENDATIONS
General principles to improve the process and content of
RESULTS care when working with children and young people with
The guideline comprises 13 recommendations: four CP and their families are recommended for addressing
evidence-based graded recommendations (three systematic functional goals. These recommendations are relevant to
reviews inclusive of randomized trials, 30 randomized tri- all subtypes of CP. Clinical reasoning and decision-making
als, and five before–after studies) and nine ungraded good should always involve weighing up individual children and
practice recommendations. Search results are summarized young people’s and families’ preferences, context, clinical
in a Preferred Reporting Items for Systematic Reviews and and health system affordances, plus the certainty of the evi-
Meta-Analyses (PRISMA) flowchart (Fig. S1). dence. Depending on the circumstances and context, it
We present broad recommendations for each functional may only be possible to follow some, rather than all, of
goal, followed by more specific recommendations about these recommendations; this decision should be grounded

Table 1: Good practice recommendations for interventions to improve physical function for children and young people with cerebral palsy
Recommendation 1: Client-chosen goals should be set
• Intervention should always begin with understanding the child’s functional goals. If the child is unable to identify their own goals,
families should be engaged to set goals considering the child’s preferences and interests
• Goals should be functional, well defined, achievable, and measurable
• Goals should be incremented according to the child’s level of ability and progress
• A written copy of the goals should be provided to the child/family
• Goal performance should be measured at the beginning and completion of the intervention
Recommendation 2: Clinicians should determine the factors that are limiting goal achievement
• Clinicians should observe the child carrying out the task/goal to determine the specific skills or barriers that are limiting goal achieve-
ment
Recommendation 3: Intervention should directly target the child’s chosen goals
• Intervention should involve active practice of the goal. Clinicians should use a ‘hands-off’ approach as much as possible, providing
opportunities for the child to actively and independently practice the task they wish to achieve
• Clinicians can assist children and young people by encouraging child-led problem-solving, identifying where task achievement is
unsuccessful, and providing feedback on how task performance can be improved
• If the goal is broken down into part-task practice, intervention should be followed by whole-task practice of the goal once the child is
ready to do so
Recommendation 4: Intervention should be enjoyable and motivating for the child
• If the child is crying or distressed, the clinician should stop, comfort the child, and change the intervention to match the child’s ability,
needs, and preferences
Recommendation 5: Practice of goals should occur within the child’s home or community environments
• Functional training is maximized by considering the context of practice. Achievement of the goal is more likely to be carried over into
everyday life if it is practised within everyday environments, such as the child’s home or community
• When this is not possible, practice should occur within an environment that simulates real-life as much as possible
• Recommendations for practice at home should be given in written or visual formats
Recommendation 6: Parent-delivered intervention is a key component of all intervention
Clinicians should provide the following:
• Education, coaching, and information to support caregivers to be actively engaged in the intervention, including encouraging auton-
omy, problem-solving, and task-specific practice of goals
• A structured home programme, which involves practice of the child’s chosen goals
• Ongoing review as well as child and family support
Recommendation 7: Children and young people and parents should remain the decision-makers throughout
• Clinicians have a responsibility to provide families with up-to-date evidence, to enable them to make informed decisions about the
best intervention for their child
• Parental engagement is a key factor in the success of an intervention
• Intervention recommendations should be tailored to match the child’s functional ability and potential
• Timing and content of interventions should consider individual factors, such as age, ability level, resources, and individual child and
family preferences
• Only feasible, acceptable, and effective interventions should be recommended and/or performed
Recommendation 8: A high enough dose of practice needs to be undertaken to achieve functional goals
• Clinicians should consider how an optimum dose can be achieved when planning intervention, including face-to-face therapy and
home practice
• The optimum dose may vary depending on the child, the complexity of the goal, the type of intervention chosen, and context/resources

Recommendation 9: A team approach should be used to set goals and the intervention regimens
• A team approach (including the child and family as team members) to setting goals and making decisions about intervention regi-
mens can streamline services and prevent overburdening of families

540 Developmental Medicine & Child Neurology 2022, 64: 536–549

Table 2: Evidence-based practice recommendations for interventions to improve physical function for children and young people with cerebral palsy
(CP)
Strength of recommendation and quality of
Evidence-based practice recommendations evidence

