Physical Therapy and Occupational Therapy Services of Young Children with Cerebral Palsy Denise Begnoche, PT, DPT, Lisa Chiarello, PT, PhD, PCS, Doreen Bartlett, PT, PhD, Robert Palisano, PT, ScD Hui-Ju Chang, PT, MS, Audrey Wood, PT, MS, PCS
Purpose 1. Describe the types and amount of community recreational programs children with cerebral palsy are involved in. 2. Describe the focus and intensity of physical and occupational therapy services. 3. Examine differences in community programs, focus and intensity of physical and occupational therapy based on children s age, gross motor function level and geographic region of residence. 4. Describe the percentages of children receiving physical and occupational therapy services in early intervention or school settings and in hospitals, rehabilitation centers or private therapy clinics.
Participants 399 young children with cerebral palsy and their parents 92% of respondents were mothers, average age 34.4 years, SD=6.6 years Children were 23-74 months old, mean age 44.9 months, SD=11.7 months Children s gross motor function was distributed across the five levels of gross motor function (GMFCS) 85% of children attended early intervention or school programs
Gross Motor Function Classification System (GMFCS) Palisano et al. (2008) Level I sits alone and walks alone between 18-24 months Level II may use hands support to sit on floor, walks using assistive mobility devices (2-4 yrs) but walks alone after age 4 Level III sits on floor, crawls, often without reciprocal leg movements; walks using assistive mobility devices after age 4 and frequently transported long distances or outdoors Level IV requires trunk support for sitting; moves on floor through rolling, creeping on stomach, or crawling; requires adaptive seating to maximize hand function and is generally transported in the community (4-6 yrs); may achieve self-mobility using power wheelchair Level V limited control of movement, unable to maintain antigravity head and trunk postures, no independent mobility (transported)
Service Questionnaire Types and Amount of Community Recreational Programs Focus of Physical and Occupational Therapy Services Intensity (frequency x time) of Physical and Occupational Therapy Services Focus and intensity of therapy in home, preschool, or clinic reported by parents through telephone interview
Data Analysis One-way ANOVAs, (p<.05), Tukey post hoc tests (p<.01) to examine the effect of: 1. Age, gross motor function level and geographical residence on number of community recreational programs 2. Age, gross motor function level and geographical residence on focus of physical and occupational therapy services 3. Age, gross motor function level and geographical residence on intensity of PT and OT Describe frequencies of physical and occupational therapy services received by setting
Results of Involvement in Community Recreational Programs 64% of Children Involved in Community Programs Community Recreational Program Percent Involved Percent with Therapist Aquatics 43 39 Horseback Riding 21 66 Gym 23 46 Dance or Movement 13 27 Sports 10 7 Other 13 37 Children participated in an average of 1.2(SD= 1.2) community recreational activities.
Results of Focus of PT/OT Focus of Therapy Categories Extent of Focus M(SD) Responses 1 =Not at all 2 =To a small extent 3 =To a moderate extent 4 =To a great extent 5 =To a very great extent Primary Impairments 4.0 (0.8) Secondary Impairments 3.4 (1.0) Activity 3.7 (1.0) Primary Impairments balance, muscle tone, quality of movement Secondary Impairments strength, range of motion, endurance Activity mobility, practice of specific tasks Environmental Modifications and Equipment Self-Care Routines Structured Play Activities 3.1 (1.3) 2.5 (1.4) 3.8 (1.2)
Results of Focus by Age and Gross Motor Function Level Less focus on Secondary Impairments and Self-care in younger children (p<.01). Less focus on Activity for children in level V than children in levels I, II, III (p<.01). Less focus on Environmental Modifications/Equipment for children in level I than children in all other levels (p<.01). More focus on Self-care for children in level I than children in level V (p<.01).
