1. Cerebral palsy-specific early interventions maximise neuroplasticity

The first two years of a child’s life are critical for cognitive and motor development as the brain is undergoing constant spontaneous plasticity (Morgan et al 2013). Brain development continues after birth and is driven by motor cortex activity, so early intervention for infants with cerebral palsy is essential for developing cortical connections (Novak et al 2017).

Cerebral palsy-specific early intervention maximises neuroplasticity and minimises the development of secondary impairments related to altered muscle and bone growth (Novak et al 2017).

Physiotherapists play a key role in providing early intervention supports within an interdisciplinary team including occupational therapists, speech pathologists, social workers, early intervention teachers and psychologists.

Task-specific, motor training-based early interventions are recommended because they induce neuroplasticity and produce functional gains. This includes Goals-Activity-Motor Enrichment (GAME) which is an early, intense, enriched, task-specific, training-based intervention at home, and early constraint-induced movement therapy for infants with hemiplegic cerebral palsy (Novak et al 2017).

In addition to motor interventions, infants with cerebral palsy, especially those with bilateral presentations, should receive regular surveillance of their musculoskeletal development and timely intervention. This results in lower rates of hip displacement, contracture, and scoliosis, based on population register data (Novak et al 2017).

References

Morgan, C., Novak, I. and Badawi, N. (2013) Enriched environments and motor outcomes in cerebral palsy: systematic review and meta-analysis. Pediatrics. 132(3):e735-46. doi: 10.1542/peds.2012-3985.

Novak, I., Morgan, M., Adde, L., Blackman, J., Boyd, R., Brunstrom-Hernandez, J., Cioni, G., Damiano, D., Darrah, J., Eliasson, A., de Vries, L., Einspieler, C., Fahey, M., Fehlings, D., Ferriero, D., Fetters, L., Fiori, S., Forssberg, H., Gordon, A., Greaves, S., Guzzetta, A., Hadders-Algra, M., Harbourne, R., Kakooza-Mwesige, A., Karlsson, P., Krumlinde-Sundholm, L., Latal, B., Loughran-Fowlds, A., Maitre, N., McIntyre, S., Noritz, G., Pennington, L., Romeo, D., Shepherd, R., Spittle, A., Thornton, M., Valentine, J., Walker, K., White, R. and Badawi, N. (2017). Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy Advances in Diagnosis and Treatment. JAMA Pediatr. 171(9): 897-907. doi: 10.1001/jamapediatrics.2017.1689

2. Physiotherapists play a vital role in early childhood intervention

Physiotherapists working with children and families in the community use a range of practices based on the Early Childhood Intervention Association’s best practice guidelines.

There are four quality areas identified that comprise eight key best practices in early childhood intervention. The first area of quality is family, featuring family-centered and strengths-based practice and culturally responsive practice. The second is inclusion, featuring inclusive participatory practice and engaging the child in natural environments. The third is teamwork, featuring teamwork practice and capacity- building practice, and the fourth is universal practices, featuring evidence base standards, accountability and practice, and an outcome-based approach (ecia.org.au).

In the community, families and professionals work in partnership where family priorities and choices drive what happens in planning and intervention. Strategies are embedded in the child’s natural setting where the focus is on participation in activities that promote inclusion—be that at home, in their educational setting or out in the community.

The physiotherapist takes on the role of ‘coach’, working with the family and other professionals to form a ‘team around the child’ approach to intervention (Moore 2012). Through their understanding of motor development, neurological and musculoskeletal conditions, the physiotherapist can build the skills and abilities of those who will spend most of their time with the child.

References

Moore, T.G. (2012). Rethinking early childhood intervention services: Implications for policy and practice. Invited Pauline McGregor Memorial Address to the 10th Biennial National Early Childhood Intervention Australia (ECIA) Conference and 1st Asia-Pacific Early Childhood Intervention Conference 2012, 9th August, Perth, Western Australia. 

3. People with intellectual disability are less physically active

People with an intellectual disability (ID) make up three per cent of the Australian population (ABS survey 2012). Twenty-eight per cent of National Disability Insurance Scheme (NDIS) participants identify as having a primary disability of ID, second to the largest cohort within NDIS, which is autism at 29 per cent (NDIS quarterly report 2017/18).