Recommendation 10: Mobility

To improve mobility in children and young people with CP (GMFCS I–IV, all motor Strong recommendation for mobility training
subtypes) we recommend mobility training using a goal-directed approach, with a as there is high certainty of harm from no
focus of practice within a real-life context, compared with no intervention interventiona
10.1 Walking speed and endurance Conditional recommendation for overground
To improve walking speed and endurance in children and young people with CP, walking, treadmill training, goal-directed
we suggest overground training (with or without a walker) (GMFCS I–IV), treadmill training, HABIT-ILE, and context-focused
training (GMFCS I–III), and HABIT-ILE (GMFCS I–IV), compared with no Moderate certainty for overground training
intervention OR body functions and structure intervention Low certainty for treadmill training, goal-
10.2 Gross motor function directed training, HABIT-ILE, and context-
To improve functional mobility goals and balance in children and young people focused
with CP, we suggest goal-directed training (GMFCS I–III) and HABIT-ILE (GMFCS I–
IV), compared with no intervention OR body functions and structure intervention
To improve gross motor function in children and young people with CP (GMFCS I–
IV), we suggest either altering environmental factors (e.g. ‘context focused’) OR
child-focused therapy (i.e. treatments that alter child-related factors)
We suggest clinicians consider the child’s age, ability, and child/family preferences
and tolerance of adjunctive interventions when selecting interventions
Recommendation 11: Hand use
To improve goal achievement in hand use in children and young people with CP Strong recommendation for CIMT and
(MACS I–IV, all motor subtypes), we recommend a goal-directed or task-specific bimanual
approach, compared with no intervention OR body functions and structure High certainty for CIMT. Moderate certainty
intervention for bimanual training/HABIT
To achieve functional upper-limb goals in children and young people with Conditional recommendation for CO-OP, goal-
unilateral CP, we recommend CIMT, bimanual therapy/HABIT (MACS I–III), and we directed, and HABIT/HABIT-ILE
suggest CO-OP and HABIT-ILE (MACS I–IV) compared with no intervention OR Low certainty for CO-OP, goal-directed, and
body functions and structure interventionb HABIT/HABIT-ILE
To achieve functional hand use goals in children and young people with bilateral
CP, we suggest HABIT/HABIT-ILE (MACS I–III) and CO-OP (MACS I–IV) compared
with no intervention OR body functions and structure interventionb
To improve hand use in children and young people with CP classified in MACS
level IV (unilateral or bilateral), we suggest a goal-directed focus plus
environmental adaptations and equipment/assistive technology to maximize
independence, compared with no intervention OR no equipment/assistive
technology OR body functions and structure interventionb
We suggest clinicians consider the child’s age, ability, context/resources, and
child/family preferences and tolerance of adjunctive interventions when selecting
interventions

Recommendation 12: Self-care

To improve self-care goal achievement in children and young people with CP (all Strong recommendation as there is high
motor types and severities), we recommend a goal-directed and task-specific certainty of harm from no interventiona
approach (for skills development) plus adaptive equipment (for safe, timely Moderate certainty for context-focused, goal-
independence), compared with no intervention directed training and HABIT. Low certainty
To improve self-care skills in children and young people with CP (GMFCS I–IV, all for CO-OP,a HABIT-ILE
motor types), we recommend goal-directed training, CO-OP, and HABIT,
compared with no intervention or body functions and structure intervention,b and
we suggest HABIT-ILE (GMFCS I–IV, all motor types)
To improve independence, safety, and decrease caregiver burden during self-care
tasks for children and young people with CP (GMFCS IV and V, all motor types),
we suggest adaptive equipment
Recommendation 13: Leisure
To improve performance of a leisure activity in children and young people with CP, Conditional recommendation
we suggest clinicians combine goal-directed approaches (CO-OP, goal-direct Most individuals would choose this option;
training, HABIT-ILE for GMFCS I–IV; and goal-directed training for GMFCS V) with however, there is limited direct evidence
a focus on supporting the individual to overcome environmental, personal, and Low certainty
social factors that may limit participation, compared with no intervention or body
functions and structure interventionb
a
A strong recommendation was assigned because this clinical problem area is always a high priority for families and there is high-quality
evidence of harm from no intervention (in population register studies) including decline in musculoskeletal deformity, walking, and self-
care skills when these interventions to improve are not in use. bMore detailed information on comparator interventions are available in the
Evidence to Decision Appendices S7–S10 (online supporting information). GMFCS, Gross Motor Function Classification System; HABIT-ILE,
hand–arm bimanual intensive training including lower extremity; MACS, Manual Ability Classification System; CIMT, constraint-induced
movement therapy; CO-OP, cognitive orientation to occupational performance.