Results of Focus by Geographic Region of Residence Focus on Primary Impairments: Atlanta > Canada (p=.01) Focus on Secondary Impairments: o Philadelphia > Canada (p<.01) and Atlanta > Canada and Oklahoma (p<.01) Focus on Environmental Modifications/Equipment and Structured Play Activities: Oklahoma > Canada (p<.01)
Family Centeredness Parents report therapists demonstrated family centered behavior, m(sd)= 3.7(.68). No differences in age, gross motor function level or geographical residence for parents perception of family centered behaviors. Differences in parents ability to integrate therapy recommendations into family routines Parents in Oklahoma report more ability to integrate therapy recommendations than parents in Atlanta, Seattle/Tacoma and Canada; Philadelphia parents more ability to integrate than parents in Seattle/Tacoma (p<.01)
Average Minutes/Month PT and OT 94% of children received PT, 86% of children received OT Number PT min/mo M(SD) OT min/mo M(SD) 17-30m 117 264.9 (232.0) 170.8 (191.7) 31-42m 131 269.0 (224.5) 196.8 (178.9) 43m+ 151 280.9 (247.2) 207.0 (176.9) GMFCS level I 147 180.8 (180.7) 156.6 (170.2) GMFCS level II 46 322.2 (234.0) 196.8 (198.3) GMFCS level III 50 344.7 (258.7) 176.4 (139.8) GMFCS level IV 69 308.4 (230.6) 215.2 (165.8) GMFCS level V 87 330.1 (261.4) 244.4 (213.4) Canada 134 164.4 (186.4) 105.9 (129.8) Philadelphia 79 358.9 (241.7) 265.7 (181.2) Atlanta 51 367.3 (271.2) 268.7 (196.3) Oklahoma 69 280.9 (220.8) 191.2 (208.0) Seattle/Tacoma 66 305.2 (219.4) 226.3 (163.6) TOTAL 399 272.3 (235.0) 193.0 (182.2)
Results of Intensity of Therapy Children in GMFCS level I received less PT time than children in levels II-V (p<.01). Children in GMFCS level I received less OT time than children in level V (p<.01). Children in Canada received less PT and less OT time than children in all geographical regions of the United States (p<.01).
Percentage of Children Receiving PT and OT Services by Setting Rehabilitation Service (N=399) Percent Not Receiving Service Percent Receiving Services in EI/School Only Percent Receiving Services in Clinic Only Percent Receiving Services in EI/School and Clinic Physical Therapy 6.0 28.6 32.1 33.1 Occupational Therapy 13.8 30.6 27.3 27.6
Intensity (frequency x time) of PT and OT (N=399) PT/OT Time Average Min/Mo EI/School M(SD) Average Min/Mo Clinics M(SD) Average Min/Mo Both EI and Clinics M(SD) PT Time 293.3 (197.1) 187.1 (174.1) 441.2 (236.0) OT Time 194.4 (127.2) 137.6 (114.2) 357.4 (204.7) The most common frequency of PT and OT received was 2-4 times per month across all settings.
Conclusions Therapists may consider expanded roles in community recreational programs to increase participation of all children with cerebral palsy. Focus of physical and occupational therapy is individualized, based on child and family needs, child age and gross motor function. Understanding of differences in focus among therapists in some US regions and therapists in Canada will inform decision making.
Conclusions Less PT and OT time in Canada than all US regions may reflect different health care delivery systems. Understanding of family and child needs of those receiving services across multiple settings will inform therapists and service coordinators. Communication and coordination needed to provide efficient and comprehensive therapy services.
Implications Child and Family Goals >>> ICF framework PT and OT services may extend beyond the home, school, or clinic to increase activity and participation of children with cerebral palsy in community recreational programs. Decision making Examine rationale for PT and OT services during a significant period of development in children. Service delivery Episodes of more or less intensive services determined by child needs and family goals and priorities.
Physical and Occupational Therapist Roles Collaboration with parents to decide intensity, i.e. focus and dose of PT and OT services. Communication and Coordination with community recreational providers to address physical and attitudinal barriers to participation of children with cerebral palsy. Consultation to provide comprehensive programs ensuring intensity of practice in various settings for optimal participation outcomes.
Thank You! Move & PLAY Study Team