# Exercise as it relates to Disease/The effect of intense physical therapy for children with cerebral palsy

The following information is an analysis of the original investigation article relating to "The effect of intense physical therapy for children with cerebral palsy".

## What is the background to this research?

Cerebral Palsy (CP) is the term for a range of physical disabilities that impair an individual’s movement and posture due to damage to the developing brain either during pregnancy or shortly after birth. The most common physical disability in childhood, over 17 million CP cases exist worldwide with an incidence rate of 1 in every 500 births.
CP children usually receive physical therapy services throughout childhood, with their formative years the most vital for developing motor skills. The optimal frequency, intensity and timing considered to provide the most significant improvement in sufferers is still relatively unknown. The need for an optimal intervention program is vital, as without reliable rehabilitation and orthopedic management, an individuals CP severity will increase. In regards, to intense physical activity interventions, it is important that researchers quantitatively determine the impact this type of program can have on functional activities and participation, and whether the intervention witnesses improvement significant enough to justify the time, cost and stress it can place on the CP child and their family.

## Where is the research from?

The Department of Physical Therapy at the University of Alabama at Birmingham provided the funding to this CP study with the Constraint-Induced Movement therapy approach to rehabilitation having been based on research at this institution.
Author Jennifer Braswell Christy, an associate professor at the university, has researched and published studies relating to the improvement of motor development and postural control for the past 12 years.
The study was published in the Journal of Paediatric Rehabilitation Medicine, a peer-reviewed academic journal.
As the sources of this study are reputable, it can be assumed that the results obtained (unless condemned by the authors) are valid and any assumptions made from this study on CP are reasonably accurate.

## What kind of research was this?

The study used a single group pre-test, post-test design which is a productive approach to assess the effectiveness of an intervention. This methodology assesses outcomes before and after an intervention to determine the success of the implemented program.
Results using this methodology often have a low level of evidence compared to a randomised controlled study due to the absence of any randomisation procedure and control group. This study therefore is prone to many forms of bias and the methodology used can sometimes be considered unsuitable to thoroughly assess the effectiveness of an intervention.

## What did the research involve?

Seventeen children (8 males and 9 females) with CP between the ages of 4 and 12 years participated in the intervention which lasted for three weeks involving four hours of a modified TheraSuit$^{TM}$ protocol from Monday to Friday. The protocol consisted of activities involving muscle stretching, muscle strengthening and gross motor skills such as walking, jumping and climbing.
The outcome measures were recorded using the Gross Motor Function Measure, Step-Watch Activity Monitor, Canadian Occupational Performance Measure and Pediatric Outcomes Data Collection Instrument which measured the performance of gross motor function, activities of daily living and walking parameters. Participants were tested twice at baseline and post-intervention four weeks and three months apart respectively.
The Canadian Occupational Performance Measure whilst considered valid and reliable can provide statistical problems as caregivers are required to report the ability of the child to perform certain activities and if the caregiver responds with inconsistent answers over the test period the overall variability of scores is affected.
The inclusion criteria for the study included a Gross Motor Function Classification System level I-III (See further readings 1), with all participants being Caucasian and from the outpatient Physical Therapy Department at Children’s of Alabama in Birmingham. This limits the study to a very small sample size, meaning results obtained cannot necessarily be considered valid and reliable to other CP children of different backgrounds.

## What were the basic results?

The study found improvements in performance of gross motor function and activities of daily living, as well as some walking parameters such as time spent active and the time at moderate-high levels of activity. However, it did not witness an improvement in the mean number of steps taken by participants.
The authors interpreted the results to be clinically important for gross motor function and statistically significant for the improvements in activities of daily living as they both improved on the results obtained from similar studies conducted by Oeffinger et al. and Bar Haim et al. (See further readings 2 & 3). The results of the walking parameters whilst encouraging were considered not statistically significant as the standard deviation between participants was very high indicating extreme variability between scores.

## What conclusions can we take from this research?

The results obtained whilst encouraging contain a number of factors that could influence the results leading to what is a perceived yet false improvement. Factors such as natural improvement due to maturation and a small sample size underpin the author’s findings. Contrary to this study, more recent literature by Kruijsen-Terpstra et al. has found intense physical therapy negatively affects a child’s well-being as well as causing fatigue (See further readings 4).
The study has shown further research is required to determine if the advantages of an intense physical therapy program for CP children outweigh the disadvantages. The study only provides results on CP patients who seek out and have similar resources available to them.

## Practical advice

Whilst more research is needed, an intense physical therapy intervention appears to be beneficial in improving some movement parameters of a CP child. The major consideration required when using an intense physical therapy intervention to treat CP, is whether the program can negatively affect the well-being of the child, with further consideration on whether results justify the expense and stress placed on families.

## Further reading

1. Gross Motor Function Classification System
2. Clinical applications of outcome tools in ambulatory children with cerebral palsy
3. Comparison of efficacy of Adeli suit and neurodevelopmental treatments in children with cerebral palsy
4. Parents’ experiences with physical and occupational therapy for their young child with cerebral palsy: a mixed studies review

## References

* 1 2 3 4 5 6 7 8 9 10 11 12 13 Christy, J. et al. (2012) 'The effect of intense physical therapy for children with cerebral palsy'. Journal of Pediatric Rehabilitation Medicine. Vol 5 (3): pp 159-170
* 1 2 Cerebral Palsy Alliance (2016), What is Cerebral Palsy. Available from https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/. [6 September 2016].
* 1 2 Cerebral Palsy Alliance (2016), GMFCS E&R (Gross Motor Function Classification System – Extended and Revised). Available from: https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/severity-of-cerebral-palsy/gross-motor-function-classification-system/. [8 September 2016]
* ↑ Cerebral Palsy Alliance (2016), Facts about Cerebral Palsy. Available from: https://www.cerebralpalsy.org.au/what-is-cerebral-palsy/facts-about-cerebral-palsy/. [6 September 2016]
* ↑ University of Alabama at Birmingham (2016), Constraint-Induced Movement Therapy. Available from: https://www.uab.edu/citherapy/. [8 September 2016]
* ↑ University of Alabama at Birmingham (2016), PhD in Rehabilitation Science. Available from: https://www.uab.edu/shp/pt/rsphd/phdfaculty/20-facultyandstaff/phd-faculty/63-jennifer-christy. [8 September 2016]
* ↑ IOS Press (2016), Journal of Pediatric Rehabilitation Medicine. Available from: http://www.iospress.nl/journal/journal-of-pediatric-rehabilitation-medicine/. [8 September 2016]
* ↑ National Health and Medical Research Council (2009), NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf. [26 September 2016]
* ↑ Polit, DF. Beck, CT. 2004, Nursing Research: Principles and Methods, Lippincott Williams & Wilkins, Philadelphia.
* 1 2 Oeffinger, D. et al. (2009) 'Clinical Applications of Outcome Tools in Ambulatory Children with Cerebral Palsy'. Physical Medicine and Rehabilitation Clinics of North America. Vol 20 (3): pp 549-65
* 1 2 Bar-Haim, S. et al. (2006) 'Comparison of efficacy of Adeli suit and neurodevelopmental treatments in children with cerebral palsy'. Developmental Medicine and Child Neurology. Vol 48 (5): pp 325-330
* 1 2 Kruijsen-Terpstra, AJA. et al. (2013), 'Parents’ experiences with physical and occupational therapy for their young child with cerebral palsy: a mixed studies review.' Child: Care, Health & Development. Vol 40(6): pp 787-796