Clinical Practice Guide Michelle Jackman et al. 541

in good clinical reasoning. It is likely that knowledge trans- practice may be undertaken as a first step towards whole-
lation efforts will be needed by the field to overcome task practice. Providing feedback to the child is an impor-
health system barriers that limit implementation of these tant part of learning a new task or skill.29,30 Feedback can
recommendations (e.g. availability of intensive therapy). be provided verbally or may involve child-led problem-
solving as a part of the intervention. Feedback can be
Good practice recommendation 1 inherently built into task practice so that the child knows
Client-chosen goals should be set21–24 when they have succeeded.
Intervention should begin with understanding the children If a body functions and structure barrier to goal perfor-
and young people’s goals to harness the ICF personal fac- mance is identified, intervention might include a body
tor of motivation and interests. Inviting children and functions and structure intervention paired with task-
young people to identify the functional skills and abilities specific training to support task performance. For example,
that are most important to them, then setting small, realis- if the goal was to play tennis and one of the goal-limiting
tic goals, can improve motivation and outcomes.25 If the factors was that the child could not sustain their grip of
child is unable to identify their own goals (owing to age or the racket, grip strength training might be paired with
ability), goals should be discussed with families (‘family’). practice in maintaining a grip of the racket while playing
Some children and young people and families may find tennis.
setting goals challenging, particularly if they have no expe-
rience, or a cultural preference for expert-delivered care. Good practice recommendation 4
Therapists can discuss what is realistic for the child on the Intervention should be enjoyable and motivating for the
basis of their ability level while ensuring the child’s inter- child28,31,32
ests and preferences are included when setting goals. For Intervention should involve enjoyable, motivating, and
younger children, caregivers may need information about challenging activities. If the child is crying or distressed,
realistic developmental and prognostic trajectories the clinician should stop, comfort the child, and change
(‘family’). To identify goals, clinicians can discuss the the intervention to match the child’s needs and prefer-
child’s ‘typical’ daily routine, or use a standardized tool ences. If the intervention is painful and/or distressing, it is
such as the Canadian Occupational Performance Mea- not recommended.
sure.26 It is important to consider activities the child enjoys
or wishes to participate in (‘fun’), and that are most impor- Good practice recommendation 5
tant to them. Goals should be specific and measurable, Practice of goals should occur within the child’s home or
such as the SMART (specific, measurable, achievable, real- community environments where possible11
istic, timely) goal format.27 Clinicians should set a time- The child is more likely to be able to achieve their goal in
frame within which the goal is achievable, and measure the everyday life if it is actually practised within their home or
goal at the beginning and end of intervention with feed- community. When this is not possible, practice should
back to the family because this promotes adherence, satis- occur within an environment that simulates real-life as
faction, and adequate intensity of practice.28 much as possible. This may include practice of the whole
task within the clinic environment, or similar environment
Good practice recommendation 2 (e.g. an outdoor space if the goal is an outdoor activity).
Clinicians should determine the factors that are limiting Children and young people and families can bring
goal achievement10 resources for goal practice into the clinic (e.g. if the goal is
Once the child has identified their goals, clinicians should improving basketball skills, the child can bring the ball
carry out structured observations and task analysis of the they use at home/school). Clinicians can plan with the
child attempting their goal. Clinical reasoning is then used child and family how and when practice can be undertaken
to determine the factors that are limiting goal achievement during the family’s daily routine.28 This will facilitate
and to identify the task components or specific skills that carry-over of skills into everyday life.
need to be targeted, while considering barriers (including
environmental and social barriers and/or body functions Good practice recommendation 6
and structure). Parent-delivered intervention can be used to supplement
face-to-face therapy when appropriate education is
Good practice recommendation 3 provided33
Intervention should directly target the child’s set goals10 Parent-delivered intervention is recommended as an
Intervention should focus on actively practising the goals, important supplement to face-to-face therapy. To support
rather than attempting only to address underlying impair- a home programme, clinicians should (1) establish a collab-
ments (such as muscle weakness, joint range of motion, or orative partnership with the family; (2) empower the child
proprioception). A child’s active practice involves a ‘hands- and family to set their own goals for intervention; (3) pro-
off’ therapy and coaching approach, allowing them to self- vide a list of feasible and enjoyable activity ideas and
initiate and perform tasks to their full potential.10 When resources in written format with photographs, ideally of
the child is unable to practise the whole task, part-task the child doing the task, that can be done at home; (4)

