There are so many choices of interventions for children with cerebral palsy and cerebral palsy like conditions (this includes neurodevelopmental conditions and children with a diagnosed or undiagnosed rare disease). With the variety of approaches that are coupled with marketing “lingo,” it does make the decision about what to choose even more difficult! And choose we must because there are only so many hours in the day. There is family, work, friends and school to consider.
So how do we choose and how do we prioritise what interventions to engage with?
We established The Healthy Strides Foundation in 2018, on the back of a research study that we conducted at Princess Margaret Hospital, now Perth Children’s Hospital between 2015 and 2017. This study was designed to address a major gap in interventions for children with cerebral palsy that rely on equipment and physical assistance throughout the day. The results from the study as well as the persistent urge from the families in the study was the sole reason why we, as the research team decided that we had something to contribute to our community.
As a team, we were committed to bringing the research findings to the wider community so that more children and young people would benefit from what we had found. We were committed to being a not-for-profit organisation, we were committed to being grounded by the research and evidence and we were committed to continually contribute to the research so that more children, not just in Western Australia but Australia wide and globally would benefit from new and effective interventions. We saw first-hand, the impact of research findings derived from well-designed studies on the health and well-being of children with physical disabilities.
We are a lean organisation – we use our resources and time in the most efficient way possible, helping our dollar and time to go further so that we can spend our valuable time providing evidence-based interventions for the children that come through our doors. With this in mind, we are also very mindful of the impact that interventions have on families that already have so much to think about. This is the reason why our core value is in the provision of evidence-based interventions.
Evidenced based practice is the “conscientious, explicit, judicious and reasonable use of current best evidence in clinical decision making”.[2, 3]
Evidence based practice is an ethical obligation of health professionals for the utilisation of what is often public resources or funding that aims to maximise clinical or health benefits whilst minimising harm.
Practices that are informed by the evidence comes from research and are underpinned by good quality science. This means that interventions provided are the most effective in achieving the desired outcomes. Where high-quality evidence is not available, it is then essential that interventions offered are still underpinned by the evidence base.[3, 4]
It is important to know that evidence-based practices are not prescriptive in nature. Rather, it is the integration of the best available research evidence, combined with clinical expertise as well as the values and goals of the individual that is receiving the services (Figure 1.0).
Our commitment to only providing evidence-based interventions means that we are using limited resources (both time and money) in the most effective way to achieve the desired outcome. By doing this, children spend the least amount of time having to engage in therapy which means the maximum amount of time doing what kids should be doing – making friends, spending time with their family, having fun, going to school – learning and enjoying these experiences. For parents, this means less appointments, less driving, being able to work and spend more time with siblings and friends!
In fact, this is a recognised area in research. Professor Peter Rosenbaum and Professor Jan Gorter called this the “F-words” in childhood disability in 2012. This represented a reconfiguration of the World Health Organisation’s International Classification of Functioning Disability and Health 2001 (the ICF Figure 2.0) to employ a strength’s-based approach. By using the “F-words” being function, family, fitness, fun, friends and future, health professionals can better support children with neurodisabilities (Figure 3.0). This establishes the essential framework for how we provide interventions for children with neurodisabilities.
Over the last decade in particular, researchers in child health have been working to develop guidelines to identify the most effective interventions available. Researchers have been working with families to identify areas of importance and where efforts should be placed to develop new interventions.
