Contemporary literature regarding therapy approaches for children with cerebral palsy (CP) emphasizes the importance of establishing functional goals.1–3 It describes a shift in intervention from a remediation focus (eg, “inhibiting primitive reflexes,” “normalising muscle tone”) to a focus on functional activities (eg, “riding a bike,” “getting on the school bus independently”).4 The framework of the International Classification of Functioning, Disability, and Health (ICF)5 also encourages therapists to be aware of the component of the ICF represented in their goals, interventions, and expected outcomes.6 Intervention strategies used by therapists to achieve functional goals in children with CP can reflect 2 fundamentally different approaches. One approach emphasizes remediation of components of movement such as range of movement, muscle tone, and muscle strength with the assumption that the improvement of these “building blocks” of movement will generalize to improve functional ability in a variety of movement skills.7 This approach is often labeled as a “bottom- up” approach.8,9 Another, more task-oriented approach10 works directly on the functional activity or goal in context and does not break the task into component skills.4,11 The term “top-down” is sometimes used to describe this intervention strategy. Another consideration for intervention is whether therapists should accept the compensatory movement strategies that children with CP often spontaneously discover or instead, aim for typical movement patterns to achieve functional goals.12,13 Two examples of such compensatory strategies are the W-sitting posture for independent sitting and the adaptive pencil grasps used by children with CP.
Little is known about how discussions in recent literature encouraging a move from remediation goals to functional goals have influenced practice. Are therapy goals always functional or are remediation goals still prevalent? What approach, remediation of components or task oriented, do therapists use to achieve goals? Do therapists accept the use of compensatory movement strategies? The objectives of this study were to identify the types of therapy goals described by pediatric occupational therapists (OTs) and physical therapists (PTs), to explore their assumptions about the relationship between interventions and expected outcomes, and to examine their acceptance of compensatory movement strategies.
This research was part of a larger study evaluating the extent to which contemporary approaches to rehabilitation discussed in the literature (family-centered approach, functional goals, and continuity of service) are present in programs for children with CP. Programs providing services to children with CP in both urban and rural locations from the 9 health regions in the province of Alberta, Canada were identified. Because most programs target specific age groups, the programs were stratified by the age of the children served: (1) early intervention (younger than 3 years), (2) early education (3–5 years, 11 months), and (3) school-age (6–18 years). One program representing each age group was randomly selected from 1 urban and 1 rural site in each health region to achieve a representative sampling of programs across the health regions. In some rural areas only 1 program was available and random selection was not possible. The managers from each program asked 1 therapist working in the program to participate in the study. Thirty-one PTs and 23 OTs from 54 participating programs completed interviews. On average, therapists had 11.6 years of experience (SD = 9.8, range = 0.5–34 years). Fifteen therapists (3 OTs and 12 PTs) worked primarily with children younger than 3 years, 22 therapists (12 OTs and 10 PTs) saw children 3 to 5 years 11 months of age, and 17 therapists (8 OTs and 9 PTs) had caseloads of children primarily 6 to 18 years of age. Ethical approval was obtained from the appropriate boards in each health region and the Health Research Ethics Board at the University of Alberta. All participants provided written consent.
During face-to-face interviews with trained interviewers, therapists responded to two standardized scenarios designed to explore their goal setting and intervention approaches. Therapists received the case scenarios 1 week before the interview. All interviews were recorded digitally and transcribed. The research team designed the scenarios and 3 therapists in clinical practice reviewed them for clarity and relevance. The content of the scenarios was specific to each of the 3 age groups. For the goal setting scenario, the interviewers asked each therapist 3 questions: “what is your main treatment goal?,” “why did you choose this goal?,” and “what would you do to encourage this goal?” The responses provided information about the types of goals selected and therapists’ assumptions about relationships between their goal, their intervention approach, and the expected outcomes from the intervention. The second scenario explored therapists’ acceptance of compensatory movement strategies. The interviewer could provide clarification related to the scenario if necessary. Therapists were reassured that there were no wrong answers. In total, there were 6 scenarios, 2 for each age group. An example of each type of scenario is provided in Appendix 1.
The framework and terminology of the ICF was used to develop quantitative coding criteria for therapists’ goals and the relationship between therapists’ interventions and expected outcomes. Goals were identified from responses to the first question in the goal setting scenario and were coded by the ICF component (body function and structure, activity, or participation) that best represented the intent of the goal. In the discussion about how therapists sought to reach their goal (question 3), it became apparent that a therapist’s stated main goal (eg, encouraging symmetrical movement) and the expected outcome that emerged during the discussion about intervention (eg, crawling) were not always the same and did not necessarily always represent the same ICF component. Therefore, therapists’ assumptions about the relationship between their chosen intervention and the expected outcomes were coded using a matrix of 6 different relationships between a therapist’s intervention approach and the expected outcome (Table 1). For the second scenario addressing movement strategies, there were 3 coding choices: (1) does not accept use of compensatory movement strategies; (2) accepts short-term use of compensatory movement strategies, but prefers typical patterns of movement; and (3) accepts compensatory movement strategies as an alternative to typical movement patterns.