542 Developmental Medicine & Child Neurology 2022, 64: 536–549

demonstrate, educate, and coach parents on how to sup- To achieve functional goals, goal-directed training, in
port practice at home; and (5) check in regularly with fam- which the whole goal is practised, is recommended. Goal-
ilies (telephone, video, e-mail, or face-to-face) to provide directed training is feasible, even in settings where high-
support and update the programme as needed.33 Parent- dose or high-intensity interventions are not affordable or
delivered interventions may be particularly important in available. The optimum dose of intervention will vary
underdosed models of healthcare.34 It is also important for depending on the individual, the complexity of the goal,
therapists to support parents to remain in the role of par- and the type of intervention. As a general guide, a thresh-
ent, and not become a therapist at home (‘family’). Some old dose of 15 to 25 hours of goal practice may be needed
families may find it preferable for the intervention to be (for three upper-limb goals).37 More than half of this can
clinician-delivered so as not to disrupt family routines and be family-led practice.37 If the goal of intervention includes
roles. Clinicians should adapt the intervention plan accord- more generalized improvement of motor ability (rather
ing to family preferences. than a specific functional goal) it is likely that a threshold
dose of over 40 hours of practice is needed.37 An intensive
Good practice recommendation 7 block of therapy is recommended over regular low-dose
Children/young people and parents should remain the distributed therapy, as children and young people may find
decision-makers throughout28,35,36 it easier to learn a new skill within a dedicated timeframe.
Clinicians should provide families with up-to-date evidence, Practice and progress can be tracked by a logbook or
to enable families to make informed decisions about the best reward chart.
intervention for their child. In addition to considering the The natural history of CP involves physical decline with
child’s goals, age, and ability level, families should be age. Mobility and self-care skills are known to be particu-
invited to develop their own ideas about how to achieve the larly vulnerable to decline, and regular use of these skills at
goals and to consider the most important people in the a high enough dosage will be required for maintenance of
child’s life to support learning. Parental engagement is a skills. Furthermore, some body functions and structures,
key factor in the success of an intervention (‘family’). Build- such as muscle strength and ‘fitness’, also decline with
ing a strong relationship between the clinician, child, and sedentary behaviour and may require intervention so as not
family, and allowing children and young people and families to confound goal achievement.
to be actively engaged in decision-making, leads to better
clinical outcomes.28 Clinicians should empower parents to Good practice recommendation 9
understand that choosing not to do certain interventions or A team approach should be used to set goals and
using compensatory approaches such as equipment and intervention regime38
environmental adaptation is not giving up; rather, it is facili- Multidisciplinary/interdisciplinary teamwork can streamline
tating increased independence and respect for the child’s services and prevent overburdening of families. As children
time and preferences. Clinicians should not recommend and young people have needs across many areas and
interventions known to be ineffective or unsuitable to the disciplines, child-led goal-setting, prioritization, and inter-
child’s functional abilities. vention should occur as a team, rather than multiple
single-discipline goals being practised in isolation. It is rec-
Good practice recommendation 8 ommended that the child (rather than clinicians) prioritizes
A high enough dose of practice needs to be undertaken three goals, and the appropriate clinicians support inter-
to achieve functional goals vention planning. Once these goals have been achieved,
It is important to consider dose of practice when making a new goals can be set.
decision about intervention options as different interven-
tions may require more or less practice to be successful.
EVIDENCE-BASED RECOMMENDATIONS
Clinicians and families may need to plan how the effective
dose will be achieved. Clinicians should inform families
Evidence-based recommendation 10
Gross motor function and mobility
when an intervention is unlikely to be successful if their
To improve mobility in children and young people with
child does not practice enough to reach the threshold dose.
CP (classified in Gross Motor Function Classification Sys-
For interventions aimed at improving function, the thresh-
tem [GMFCS] levels I–V, all motor subtypes), we recom-
old dose is the amount of practice needed to achieve a
mend mobility training using a goal-directed approach,
goal. In many settings, ‘intensive’ or ‘high-dose’ interven-
with a focus on whole-task practice within a real-life con-
tions may not be realistic, often because of historical mod-
texts, compared with no intervention.
els of service and/or funding constraints. Therapists and
families should discuss how threshold doses can be reached
through a combination of face-to-face therapy and families Strong recommendation based on high certainty evidence
providing the other necessary portion of the known effec- of harm from no intervention
tive dose. Providing underdosed services is not recom- Walking speed and distance. When aiming to improve walk-
mended and is potentially an ineffective use of the child’s ing speed and distance for children and young people clas-
time and the health system’s finances. sified in GMFCS levels I to III, we suggest the practice of

