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Timing and Intensity

Van Sant, Ann F. PT, PhD, FAPTA

Pediatric Physical Therapy: Summer 2009 - Volume 21 - Issue 2 - p 139
doi: 10.1097/PEP.0b013e3181a4cf31


Early intervention is a fundamental concept in the provision of service to infants and young children with developmental disabilities. Although we are getting better at identifying the children who need early intervention, Meade et al,1 in this issue of Pediatric Physical Therapy, point out that physicians still find the use of screening tools to be time consuming in their busy practices. As Meade et al demonstrate, this barrier could be overcome if health professionals, other than busy physicians, were routinely screening young infants for developmental risks. The screening tool developed by Meade et al is designed for examining infants at 4 months. Assuming that we all ascribe to the concept that earlier identification is better, a routine screen made available at 4 months for all infants in the United States whose parents have concerns about their development just makes good sense, and such an effort is something we should champion as a profession.

But in this issue, we are also called upon to consider the issue of not just early intervention but also the intensity of therapy. LaForme Fiss et al2 demonstrated in their pilot study that adding group sessions for preschool-aged children with Down syndrome resulted in improved skill acquisition. The authors pointed out that these sessions afforded practice of specific skills identified as individual goals for the child.

Also in this issue of Pediatric Physical Therapy, Ustad et al3 report that subjects with cerebral palsy benefited from intensive therapy, but the children also made developmental progress when therapy was less intense. So intensity alone is not the preeminent factor in improving outcomes. They pointed out that some parents of their young subjects were still adjusting to their child's developmental problems. They suggest that until we know more, we should individualize the schedule of therapy for our young clients and their families.

Could it be that the timing of intensive therapy might be critical? We should not only think about the parents' capacity to participate in our interventions but also consider whether intensive therapy should be timed to coincide with the emergence of a new skill when opportunities to practice that skill are critical.

I am reminded of the work by Adolph et al reported at the III Step Conference sponsored by the Pediatric and Neurology Sections of the American Physical Therapy Association during the summer of 2005 and the astounding amount of practice that infants who are developing typically accrue when new skills are first appearing. The distance that infants covered in creeping and walking were measured in terms of city blocks and football fields. Notably Adolph et al4 have reported that in infants who are developing typically, the first 2 months of practice of gait lead to development of a walking pattern that is relatively indistinguishable from that of a kindergartener. So for the establishment of gait, those early months after the emergence of the skill are critical. I am also struck by the work of the Ulrich et al5,6 in treadmill training of children with Down syndrome and how they are able to foster motor progress using practice conducted by parents.

When we think of early intervention, we should think beyond how many sessions are scheduled with a therapist and begin to focus on what I suspect are more important variables: the timing of practice of a newly emerging skill and the capacity of parents to foster that practice. We need to intervene at the right time and with the right intensity!

Ann F. Van Sant, PT, PhD, FAPTA


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1.Meade V, Sweeney J, Chandler L, et al. Identifying 4 month-old infants at risk in community screening. Pediatr Phys Ther. 2009;21:150–157.
2.LaForme Fiss A, Effgen S, Page J, et al. Effect of sensorimotor groups on gross motor acquisition for young children with Down syndrome. Pediatr Phys Ther. 2009;21:158–166.
3.Ustad T, Sorsdahl A, Ljunggren A. Effects of intensive physiotherapy in infants newly diagnosed with cerebral palsy. Pediatr Phys Ther. 2009;21:140–149.
4.Adolph KE, Verigjen B, Shrout PE. What changes in infant walking and why. Child Dev. 2003;74:475–497.
5.Ulrich DA, Ulrich BD, Angulo-Kinzler RM, et al. Treadmill training of infants with Down syndrome: evidence-based developmental outcomes. Pediatrics. 2001 Nov;108:E84.
6.Ulrich DA, Lloyd MC, Tiernan CW, et al. Effects of intensity of treadmill training on developmental outcomes and stepping in infants with Down syndrome: a randomized trial. Phys Ther. 2008;88:114–122.
© 2009 Lippincott Williams & Wilkins, Inc.