Tineke Dirks

Does early intervention in infants at high risk for a developmental motor disorder improve motor and cognitive development

Infants at high risk for developmental motor disorders are in general referred to early intervention (EI) services. It is a matter of debate to which extent EI may facilitate outcome in various developmental domains. We reviewed the effects of EI programmes aiming at promoting motor and cognitive development. With respect to motor development the data indicated that EI prior to term age probably is most effective when it aims at mimicking the intrauterine environment; after term age general developmental programmes probably are most effective. Some evidence was provided that EI prior to term age has a beneficial effect on cognitive development regardless the type of intervention which is applied. After term age only general developmental programmes seemed to have an effect on cognitive development. The review concludes with preliminary data on the effect a new intervention programme, COPCA, applied between 3 and 6 months corrected age on developmental outcome till 18 months. The results indicated that COPCA was more beneficial for the development of sitting behaviour and cognition than traditional paediatric physiotherapy.

Development of postural control in typically developing children and children with cerebral palsy: possibilities for intervention?

The basic level of postural control is functionally active from early infancy onwards: young infants possess a repertoire of direction-specific postural adjustments. Whether or not direction-specific adjustments are used depends on the childs age and the nature of the postural task. The second level of control emerges after 3 months: children start to develop the capacity to adapt postural activity to environmental constraints. But the adult form of postural adaptation first emerges after adolescence. Children with cerebral palsy (CP) in general have the ability to generate direction-specific adjustments, but they show a delayed development in the capacity to recruit direction-specific adjustments in tasks with a mild postural challenge. Children with CP virtually always have difficulties in the adaptation of direction-specific activity. The limited data available on the effect of intervention on postural development suggest that intervention involving active trial and error experience may accelerate postural development in typically developing infants and may improve postural control in children with or at high risk for a developmental motor disorder.

Pediatric Physical Therapy in Infancy: From Nightmare to Dream? A Two-Arm Randomized Trial

Background Systematic reviews have suggested that early intervention by means of specific motor training programs and general developmental programs in which parents learn how to promote infant development may be the most promising ways to promote infant motor and cognitive development of infants with or at high risk for developmental motor disorders. Objective The purpose of this study was to investigate the effects of a recently developed pediatric physical therapy intervention program (“Coping With and Caring for Infants With Special Needs” [COPCA]) on the development of infants at high risk for developmental disorders using a combined approach of a 2-arm randomized trial and process evaluation. Setting The study was conducted at the University Medical Center Groningen in the Netherlands. Participants and Intervention Forty-six infants at high risk for developmental disorders were randomly assigned to receive COPCA (a family-centered program) (n=21) or traditional infant physical therapy (TIP) (n=25) between 3 to 6 months corrected age (CA). Developmental outcome was assessed by blinded assessors at 3, 6, and 18 months CA with a neurological examination, the Alberta Infant Motor Scales, the Pediatric Evaluation of Disability Inventory, and the Mental Developmental Index (MDI) of the Bayley Scales of Infant Development. Contents of the intervention were analyzed by a quantitative video analysis of therapy sessions. Quantified physical therapy actions were correlated to evaluate associations between intervention and developmental outcome components. Results The trial revealed that developmental outcome in both groups was largely identical. Process evaluation showed that typical COPCA actions—(1) family involvement and educational actions, (2) application of a wide variation in challenging the infant to produce motor behavior by himself or herself and allowing the infant to continue this activity, and (3) stimulation of motor behavior at the limit of the infants capabilities—had positive correlations with developmental outcome at 18 months CA. The use of handling techniques was negatively associated with the Pediatric Evaluation of Disability Inventory outcome at 18 months CA. Limitations Major limitations were the limited size of the groups studied and the differences between the groups in frequency and duration of physical therapy sessions. Conclusion Extending the randomized trial with process evaluation was needed to obtain insight into associations between the components of intervention and developmental outcome. Specific therapist behaviors of parent coaching are associated with improved developmental outcome measures. Further studies are needed to examine whether these associations are caused by therapist behavior or whether therapist behavior is modified by childrens motor skills.