Clinical Practice Guide Michelle Jackman et al. 543

walking.39,40 Treadmill training can increase the dose of Strong recommendation based on low to high certainty
walking practice if this equipment is available. evidence
General mobility training, overground walking, and sit- For all children and young people with CP who have goals
to-stand training may improve walking speed and dis- related to use of their hands, a goal-directed approach
tance.39–42 These interventions should be supplemented involving whole-task practice is recommended (e.g. train-
with practice of walking within the child’s real-life environ- ing the whole task of handwriting, not training finger dex-
ments and terrains. terity, and assuming this will transfer to improved
For children and young people classified in GMFCS handwriting). There are numerous effective intervention
levels IV and V, overground walking practice is more options, and the choice will depend on the child’s cogni-
effective than partial bodyweight-supported treadmill train- tive ability, motor-type, topography, goal, child and family
ing for improving walking distance, but both treatments preferences, and available resources.
provide the experience of supported walking and will not For children and young people classified in MACS level
lead to independent walking. For children and young peo- IV, clinicians should use goal-directed training and con-
ple classified in GMFCS levels IV and V, the experience of sider environmental adaptations and equipment that can
walking might be a well-being and inclusion goal, rather increase the child’s independence and decrease caregiver
than a functional mobility goal (‘friends’). Despite this, burden.
partial bodyweight-supported treadmill training may lead An upper-limb decision algorithm (Fig. 2) has been
to improved transfer abilities. In low- to middle-income developed to guide clinicians, although individualized clini-
contexts, whole-task practice is more affordable and feasi- cal reasoning should always take precedence.
ble than partial bodyweight-supported treadmill training For children and young people with unilateral or asym-
and is therefore preferentially recommended in these con- metric CP, in MACS levels I to III, intensive models of
texts. CIMT and bimanual therapy lead to similar sized improve-
Gross motor function. When aiming to improve gross ments,49 but CIMT will produce unimanual improvements
motor function for children and young people classified in whereas bimanual therapy will produce bimanual improve-
GMFCS levels I to III, goal-directed or task-specific train- ments. This means the goals for intervention must be con-
ing in which the whole task or goal is practised is sug- sidered. When both unimanual and bimanual outcomes are
gested. Part-task practice may be undertaken as a first step sought, families can choose the approach that suits them
towards whole-task practice. best. When using either approach, the intervention should
HABIT-ILE,43,44 context-focused therapy,45,46 and goal- be targeted at the desired goals and followed by whole-task
directed motor training47,48 can also be used to improve practice of the child’s goals.
gross motor function in children and young people classi- CIMT may be the most appropriate intervention option
fied in GMFCS levels I to IV. when the child is unable to use their more affected hand as
Independent mobility for children and young people an effective ‘helper hand’, and they can tolerate a
classified in GMFCS level IV should focus on adaptive restraint.49 Intervention should not aim for the child to be
equipment (e.g. powered mobility) that supports effective able to use their more affected hand equally as well as their
and efficient goal achievement, rather than focusing on preferred hand because in most real-life tasks the dominant
general gross motor skills. For children and young people and non-dominant hands take different roles and have dif-
classified in GMFCS levels III to IV, we recommend that ferent skill levels. CIMT trials have mostly included chil-
functional goals be addressed in combination with equip- dren with active wrist extension and ability to grasp.49
ment, technology, and environmental adaptations to maxi- Caution using CIMT is warranted in children and young
mize independence, inclusion, speed of task completion, people with limited hand function, as frustration can arise
and to reduce energy consumption and caregiver burden. and the age appropriateness of simple one-handed actions
We recommend that the child sets specific and achievable and activities should be considered. In children younger
mobility goals and directly practises these (e.g. reposition than 2 years of age, lower doses of CIMT are recom-
themselves in bed). mended to safeguard the development of the dominant
More detailed recommendations to improve functional hand.
mobility are provided in Appendix S7. There is limited benefit to wearing the restraint unless
targeted task practice is undertaken concurrently.49 Similar
Evidence-based recommendation 11 improvements occur from mitts, slings, splints, or casts,
Hand use in functional activities with removeable soft restraints preferred by children. The
To improve goal achievement in hand use in children and child should be given as much control as possible over the
young people with CP (in Manual Ability Classification type of constraint chosen (e.g. choice of material or col-
System [MACS] levels I–IV, all motor subtypes), we rec- our). If the child is distressed by the restraint, a different
ommend a goal-directed or task-specific approach, com- approach should be used (i.e. bimanual therapy or goal-
pared with no intervention or body structures and function directed training). CIMT should always be followed by
intervention. whole-task practice without the restraint.

