A randomized controlled trial comparing two rehabilitation interventions for young children with cerebral palsy

Transcription

1 A randomized controlled trial comparing two rehabilitation interventions for young children with cerebral palsy CO-PRINCIPAL INVESTIGATORS Mary Law and Johanna Darrah RESEARCH TEAM Brenda Wilson Nancy Pollock Barb Galuppi Stephen Walter Dianne Russell Peter Rosenbaum

2 Children with cerebral palsy receive physical and occupational therapy to Facilitate development and Enhance function and participation in selfcare, play, and school activities

3 International Classification of Functioning, Disability and Health (ICF) Framework Health condition (Disorder or Disease) Activity (Limitation)

4 International Classification of Functioning, Disability and Health (ICF) Framework Health condition (Disorder or Disease) Activity (Limitation) Environmental Factors Personal Factors

5 International Classification of Functioning, Disability and Health (ICF) Framework Health condition (Disorder or Disease) Body Structure & Functions (Impairment) Activity (Limitation) Environmental Factors Personal Factors

6 International Classification of Functioning, Disability and Health (ICF) Framework Health condition (Disorder or Disease) Body Structure & Functions (Impairment) Activity (Limitation) Participation (Restriction) Environmental Factors Personal Factors

7 Cerebral palsy causes impairments in body function and structure Muscle tone, strength, reflexes and range of motion Impairments are associated with significant limitations in activity and participation

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9 But does therapy aimed at improving function at the level of the body result in a change to functional performance and participation in activities?

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12 To compare two treatment approaches to improve the child s skills: Child-Focused Therapy Improving function by working with the child Context-Focused Therapy Improving function by changing or adapting the task and/or environment around the child

13 Who Participated? 128 children with Cerebral Palsy, and their families - 1 to 5 years old 72 OTs and PTs 19 rehabilitation facilities and community agencies and services in Alberta and Ontario

14 Sites in Alberta Grand Prairie Queen Elizabeth Hospital Crystal Park School Edmonton Glenrose Rehab Home Care GRIT Red Deer Red Deer Pediatric Rehab Calgary Providence CDC Renfrew Educational Services PACE Kids Alberta Children's Hospital Anne Lundmark (Private Practice) Helen Enns (Private Practice) Lethbridge Children s C.A.R.E. Services

15 Hamilton Children s Developmental Rehabilitation Program Sites in Ontario Ottawa Ottawa Children s Treatment Centre London Thames Valley Children s Centre Mississauga Erinoak Oshawa Grandview Children s Centre Peterborough Five Counties Children s Centre Sudbury Children s Treatment Centre Windsor John McGivney Children s Centre

16 Primary Measure Pediatric Evaluation of Disability Inventory (PEDI) Secondary Measures Pediatric Evaluation of Disability Inventory (PEDI) Gross Motor Function Measure (GMFM-66) Children s Assessment of Participation and Enjoyment ( CAPE) Family Empowerment Scale (FES) Range of Motion

17 Results

18 Difference Between Intervention Approaches Both groups improved during the intervention No differences between the two treatment groups Both treatment protocols were equally effective in improving the functional abilities of the children

19 Responsiveness to Intervention More severely involved children changed less on the outcome measures Older children (3 years and up) changed more

20 Frequency of Intervention A frequency of sessions over 6 months positively influenced most children s functional skill performance Equivalent to 3-4 times a month Typically, in Alberta, children receive therapy 1-2 times a month

21 PEDI Functional Skills Mobility

22 Independently climbs on and off potty or toilet Moves 150 feet, but with difficulty Independently gets in and out of bed Moves 150 feet with no difficulty Sits down and stands up in bath tub Walks up entire flight of stairs, but with difficulty Gets in and out of chair Independently gets in and out of car or car seat

23 Prepares toothbrush with paste and water Brings brush or comb to hair Puts on and removes front-opening shirt Brushes or combs hair Tries to assist with buttons and zippers Dries body thoroughly after a bath Blows and wipes nose without request

24 Prime Therapist Model The use of the prime therapist model worked as well as having two therapists at every appointment - was as effective as traditional model of service delivery One advantage is that families have a primary contact

25 Range of Motion Positive functional changes occurred when passive stretching was excluded from intervention however, we did not control for stretching done by the family Clinical assumptions about passive stretching need to be evaluated further

26 Challenges for Parents The study revealed that families have very busy lives many appointments multiple episodes of children s illnesses associated with CP Key Message Intervention must be individually tailored to each family s needs, the child s health, and the child s community program

27 Collaborative Relationships Working in a collaborative way with families to identify functional goals was very successful well received by both therapists and families. many agencies have reported that they continued to use the COPM to identify family goals conducive to a no-fault partnership between therapists and parents

28 So What? One size does not fit all! Our study supports the idea that families can choose the intervention that best suits their child s needs. Families need to have the opportunity to work with the therapist to - -

29 One size does not fit all! choose goals that are relevant and important to them and their children identify the type of therapy approach that works best for them and their child work with the OT and PT to determine a frequency of treatment that will help the child without overwhelming to the family

30 Implications for Health Service Delivery Meaningful improvement occurs after 6 months of frequent intervention Improvement in skills was maintained when frequency decreased The episodic care was as effective as more regularly scheduled appointments Intervention should be individualized for each family

31 Acknowledgements Children, parents, therapists and facilities who made this study possible. The National Institutes of Health (USA) and The Alberta Center for Child, Family and Community Research, for funding support