Two members of the research team (J.D. and L.W.) read all the interviews, coded them independently and discussed any discrepancies. There were no discrepancies for coding goals, 4 discrepancies for coding the relationship between intervention and expected outcome, and 2 for coding acceptance of compensatory strategies. All discrepancies were resolved by consensus, and by referring back to the ICF domains and coding structures.
Table 2 summarizes therapists’ goals coded by the ICF component. The majority of therapists (n = 33) identified goals represented by the ICF component of activity such as “improve walking” and “improve keyboarding skills.” Therapists working with children in the youngest age category were most likely to describe goals representing body function and structure. Examples of goals across age groups coded at this ICF component are “maintain symmetry,” “encourage typical patterns of movement,” and “improve pencil grasp.” Only 8 therapists described goals that represented life roles and skills as described by the ICF component of participation. Examples of goals included “participate fully with peers” and “independence in school activities.”
Table 3 summarizes the frequencies for the codes representing relationships of intervention strategies and expected outcomes by ICF components. Nine therapists working with children younger than 3 years described interventions addressing body function and structure (eg, symmetry, range of motion, weight shift), but 7 of these therapists assumed that this remedial type of intervention would result in outcomes represented by the ICF component of activity (eg, sitting, crawling). In contrast, no therapist working with children aged 6 to 18 years described interventions that targeted body function and structure. They most often (n = 11) described interventions focused at the ICF component of activity and expected changes at the activity level. For example, many therapists described evaluating mobility options so that the child or adolescent could be independent as possible in the school environment. They also described evaluating keyboarding skills and writing to ensure that written communication was as efficient as possible. Only 4 therapists described intervention strategies coded at the ICF component of participation. One therapist working with children in the 3 to 6 year age category described a long-term goal of improving the child’s competence in school activities such as multiple-choice examinations. Her intervention was to meet and discuss options with the teachers, evaluate the school’s computer policies, and work with the teachers and family to determine the best solutions. The other 3 therapists saw children 6 to 18 years of age and described outcomes such as assisting the adolescent to interact with peers in school by meeting with the teachers and family to review class location, and to explore a buddy system to ensure regular opportunities for interaction with peers.
Table 4 summarizes therapists’ levels of acceptance of compensatory movement strategies. Only 11 therapists (20%) would not allow any use of compensatory movement strategies.
Seventy-eight percent of therapists (n = 42) identified goals either to improve functional abilities, or to enhance participation in life roles of children with CP, suggesting that their identified goals are congruent with contemporary literature on functional goals. Goals representing the ICF component of body function and structure were most often described by therapists who worked with children younger than 3 years.
The matrix developed to code the assumed relationship between a therapist’s intervention approach and the expected outcome of the intervention proved very useful. It revealed that clinical reasoning is more complex than the simple dichotomy of bottom-up and top-down intervention approaches. Some therapists described an intervention representing a functional activity with the assumption that the intervention would result in improvement represented by body function and structure. For example, 1 therapist encouraged standing in a young child to achieve pelvic stability, whereas another described working on stair climbing and playground activities with the intent of achieving increased muscle strength. These examples demonstrate that some therapists use a top-down approach with the specific aim of improving components of movement rather than functional activities.
Twenty-four therapists (44%) assumed a causal relationship between interventions and expected outcomes represented by different ICF components. The framework of ICF cautions against assuming a linear relationship across components. For example, increased muscle strength does not necessarily translate to improved functional activities. Our results suggest that assumed relationships are common in clinical decision making. Assumed relationships that form the basis of intervention strategies used clinically need to be systematically identified and evaluated. Clinicians can evaluate these relationships by using outcome measures that represent the ICF components addressed by intervention strategies and expected outcomes. For example, if it is assumed that muscle strengthening will result in improved stair climbing, outcome measures need to include both measures of muscle strength and stair climbing abilities. Clinical adaptation and use of an ICF matrix similar to the one developed for this study may assist clinicians in identifying their assumptions regarding interactions among their goals, intervention strategies, and expected outcomes. By systematically documenting and evaluating their intervention assumptions and expectations, clinicians can contribute to the identification of effective intervention strategies.
Current research does not provide conclusive evidence to guide therapists working with children with CP in their choice of a bottom-up or top-down approach or the various permutations identified in this study. It is likely that the effectiveness of a specific approach may depend on the interaction among the characteristics of the child, the goals of the family, and environmental factors. For example, our results suggest that the age of the child influences therapists’ goals and intervention approaches, with therapists in programs for very young children more likely to identify goals and intervention approaches represented by the ICF component of body function and structure. An emphasis on components of motor skills may be justified with younger children as their motor skills are still emerging and focusing on components of movement may improve the quality of an array of motor skills. For example, weight shift and upper extremity weight bearing may affect sitting, crawling, and more refined grasp. In addition, the nervous systems of younger children systems may be more amenable to shaping motor behaviors. An area for future research may be to understand why the emphasis on impairment decreases as children age. Do therapists’ perceive that the effectiveness of body function/structure focused intervention decreases or do parents’ goals change? Is the culture of early intervention focused on remediation?