Differences Between the Family-Centered “COPCA” Program and Traditional Infant Physical Therapy Based on Neurodevelopmental Treatment Principles

Background Evidence for effectiveness of pediatric physical therapy in infants at high risk for developmental motor disorders is limited. Therefore, “Coping With and Caring for Infants With Special Needs” (COPCA), a family-centered, early intervention program, was developed. The COPCA program is based on 2 components: (1) family involvement and educational parenting and (2) the neuromotor principles of the neuronal group selection theory. The COPCA coach uses principles of coaching to encourage the familys own capacities for solving problems of daily care and incorporating variation, along with trial and error in daily activities. Objective The purpose of this study was to evaluate whether the content of sessions of the home-based, early intervention COPCA program differs from that of traditional infant physical therapy (TIP) sessions, which in the Netherlands are largely based on neurodevelopmental treatment. Setting The study was conducted at the University Medical Center Groningen in the Netherlands. Design A quantitative video analysis of therapy sessions was conducted with infants participating in a 2-arm randomized trial. Patients and Intervention Forty-six infants at high risk for developmental motor disorders were randomly assigned to receive COPCA (n=21) or TIP (n=25) between 3 and 6 months corrected age. Intervention sessions were videotaped at 4 and 6 months corrected age and analyzed with a standardized observation protocol for the classification of physical therapy actions. Outcome parameters were relative amounts of time spent on specific physical therapy actions. Results The content of COPCA and TIP differed substantially. For instance, in TIP sessions, more time was spent on facilitation techniques, including handling, than in COPCA sessions (29% versus 3%, respectively). During COPCA, more time was spent on family coaching and education than during TIP (16% versus 4%, respectively). Limitations The major limitation of the study was its restriction to the Netherlands, implying that findings cannot be generalized automatically to other countries. Conclusion The COPCA program differs broadly from TIP as applied in the Netherlands. Studies on the effectiveness of this family-centered program are needed.

Does physiotherapeutic intervention affect motor outcome in high-risk infants? An approach combining a randomized controlled trial and process evaluation.

Aim  The aim of this study was to examine the effects of intervention in infants at risk of developmental disorders on motor outcome, as measured by the Infant Motor Profile (IMP) and using the combined approach of a randomized controlled trial and process evaluation.

The Role of the Family in Intervention of Infants at High Risk of Cerebral Palsy: A Systematic Analysis.

During the past two decades, awareness of the role of the family in the child’s life has increased and the term ‘family‐centred services’ (FCS) has been introduced to facilitate care for children with special needs and their families. It is, however, unclear how various early intervention programmes incorporate family involvement in service delivery. The present study systematically analyses the nature of family involvement in six frequently used early intervention programmes for infants at high risk of developmental disorders: neurodevelopmental treatment, treatment according to Vojta, Conductive Education, Infant Health and Development Program, Infant Behaviour Assessment and Intervention Program, and Coping with and Caring for infants with special needs – a family‐centred programme (COPCA). The analysis shows that the role of the family is diverse: it varies from parent training to be a therapist without attention to family function (in Vojta) to the autonomous family that receives coaching (COPCA). The data suggest two trends over time: (1) from child‐focused to family‐focused orientation; and (2) from professionally directed guidance to coaching based on equal partnership.

LEARN 2 MOVE 0-2 years: effects of a new intervention program in infants at very high risk for cerebral palsy; a randomized controlled trial.

BackgroundIt is widely accepted that infants at risk for cerebral palsy need paediatric physiotherapy. However, there is little evidence for the efficacy of physiotherapeutic intervention. Recently, a new intervention program, COPCA (Coping with and Caring for infants with special needs - a family centered program), was developed. COPCA has educational and motor goals. A previous study indicated that the COPCA-approach is associated with better developmental outcomes for infants at high risk for developmental disorders. LEARN 2 MOVE 0-2 years evaluates the efficacy and the working mechanisms of the COPCA program in infants at very high risk for cerebral palsy in comparison to the efficacy of traditional infant physiotherapy in a randomized controlled trial. The objective is to evaluate the effects of both intervention programs on motor, cognitive and daily functioning of the child and the family and to get insight in the working elements of early intervention methods.Methods/designInfants are included at the corrected age of 1 to 9 months and randomized into a group receiving COPCA and a group receiving traditional infant physiotherapy. Both interventions are given once a week during one year. Measurements are performed at baseline, during and after the intervention period and at the corrected age of 21 months. Primary outcome of the study is the Infant Motor Profile, a qualitative evaluation instrument of motor behaviour in infancy. Secondary measurements focus on activities and participation, body functions and structures, family functioning, quality of life and working mechanisms. To cope with the heterogeneity in physiotherapy, physiotherapeutic sessions are video-recorded three times (baseline, after 6 months and at the end of the intervention period). Physiotherapeutic actions will be quantified and related to outcome.DiscussionLEARN 2 MOVE 0-2 years evaluates and explores the effects of COPCA and TIP. Whatever the outcome of the project, it will improve our understanding of early intervention in children with cerebral palsy. Such knowledge is a prerequisite for tailor-made guidance of children with CP and their families.Trial registrationThe trial is registered under NTR1428.

