Two articles in this issue focus on the needs of clients with severe cerebral palsy (CP), Gross Motor Function Classification System (GMFCS) level V. The reports compel us to think further about our roles and responsibilities in assuring the best possible prognosis for the children and families we serve. Each of the articles bring to the forefront needs of our most vulnerable clients at different points in their lives and highlight our roles in maximizing their potential from the earliest years through adolescence, and yes, into adulthood.
Heathcock and colleagues1 present an intensive therapy approach for children at GMFCS level V, who are under 2 years of age, demonstrating their capacity to respond to a motor learning program with positive outcomes across several developmental domains. The authors' findings suggest the potential to change the developmental course, and thus, the prognosis for these young children at a time when plasticity is greatest. I think this finding is HUGE! And although this is preliminary work, with much more study to be done, the authors demonstrate the way we need to be thinking about the dosage of our interventions. The idea that exercise should be viewed as a drug is not new,2 but as pediatric physical therapists we need to get serious about our concepts related to dosage in order to achieve the best possible outcomes for our clients with severe disabilities. Heathcock et al,1 suggest several questions that need to be addressed to follow up on her findings and research the intensity and duration of exercise interventions. Admittedly the purpose of exercise based in a motor learning paradigm differs from one that is based in an health and fitness paradigm, but the message is clear: to be more precise and efficient in our roles as doctors of physical therapy, we need to know a lot more about the dosage needed to achieve specific outcomes.
The report by Lephart and Kaplan3 compares seating systems for a young man with CP, GMFCS level V and severe scoliosis, and the consequent changes in physiologic function, activity, and participation derived from a custom molded back support. The comprehensive exploration of effects within all components of the International Classification of Functioning, Disability, and Health is noteworthy and demonstrates the importance of proper supportive devices that enhance physiologic function and personal comfort. The challenges of documenting the effects of this intervention including selecting appropriate measures points out the need to develop more sensitive tests for those with severe disabilities. But importantly, the gathering of data on oxygen saturation levels in each of the seating systems reminds us that pulmonary compromise is a serious secondary impairment that affects the prognosis of those with CP, GMFCS level V.
These 2 reports prompt us to look carefully at how we view the prognosis of children and adolescents with severe levels of disability. We need to extend intervention studies to individuals with severe disabilities and attend to reports of innovations that improve the functioning and quality of life of those with severe disabilities, lest we err in our prognoses.
Ann F. Van Sant, PT, PhD, FAPTA
1. Heathcock JC, Baranet K, Ferrante R, Hendershot S. Daily intervention for young children with cerebral palsy in GMFCS level V: A case series. Pediatr Phys Ther. 2015;27: 285–292.
2. Lee IM (2007). Dose-response relation between physical activity and fitness: even a little is good; more is better. JAMA. 2007;297: 2137–2139.
3. Lephart K, Kaplan SL. Two seating systems' effects on an adolescent with cerebral palsy and severe scoliosis. Pediatr Phys Ther. 2015;27: 258–266.