544 Developmental Medicine & Child Neurology 2022, 64: 536–549

 Goal setting: Child has functional goal requiring hand use

Unilateral CP Bilateral CP

MACS I–III MACS I–III MACS IV–V

Goal = Improved unimanual Goal = Improved bimanual Asymmetrical Symmetrical Sufficient motor capacity to achieve the goal?
(unimanual goal may be set to
work towards bimanual goal)
No Yes
Affected hand has the motor
capacity to achieve the goal?
Yes Does the lesser affected Would addressing the goal limiting Consider Consider
Is there potential to change
Yes No hand have grasp? factors enable a training approach? Task adaptation Goal-Directed
capacity of affected hand? Equipment Training
Consider No Yes No Assistive HABIT-ILE
Yes No Technology CO-OP
Bimanual Training
Suffient vision and Goal-Directed Training
HABIT-ILE
tolerance for CIMT? No
CO-OP Goal Achieved?
Yes No Evaluate INTERVENTION SPECIFIC CONSIDERATIONS
Goal limiting factors:
Bimanual Training
Consider Spasticity / Dystonia | Consider Appropriate for functional goals or when the aim of intervention is to improve overall bilateral motor ability.

CIMT followed by Goal Achieved? May require 30–40 hours of practice

Botulinum neurotoxin A
Bimanual Training Pharmacological management CO-OP
No
Children need to set own goals. Language and cognition skills needed for child to problem-solve. Those under
Cognition | Consider 5 years of age, or significant cognitive impairment may not be appropriate. May require 15–25 hours of practice.
Consider Bimanual Training
Task adaptation Goal-Directed Training CIMT
Equipment Appropriate for children whose goal is to improve use of ‘helper hand’. Children with poor tolerance of restraint
Assistive Tolerance | Consider
and those with very limited active movement of affected hand may not be appropriate. 30–40 hours of practice.
Technology Bimanual Training
Goal-Directed Training
Mirroring | Consider Children with cognitive difficulties or very poor attention may benefit from Goal-Directed Training, as it
IMPORTANT: Clinical reasoning should always take Bimanual Training provides more structured, step-by-step instruction from the therapist. May require 15 to 25 hours of practice.
precedence. Individual factors including child and family
preferences, type of goal, cognition, behavior, and Vision | Consider HABIT / HABIT-ILE
available resources are important considerations. Adjunctive visual strategies Appropriate for those 6 years and over. Requires 80–90 hours of intensive intervention with trained clinician.

Figure 2: Decision algorithm for hand use in functional activities.

Bimanual therapy involves selecting activities and setting Strong recommendation based on high certainty of harm
up the environment to promote spontaneous use of both from no intervention
hands, and negate the need for verbal or physical prompts. Goal-directed and task-specific training can lead to
Activities and games need to be carefully selected to promote achievement of self-care goals and is recommended over
bimanual hand use while concurrently considering the role interventions that address underlying impairments. CO-
of the more affected hand when completing the desired OP, HABIT, and goal-directed training are all effective
bimanual activity (e.g. stabilization by weight/support, stabi- goal-directed and task-specific approaches.33,43,51,53 Envi-
lization by grip or manipulation). HABIT/HABIT-ILE are ronmental adaptations and equipment that can complement
two protocolized versions of bimanual therapy.43,50 Similar the task-specific approaches to achieve goals are recom-
to CIMT, bimanual therapy should be followed by whole- mended but may not be available in low-income contexts.
task practice of the specific goal. CO-OP is feasible with children with all subtypes of CP
For children and young people with bilateral CP, there is older than 4 years,51,53 MACS levels I to IV, with verbal
emerging research into effective therapies to improve hand communication (or communication device), and problem-
function. We recommend using a goal-directed training solving skills. Importantly, CO-OP seems to be beneficial
approach, in which the focus of intervention is whole-task prac- for children with dystonic CP.54
tice (all ages, MACS levels I–IV) or CO-OP51 (aged >4y, HABIT or HABIT-ILE is suggested because it is fea-
MACS levels I–IV), HABIT-ILE44 (aged >6y, GMFCS levels sible with children classified in GMFCS levels I to IV
I–IV, MACS levels I–III), or HABIT52 (aged >4y, GMFCS with all subtypes of CP older than 4 years, and may lead
levels I–IV, MACS levels I–III) to achieve hand function goals. to improvements in overall motor ability, self-care, and
More detailed recommendations to improve hand use individual goal achievement.43,44 HABIT and HABIT-
are provided in Appendix S8. ILE are high-intensity approaches that require a high
dose (90h over 10d) to be effective. CO-OP requires a
Evidence-based recommendation 12 lower dose of intervention than HABIT and HABIT-
Self-care ILE, and therefore may be more feasible and cost effec-
To improve self-care goal achievement in children and tive. If the therapist is not certified in CO-OP, or
young people with CP (all motor types and severities), we trained in HABIT or HABIT-ILE, goal-directed training
recommend a goal-directed and task-specific approach (for is recommended.
skills development) plus adaptive equipment (for safe, More detailed recommendations to improve self-care
timely independence), compared with no intervention. goals are provided in Appendix S9.

