Intervention to Advance Postural Transitions and Problem Solving Ability in Children With Cerebral Palsy

Xin Zhang 1, Swati M. Surkar 2, Regina T. Harbourne 2, Sandra Willett 2, Max J. Kurz 2, Lynne M. Capoun 2

1University of Nebraska Medical Center, Physical Therapy Education, Omaha, Nebraska 2University of Nebraska Medical Center, Munroe Meyer Institute, Omaha, Nebraska

ACKNOWLEDGEMENTS: This work was supported by American Physical Therapy Association, Session on Pediatrics.

BACKGROUND INFORMATION: §  The relationship of postural control and early self-mobility to cognitive

development, although implied in many descriptions, is not well understood.

§  We know that crawling has been linked to the ability to perceive object permanence. However, no studies have specifically examined self-mobility and the progression of cognitive skill in children with neuromotor disorders.

§  The ability to learn about objects partly relies on motor abilities, and should be reflected in problem solving ability.

PARTICIPANTS:

§  Twelve children with mild to moderate CP, 6 in each therapy group §  Between the ages of 9 months to 3 years (17.8 months for BWS & 18.2 months for PMA intervention) §  Children entered the study when they were able to sit for one minute alone §  Intervention was twice weekly for 12 weeks， 60 minutes every time.

INTERVENTION:

§  PMA emphasized child-directed, self-initiated movement in various sitting positions, with suggestions from the therapist for variability. This approach focuses on helping the child to obtain a functional goal, which may not necessarily lead to “normal” movement pattern. The expectation is that the child will chose the movement strategy rather than the therapist. §  BWS was provided by suspension system or by physical therapy assistance to maintain an erect body position for standing or walking. Each therapy session included a total of thirty minutes of walking. Body weight support was reduced gradually along the time. Examples of PMA treatment principles:

CONCLUSIONS:

§  BWS training and perceptual motor approach are both useful in promoting postural transitions.

§  Considering the limited sample size, statistical differences between two interventions could not be detected.

§  The descriptive data imply that BWS intervention was more helpful in advancing dynamic motor abilities, such as crawling and walking. In contrast, the perceptual motor approach was more beneficial in improving static posture control, such as sitting and standing.

§  BWS intervention may not benefit the children with CP in their problem solving ability. However, problem solving skills in the perceptual motor intervention group may help with it.

CLINICAL IMPLICATIONS FOR INTERVENTION: §  We suggest to use different interventions to improve different types of posture

control for infants with CP. BWS may beneficial for dynamic motor while PMA may improve static posture.

§  Problem solving skills can be addressed and improved with specific types of motor interventions.

METHODS: §  Gross Motor Function Measure-88 (GMFM), sitting/ crawling/standing/walking dimensions. §  Toys play and problem solving was taped, then assessed using a tool called EPSI (Early Problem Solving Indicator). The EPSI assessment was composed with 3 standard toys in a roll, pop-up pets, stacking cups, gumball machine. Infants are offered those toys for 6 mins, 2 mins each. Manipulation events (look, explore, function and solution) are coded for 6 mins. §  Data collected pre-intervention and post-intervention EPSI toys example:

Environment set up to require small changes in skill, to provide “rich” perceptual information.

Self-initiated, functionally directed movement is the focus of intervention. Passive movement are not used.

Increased variability of active movement is encouraged, and abnormal movements are not blocked or discouraged

REFERENCES:

§  Harbourne, RT, Willett, S, Kyvelidou A, Deffeyes J, Stergiou N. (2010). A comparison of interventions for children with cerebral palsy to improve sitting postural control. Physical Therapy, 90, 1850-1859.

§  Greenwood, Charles R.; Walker, Dale; Carta, Judith J.; Higgins, Susan K. Developing a General Outcome Measure of Growth in the Cognitive Abilities of Children 1 to 4 Years Old: The Early Problem-Solving Indicator. School Psychology Review, Vol 35(4), 2006, 535-551.

PURPOSE: §  The purpose of this pilot study was to investigate and compare the

effects of a perceptual motor approach (PMA) and a body weight support (BWS) intervention in advancing postural transitions and problem solving skills in children with CP. The PMA which focuses on enhancing complexity of movement variability, was shown effective to improve sitting control and play skills in our previous study.

RESULTS:

Pop-up Pets Stacking cups Gumball machine

§  The GMFM in all dimensions significantly increased overall from pre to post intervention (P=0.006, P=0.008, P=0.004 and P=0.031).

§  The change scores of the GMFM in crawling and walking dimensions in the BWS group are larger (19.67±18.11% and 5.67±5.47%, respectively) than the perceptual motor group (15.00± 22.19% and 3.17±5.38%)

§  The change scores in the sitting and standing dimensions are smaller in the BWS group (13.83±12.95% and 4.50±5.96%) than in the perceptual motor group (18.501±11.86% and 10.50±9.91%).

§  The scores of EPSI explores and functions decreased in BWS group (-0.50±.051, -0.83±10.72 and -1.5±5.71); conversely, the scores of explores and functions in the PMA group increased (3.00±10.56 and 7.17±11.44).

§  Manipulate events of EPSI: ­  Look: infant faces or moves head toward a toy for any amount of time ­  Explore: infant touches, mouths, rubs, pulls, shakes or explores the toy ­  Function: infant perform a function or create an effect in a intended

manner ­  Solution: infant display full function of a toy