Factors Influencing the Gross Motor Outcome of Intensive Therapy in Children with Cerebral Palsy and Developmental Delay
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Article Summary:
Title: Factors Influencing the Gross Motor Outcome of Intensive Therapy in Children with Cerebral Palsy and Developmental Delay
Purpose: The purpose of this study was to identify factors that are influential in determining the effectiveness of intensive therapy programs on gross motor function in children who have cerebral palsy (CP) or various developmental delays.
Study Population: The population of this study targets children with CP or developmental delays. Inclusion criteria for this study required participants to be less than 7 years old with developmental delays that required both physical and occupational therapy. Mean age at initiation of treatment was 32.62 months with a mean corrected age of 31.09 months. 103 participants, 51 males and 52 females, were recruited via caregiver request or physician recommendation. 80 participants had CP, 11 participants had genetic abnormalities, and 12 participants had developmental delays of unknown cause. 58 of these participants were born prematurely and 39 participants had seizure disorders. Additionally, 73 of the participants had spastic type CP and 19 of these 73 participants had received botulinum toxin injections during or within 1 month prior to treatment.
Methods and Intervention: Subjects participated in an intensive therapy program daily for 8 consecutive weeks. Each daily session involved 3 hours of treatment; 2 hours of therapist-lead intervention with a break every 30 minutes and 1 hour of self-lead therapy. Self-therapy was supervised by therapists and included activities such as ergometry, standing with a stander, etc. Therapist-lead interventions were personalized and were determined by the participant’s development and condition. The following principles were applied to all individuals though: “(1) functional goal directed training, focusing on specific activities that are important in the developmental milestones of each child; (2) during the first week of treatment, parents were asked about their overall goals during the 8 weeks of therapy and this information was shared with the pediatric rehabilitation team. Patients’ goals, ongoing therapies, and any change in or new information pertaining to the patients were shared and discussed weekly among physicians and therapists; (3) application of neurodevelopmental therapy encompassing motor learning concepts; (4) standing at the standing frame or exercising on the cycle ergometer daily”. Additional individual information that was obtained and analyzed included age, sex, birth history, seizure history, medication history, and botulin toxin injection history. Data analysis was calculated at the end of the study based on the division of participants into 3 groups classifying cause of their developmental delay; CP, genetic disorder, or unknown cause.
Outcome Measures: The Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) were utilized to evaluate each child’s gross motor function. These measurements were both gathered at the beginning and end of participation in the intensive rehabilitation program. Depending on developmental age, the status of general development was assessed using the Bayley Scales of Infant and Toddler Development-III or the Gessell Developmental Test.
Results: This study revealed that 8 consecutive weeks of a daily intensive rehabilitation program resulted in an overall increase in GMFM score of 4.67 ±3.93 (P < 0.001). In the good responders group (top 25th percentile of change in GMFM score); GMFCS level II was determined to be the greatest influential factor in determining significant change in GMFM when compared to level III (P = 0.001), IV (P < 0.001), and V (P < 0.001). Positive responses to treatment were also associated with absence of seizure disorders (P = 0.002) and absence of cognitive impairments (P = 0.030). In the poor responders group (bottom 25th percentile of change in GMFM score); independent factors of age of ≥36 months (P = 0.013), GMFCS level IV and V (P= 0.002), and cognitive impairments (P = 0.039) were predictive of poor responses post-treatment and were not significant predictors in the effectiveness of intensive therapy on changes in gross motor via increased GMFM scores. However, combining influential factors of the poor responding groups resulted in overall poorer outcomes. Additionally, diagnosis (P > 0.05) and botox injections one month prior to or during the study (P = 0.962) were not determined to be influential factors in determining the effect of an intensive therapy program of this kind.
Strengths: This article executed a study with basic strengths involving a large sample size and reproducible interventions and assessment. Additionally, all participants were under age 7 (the age in which development of gross motor function plateaus).
Limitations: This study also had multiple limitations that could bias the stated results. There were no control groups involved and only a small number of participants in the study received botox injections and the majority of these participants were also lower level GMFCS (IV and V) which may not be a true representation of lack of botox effect. GMFM was used in this study with children with genetic diseases and developmental delays of unknown etiology; however, the GMFM has only been validated in children with CP and Down’s Syndrome. Lastly, there was no follow up study to evaluate carry over of improvements or if they were only short term effects.
Conclusion: This study demonstrated that more functional GMFCS levels (I and II) were the most indicative factor of greater response to intensive therapy on gross motor function. On the contrary, increasing age of the child (≥ 36 months) is more indicative of a poor response. Overall, GMFM measured changes in gross motor function as a result of an 8 week intensive therapy program in children with developmental delays. However, due to the lack of control groups in this study, it is difficult to state whether the identified improvements were truly due to the 8 weeks of intensive rehabilitation or if the improvements were due to natural development. There is also no evidence provided to determine potential long-term effects of this method of intervention.
Hong BY, Jo L, Kim JS, Lim SH, Bae JM. Factors Influencing the Gross Motor Outcome of Intensive Therapy in Children with Cerebral Palsy and Developmental Delay. Journal of Korean Medical Science. (2017); 32: 873-879.
5 responses to “Factors Influencing the Gross Motor Outcome of Intensive Therapy in Children with Cerebral Palsy and Developmental Delay”
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This was the exact same article I was going to review! I like that this study was more inclusive than other studies that I have looked at. I have very little experience with pediatrics, but this is definitely something I will keep in mind in the future when working with pediatric patients whom are diagnosed with CP.
I found this to be an interesting read. After reading the summary I began to think that since the GMFM has only been validated with children who have CP and Down’s Syndrome why include those who had an unknown cause of developmental delay? I wonder if it was to incorporate a larger sample size given that this demographic compromised nearing a tenth of the subjects in the overall study?
Very interesting study, especially because my client to class fits this inclusion criteria. 3 hours a day for 8 weeks sounds like a lot of therapy! Is this something that is typical in this population or with early intervention?
Becca,
I am not sure how common that high intensity is. In one of my clinicals we did bursts of high intensity therapy for several kids, especially during breaks from school. Our high intensity level though was only one hour/day for 4 days/week for 4-6 weeks. We saw positive effects from this intensity. However, I was not at that site long enough though to be able to see whether or not there would be any carry over when they returned to therapy several weeks or months later.
I find it interesting that the botox injections did not influence the effect of the intensive therapy program. After completing our research Case Study first year with a young man with CP, I have found that many studies place botulinum toxin injections in the exclusion criteria (with it’s possibility of affecting outcomes). I really enjoyed this article and like that it was more inclusive, also including all GMFCS levels. In regards to duration of interventions, I commend all therapists and caregivers present, because I am sure that many days those 3 hours brought some interesting challenges in emotional responses and participation.