The guiding papers to highlight evidence-based interventions in child health were published in 2013 with another revision in 2020. Both of these papers systematically and objectively evaluated the body of evidence as is currently stands in the area of cerebral palsy.[4, 7]
The results were presented by using a traffic light system with “green” light interventions suggesting that we should ‘do it’ because there is strong evidence to support its effectiveness, “yellow” light interventions which suggest that we can ‘probably do it’ and finally, “red light” interventions or stop and ‘do not do it’ because evidence has shown that they are ineffective. (Figure 4.0)
When it comes to motor interventions (i.e., approaches that improve motor skills such as gross motor or fine motor skills) there are some clear principles that have been shown to be the most effective. This relates to the principles of neuroplasticity and the “F-word” framework.[5, 8] When adopting an evidence-based approach, it is vital that we use interventions that have the greatest odds of achieving motor skills. At the core, interventions need to be:
These approaches tend to be more “hands-off” in nature. The role of the therapist is less about holding, positioning, aligning and more about setting up the environment and using equipment. This way, it is more about movements that are initiated by children. Child initiated problem solving and child initiated movement is the key to establishing the motor circuitry for neuroplastic changes. In fact, excessive external sensory input has been seen to disrupt this process.
The most current and up to date approach focuses on meaningful activities and participation in daily life. Approaches that focus on what we call “body structure and function” of the ICF framework (Figure 2.0) are less effective in achieving and improving daily, meaningful skills that are needed to be part of the community and to participate in life. As such, researchers and scientists are able to confidently say that these approaches should be “discontinued based on current evidence.”
These approaches include techniques known as neurodevelopmental therapy (or NDT), Vojta, Cuevas-Medek (or CME) and Dynamic Movement Intervention (or DMI). The basis of these approaches depart from what we know is effective in improving motor outcomes. As such, the decision for us as researchers, scientists and clinicians at Healthy Strides is to not provide these techniques because there are evidence-based interventions that have better odds or greater possibilities of achieving motor outcomes in children.
This decision is not based on a personal objection by any means. It is guided by the current state of the evidence and highlights the reasoning for Healthy Strides’ core value of providing only evidence-based approaches so that we have the greatest odds of achieving outcomes. This approach optimises the opportunities for children to spend more time out of a therapy setting, and more time in the world with their friends, family and attend school.
There is more published research in the area of cerebral palsy because it is the most common cause of physical disability in childhood. However, we know that the development of new motor skills and the framework for developing interventions (the ‘F-words’) is not diagnostic specific – in fact it relates to all of us! [8, 13]. In the absence of diagnostic specific interventions, we can still apply the active ingredients of effective motor interventions that relate to cerebral palsy.
What is hugely important is that information about interventions is provided to enable families to make an informed choice. Only families know their own circumstances, their child and what works for them so there is never any judgement about the choices that families make. At the core, families just need to be able to make a choice based on the most relevant information available. An informed choice is ultimately a good choice!
Locomotor and robotic assistive gait training for children with cerebral palsy. Developmental Medicine & Child Neurology, 2021.
Evidence-based medicine: how to practice and teach. 2nd ed, ed. Churchill-Livingstone. 2000, Edinburgh.
Interventions for children on the autism spectrum: A synthesis of research evidence. 2020, Autism CRC: Brisbane.
State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Curr Neurol Neurosci Rep, 2020. 20(2): p. 3.
The 'F-words' in childhood disability: I swear this is how we should think. Child: Care, Health and Development, 2012. 38(4): p. 457-463.
in Australian and New Zealand Cerebral Palsy Strategy. 2020.
A systematic review of interventions for children with cerebral palsy: state of the evidence. Developmental medicine and child neurology, 2013. 55(10): p. 885-910.
Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 2008. 51(1).
What is the threshold dose of upper limb training for children with cerebral palsy to improve function? A systematic review. Aust Occup Ther J, 2020.
Early intervention evidence for infants with or at risk for cerebral palsy: an overview of systematic reviews. Dev Med Child Neurol, 2021. 63(7): p. 771-784.
Let's make pediatric physical therapy a true evidence-based field! Can we count on you? Braz J Phys Ther, 2019. 23(3): p. 187-188.
An update on the prevalence of cerebral palsy : a systematic review and meta-analysis. Developmental Medicine & Child Neurology, 2013. 55(6): p. 509-19.
Defining Functional Therapy in Research Involving Children with Cerebral Palsy: A Systematic Review. Phys Occup Ther Pediatr, 2020. 40(2): p. 231-246.