Other factors that we did not examine such as a child’s severity of physical and cognitive impairments, family expectations, and the environmental context may also influence a therapist’s approach to intervention. Many therapists mentioned that in actual practice they would identify goals in collaboration with families rather than independently, and this may have changed the types of goals discussed. The influence of these and other factors on clinical decision making needs to be systematically evaluated to identify the “active ingredients” that ensure the right match between intervention choices and an individual child.14
Therapists’ acceptance of compensatory movement strategies seems to be changing from a traditional emphasis on quality and typical patterns of movement. Allowing children with CP to use compensatory movement strategies remains a controversial subject both clinically and in the literature. Advocates maintain that compensatory movement solutions represent the most efficient movement solution for the child,8,12,13 whereas others express concern that the use of compensatory movement strategies will increase secondary complications such as limited range of motion that then prevents the emergence of more mature patterns of movement.15 All therapists are concerned about secondary complications, but evidence to support or refute whether compensatory movement strategies contribute to secondary complications is lacking. The new emphasis on life-long fitness and recreational opportunities3,16 suggests therapy avenues to minimize secondary complications of CP. Longitudinal studies following children with CP to adulthood within a health promotion context are needed to fully examine the long-term consequences of allowing children with CP to use the movement solutions they spontaneously discover.
It is an exciting time in the rehabilitation of children with CP as traditional therapy styles and expectations change to embrace different approaches. Our results suggest that current therapy practice emphasizes functional goals, but that the intervention choices used to achieve function vary among therapists. Further research is needed to identify the best fit between a child and therapy goals and intervention.
The authors thank the therapists who participated in the interviews.
Palisano RJ, Snider LM, Orlin MN. Recent advances in physical and occupational therapy for children with cerebral palsy. Semin Pediatr Neurol.
Majnemer A, Mazer B. New directions in the outcome evaluation of children with cerebral palsy. Semin Pediatr Neurol.
Helders PJM, Engelbert RHH, Custers JWG, et al. Creating and being created: the changing panorama of paediatric rehabilitation. Pediatr Rehabil.
Ketelaar M, Vermeer A, Hart Ht, et al. Effects of a functional therapy program on motor abilities of children with cerebral palsy. Phys Ther.
World Health Organization. International Classification of Functioning, Disability and Health: ICF.
Geneva: World Health Organization, 2001.
Rosenbaum P, Stewart D. The World Health Organization international classification of functioning, disability, and health: a model to guide clinical thinking, practice and research in the field of cerebral palsy. Semin Pediatr Neurol.
Horn E. Achieving meaningful motor skills: conceptual and empirical bases of a neurobehavioral intervention approach. Ment Retard Dev Disabil Res Rev.
Burton AW, Miller D. Movement Skill Assessment.
Windsor, ON: Human Kinetics; 1998.
Coster W. Occupation-centered assessment of children. Am J Occup Ther.
Mathiowetz V, Haugen J. Motor behavior research: implications for therapeutic approaches to central nervous system dysfunction. Am J Occup Ther.
Law M, Darrah J, Pollock N. Family-centred functional therapy for children with cerebral palsy: an emerging practice model. Phys Occup Ther Pediatr.
Darrah J, Barlett D. Dynamic systems theory and management of children with cerebral palsy: unresolved issues. Infants Young Child.
Latash ML, Anson GJ. What are “normal movements” in atypical populations? Behav Brain Sci.
Whyte J, Hart T. It’s more than a black box; it’s a Russian doll: Defining rehabilitation treatments. Am J Phys Med Rehabil.
Kamm K, Thelen E, Jensen JL. A dynamical systems approach to motor development. Phys Ther.
Campbell S. Therapy programs for children that last a lifetime. Phys Occup Ther Pediatr.
Appendix: Example of Goal Setting/Intervention and Compensatory Movement Scenarios
Goal Setting/Intervention Scenario for Children 3 to 5 Years 11 Months.
Ryan is 5 years old with a diagnosis of mild spastic quadriplegia. He attends his community school. He is proficient at using his Kaye walker using a swing-through gait. Recently, he has started using Loftstrand crutches. His parents report that he is having difficulty keeping up with his peers at school with the crutches and he falls more often. He has weakness in his quadriceps and his hip abduction range of motion is limited to +15 bilaterally. In addition, Ryan has difficulty with printing, cutting, and coloring activities in the classroom. He is unable to grasp his pencil effectively due to excessive forearm pronation and wrist flexion. He has some keyboarding skills and uses a computer at home to color pictures.
What is your main treatment goal for Ryan?
Why did you choose this goal?
What would you do to encourage this goal?
Scenario to Explore Use of Compensatory Movement Solutions for Children 6 to 18 Years of Age.
Jake is 15 years old with a diagnosis of athetoid CP. He is unable to walk independently and has a specialized seating system in his manual wheelchair to encourage head and trunk symmetry and stability. He can move his manual wheelchair with his feet. His parents mention to you that he lies on his back and pushes with his legs to move around in his home.
What would you say to his parents about this situation? Probe whether the therapist would allow him to continue to use this movement strategy. Would the therapist place time limits on use of the adaptive strategy?
Why would you choose this strategy? What are the advantages and disadvantages of your approach?