Development of a Quantitative Tool to Assess the Content of Physical Therapy for Infants

Purpose: The study aim was to describe and quantify physical therapy interventions for infants at high risk for developmental disorders. Methods: An observation protocol was developed based on knowledge about infant physical therapy and analysis of directly observable physiotherapeutic (PT) actions. The protocols psychometric quality was assessed. Videos of 42 infant physical therapy sessions at 4 or 6 months of corrected age were analyzed. Results: The observation protocol classified PT actions into 8 mutually exclusive categories. Virtually all PT actions during treatment could be classified. Inter- and intrarater agreements were satisfactory (intraclass correlations, 0.68–1.00). Approximately 40% of treatment time was spent challenging the infant to produce motor behavior by themselves, whereas approximately 30% of time facilitation techniques were applied. Tradition-based sessions could be differentiated from function-oriented ones. Conclusions: It is possible to document PT actions during physical therapy treatment of infants at high risk for cerebral palsy in a systematic, standardized, and reliable way.

Specific postural support promotes variation in motor behaviour of infants with minor neurological dysfunction

This study evaluated the effect of specific postural support on motor behaviour of infants with and without minor neurological dysfunction (MND). The following questions were addressed: (1) Does application of supportive pillows affect the time during which the infant exhibits general movements (GMs) or specific movements? We defined specific movements as movements of specific parts of the body that occur in a specific, recognizable way. (2) Does application of pillows improve the quality of GMs or the repertoire of specific movements? (3) Is a pillow effect affected by neurological condition? Forty healthy, term infants (16 males, 24 females; mean age 3.04 m [SD 1.24 mo], range 1-5 mo) participated in the study. Twenty were neurologically normal and 20 had MND. Spontaneous motor behaviour in a supine position was video-recorded for 180 seconds in four conditions applied in random order: support by a pillow in (1) the shoulder region, (2) the pelvic region, (3) the shoulder and pelvic region, or (4) no pillow support. Two independent assessors evaluated the quality of GMs. The other movement parameters were assessed with a computer program. Duration of movements was determined and a variation index, consisting of the number of different specific movements in a condition, was calculated. The presence of pillows did not affect the time spent in GMs, specific movements, or GM quality in either group. In neurologically normal infants the shoulder pillow with or without pelvic pillow induced an increase in the variation index (p<0.01), whereas in the infants with MND, all pillow conditions resulted in a substantial increase of the movement repertoire (p<0.001). Our results demonstrate that specific postural support promotes variation in motor behaviour of young infants. This is particularly true for infants with MND.

Infant positioning in daily life may mediate associations between physiotherapy and child development-video-analysis of an early intervention RCT

BACKGROUND Paediatric physiotherapy (PPT) in high-risk infants comprises family involvement, but it is unclear whether parents mediate the intervention effect. We demonstrated in a randomized controlled trial in high-risk infants comparing the family centred programme Coping and Caring for infants with special needs (COPCA) and Traditional Infant Physiotherapy (TIP) that process evaluation revealed associations between COPCA-characteristics and outcome. AIMS To assess whether PPT affects how parents position their infant during bathing and whether this is associated with child outcome. METHODS AND PROCEDURES 21 infants received COPCA and 25 TIP between 3 and 6 months corrected age. Bathing sessions were videotaped at 3, 6 and 18 months. Time spent with specific infant positions was correlated with quantified PPT-actions and functional mobility at 18 months measured with the Paediatric Evaluation of Disability Inventory (PEDI). OUTCOMES AND RESULTS At 3 and 18 months bathing position was similar in both groups, but differed at 6 months (time spent on sitting: COPCA 77.7%, TIP 39.2%; median difference 32.0% (95% CI: 10.6-50.5%). Sitting-time at 6 months was associated with higher PEDI functional mobility scores. CONCLUSIONS AND IMPLICATIONS Early PPT may affect parental behaviour, such as infant positioning during bathing, which, in turn, may affect child development.