Physical activity levels are significantly lower in people with ID (Victorian Government report 2015, Dairo et al 2016, McGarty et al 2018). This has implications for physical and emotional health. People with ID have a wide spectrum of abilities but many barriers to physical activity, and solutions can be simple or complex. Several systematic reviews found a lack of quality research investigating outcomes for physical activity in people with ID (Dairo et al 2016, McGarty et al 2018). Existing research shows the more significant the ID, the lower the levels of physical activity (Dairo et al 2016).

Physiotherapists are well placed to work through barriers to physical exercise for people with ID by building strength, fitness, balance/skills, training families and staff in safe exercise practices, providing coaching to families and support staff addressing issues as they arise, or directing participants to quality, local recreational opportunities. The NDIS enables people with ID to access therapy services.

References

1. ABS Survey of Disability, Ageing and Carers 2012, 4433.0.55.003 - Intellectual Disability, Australia, 2012, published 2014.

2. NDIS Quarterly Report 2017-2018 Q4 National Dashboard as at 30 June 2018.

3. Victorian Government, Health, Physical Activity and Victorians with an Intellectual Disability, 2015.

4. Yetunde Marion Dairo, Johnny Collett, Helen Dawes, and G. Reza Oskrochi, Physical activity levels in adults with intellectual disabilities: A systematic review, Preventative Medicine Reports 2016 Dec(4):209- 219.

5. McGarty AM, Downs SJ, Melville CA, Harris L, A systematic review and meta-analysis of interventions to increase physical activity in children and adolescents with intellectual disabilities, Journal of Intellectual Disability Research 2018 Apr 62(4):312-329.

4. Postural care: prevention is better than cure

Postural care is protecting the body shape of children and adults with movement problems. Supported lying is described as ‘aligning the body in a comfortable non-destructive position in bed’ (Stephens et al 2018). The current evidence base for supported lying is limited, but growing.

The aim of postural care is to prevent the body from distorting through development of joint contractures, hip migration, scoliosis and bony malformations caused by the effects of immobility, asymmetry and, importantly, the impact of gravity.

The ramifications of these issues can be life-shortening as well as leading to considerable pain and discomfort. Applying a person/family-centred approach, utilising the often-forgotten hours a child or adult remains in bed overnight, and with a thorough understanding of how the body distorts, application of supported lying principles can achieve much.

Understanding the rotational distortions of the chest and how to de- rotate the sterno-spinal line, body shape distortion may be prevented, minimised or even restored by family/carer-led, gentle postural care. Corrective surgery may be avoided or delayed, while recovery from surgery is likely to be enhanced. Postural care is complementary to current services and interventions, it does not replace them. Prevention is the key, but it is never too late.

References

Stephens, M., Bartley, C.A., and Priestley, C. (2018).  Evaluation of night time therapeutic positioning system for adults with complex postural problems.  Monograph.  http://usir.salford.as.c.uk/48470/

Humphreys G., et al (2018) Sleep positioning systems for children and adults with a neurodisability: A systematic review.  British Journal of Occupational Therapy, 1-10

Hill S., and Goldsmith,. J (2010).  Biomechanics and prevention of body shape distortion.  Tizard Learning Disability Review, I 15 (2), pp. 15-32.

Innocente, R. (2014).  Night-time positioning equipment:  A review of practices.  New Zealand Journal of Occupational Therapy, 61 (1), pp. 13-19

 5. To measure is to know

There is increasing discussion in the academic literature, the profession and within society about supporting people with disability to set their personal goals so they are able to live the life they choose.

People with disability may seek the support of a physiotherapist to help them to achieve their personal goals around their mobility, their chosen activities, community participation and to address body structure and function issues.

Physiotherapists working with people with disability are encouraged to use an outcomes-based approach. This may involve using a standardised assessment to identify and measure a person’s skills and a meaningful outcome measure.

When choosing standardised assessments and outcome tools, physiotherapists need to have the appropriate qualifications or training to administer the tool, have a clear understanding of the scoring and interpretation of the tool, and consider the psychometrics of the tool—such as whether the tool has been normalised for people with a specific disability. The use of standardised assessment tools may not always be possible or appropriate, for example, when the person with disability has difficulty understanding verbal instructions.

Additional reading

Early Childhood Intervention Tools

Canadian Occupational Performance Measure (COPM)

Goal Attainment Scale