Clinical Practice Guide Michelle Jackman et al. 545

Evidence-based recommendation 13 equipment and assistive technology may not be affordable
Leisure or available in low- to middle-income contexts, which
To improve performance of a leisure activity in children and may substantially curtail the child’s inclusion. Adaptive
young people with CP, we suggest that clinicians combine equipment and assistive technologies are discussed within
goal-directed approaches (CO-OP, goal-directed training, the adjunctive interventions overview of the evidence table
HABIT-ILE for GMFCS levels I–IV; and goal-directed (Appendix S1) but are not a focus of this guideline.
training for GMFCS level V) with a focus on supporting the
individual to overcome environmental, personal, and social Adjunct, body functions and structures, and
factors that may limit participation, compared with no inter- complementary and alternative medicine interventions
vention or body functions and structure intervention. International consultation with key stakeholders identified
that clinicians often seek evidence about commonly used
Conditional recommendation based on low certainty interventions that do not meet our definition of interven-
evidence tions to improve function, and which are therefore
Children and young people with CP participate in leisure excluded from this guideline. To address this need, supple-
activities less than their peers55–57 and the variety of lei- mentary information has been developed to provide an
sure options is limited. When leisure is the focus, inter- overview of adjunctive interventions, which are concurrent
vention should include child-chosen goals, identification of interventions that might boost functional effects
individual, social, and environmental barriers (‘friends’), (Appendix S1), body functions and structure interventions
motivational interviewing, whole-task practice within real- (Appendix S2), and complementary and alternative medici-
life environments, and environment-focused strategies nes, which parents often seek to trial (Appendix S3). They
including equipment prescription and site visits. Par- are based on current best available systematic reviews and
ticiPAte CP58 and the Pathways and Resources for RCTs, retrieved using a systematic search and reported in
Engagement and Participation have been shown to lead to an overview of systematic reviews.64
improvements in individual participation goals,59 as has
intervention that directly addresses environmental and DISCUSSION
social barriers using a coaching approach.60 Research No clinical practice guideline has ever focused on physio-
focusing broadly on participation recommends that impair- therapy and occupational therapy for improving physical
ment focused interventions should not be used, and that function in children and young people with CP at the
intervention should be goal-directed and family- activities and participation level of the ICF, even though it
centred.61,62 had been a priority identified within the field.65 This
It is important that leisure goals are chosen by the child guideline provides practical and accessible recommenda-
and done for enjoyment (‘fun’), and that the focus is on tions that clinicians across the world can perform to align
participation outside of the therapy environment (‘friends’). their practice with the World Health Organization’s ICF
More detailed recommendations to improve leisure goals framework. When the aim of intervention is to improve
are provided in Appendix S10. physical function for children and young people with CP,
the following nine important elements should be included.
Children and young people with severe motor impairment (1) Client-chosen goals should be set to identify meaning-
It is acknowledged that children and young people with ful tasks and harness motivation. (2) Clinicians should
severe motor impairment (in GMFCS level V or MACS observe the child attempting their functional goal to deter-
level V) are unlikely to benefit from training interventions mine the factors that are limiting goal achievement. (3)
to improve function, although it is important to recognize Intervention should focus on whole-task practice of the
that children and young people with severe impairment goals to improve task performance. (4) Intervention should
can contribute to everyday tasks through small actions, be enjoyable and motivating to harness plasticity. (5) Prac-
and changing environmental factors through adaptive tice of the goals should occur within real-life environments
equipment can support function and inclusion.63 Comor- (or simulate the child’s real-life environment as much as
bidities in children and young people with severe motor possible) to expedite generalization. (6) Support should be
impairment can affect function and may need to be medi- provided to families to facilitate practice at home to
cally managed for functional goals to be realized. increase the dosage of practice. (7) Clinicians should
Although not the focus of this guideline, interventions to inform and empower children and young people and fami-
reduce pain, manage seizures, improve nutrition, and lies to make their own decisions about interventions to
reduce vomiting may reduce hospital admission and make respect preference and foster engagement. (8) A high
learning more successful, thus fostering participation in enough dose of practice should be planned for goals to be
everyday activities. Children and young people with severe achieved to achieve clinically meaningful gains and harness
physical disabilities benefit from adaptive equipment and plasticity. (9) A team approach to goal-setting and inter-
assistive technology to support their full inclusion within vention should be used for streamlining services and
functional activities. It is acknowledged that adaptive enhancing communication.

546 Developmental Medicine & Child Neurology 2022, 64: 536–549

 To improve mobility outcomes, direct practice of the guideline: Mina Ahmadi Kahjoogh (occupational therapist, Iran),
mobility goal should be undertaken. When the goal is Yannick Bleyenheuft (physiotherapist, Belgium), Marina Brand~ao
walking, overground walking is recommended to improve (physical therapist, Brazil), Dianne Damiano (physiotherapist,
walking distance and speed. Treadmill training (where USA), Ann-Christin Eliasson (occupational therapist, Sweden),
available) can be an effective supplement to overground James Espie (parent of young person with CP, Australia), Darcy
walking to increase the dose of practice for improving Fehlings (physician, Canada), Hortensia Gimeno (occupational
walking speed. To improve hand use outcomes, CIMT, therapist, UK), Andrew Gordon (movement scientist, USA), Asis
bimanual therapy (including HABIT/HABIT-ILE), and Ghosh (physiotherapist, India), Karen Harpster (occupational
CO-OP are effective approaches. For learning self-care therapist, USA), Karen Keith (parent of young person with CP,
skills and improving independence in self-care outcomes, Australia), Katrijn Klingels (physiotherapist, Belgium), Marjolijn
goal-directed training, CO-OP, and HABIT/HABIT-ILE Ketelaar (physiotherapist, the Netherlands), Judy Lindsay (physio-
are potential options, supplemented by adaptive equipment therapist, USA), Annette Majnemer (occupational therapist,
(where available) to improve safety and lower caregiver Canada), Eugene Rameckers (physical therapist, the Netherlands),
burden. To improve leisure performance and participation, Keiko Shikako Thomas (occupational therapist, Canada), Kristy
task-specific practice should be combined with supporting Steinau (physiotherapist, USA).
the individual to overcome environmental, personal, and LS was supported by a National Health and Medical Research
social barriers to achieve participation. Factors including Council Career Development Fellowship (1160694) and Chil-
age, cognitive and functional ability, individual preferences, dren’s Hospital Foundation Mary McConnel Career Boost for
policies, and available resources will guide the most appro- Women. RNB was supported by a National Health and Medical
priate intervention approach for the child’s chosen goal. Council Research Fellowship (1105038). The funding bodies had
This review has several limitations. There were no exist- no role in the design, conduct, or reporting of the study. The
ing systematic reviews that addressed our overarching clini- authors have stated that they had no interests that might be per-
cal questions. As such, multiple systematic reviews and ceived as posing conflict or bias.
clinical trials were identified using a systematic review
methodology, appraised and interpreted to develop these DATA AVAILABILITY STATEMENT
guidelines. Good practice recommendations are based on The data that supports the findings of this study are avail-
best available evidence; however, many of these principles able in the supplementary material of this article.
have not been verified in high-quality trials. The senior
authors resided within Australia, and although over 400 SUPPORTING INFORMATION
non-Australian clinicians were consulted and 19 non- The following additional material may be found online:
Australian authors reviewed the manuscript, this may be a Figure S1: PRISMA flow diagram of evidence.
cultural limitation for implementing recommendations in Table S1: Included studies chosen as primary evidence
all global contexts. Table S2: Included studies not selected as overarching primary
evidence
CONCLUSION Table S3: Excluded studies with reason for exclusion
When aiming to improve functional goals for children and Appendix S1: Adjunct interventions.
young people with CP, it is best practice for client-chosen Appendix S2: Body structures and function interventions.
goals to be set, and for intervention to be focused on Appendix S3: Complementary and alternative medicine inter-
whole-task practice of the goals, rather than addressing ventions.
underlying impairments. Setting functional goals, and Appendix S4: Stakeholders, review process, and managing
directly practising those goals, is a low-cost approach to conflict of interest.
intervention that can be applied across many settings, Appendix S5: Methods.
including those where resources are limited. Information Appendix S6: Search terms.
sheets have been developed to facilitate translation of these Appendix S7: Mobility (including transfers).
recommendations into practice, and are available via links Appendix S8: Hand use functional activities.
provided in Appendix S11. Appendix S9: Self-care.
Appendix S10: Leisure.
A CK N O W L E D G E M E N T S Appendix S11: Information Sheets to support translation of
We sincerely thank the expert international panel members and guideline recommendations.
consumer stakeholders who provided consultation on this

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