Early motor intervention

Early motor interventions are delivered by paediatric occupational therapists and physiotherapists.

Cerebral Palsy Alliance offers a specialised service where paediatric occupational therapists and physiotherapists skilled at early intervention with infants and young children complete a comprehensive assessment and help you decide on the best program for you and your child.

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Fees will apply for assessment and intervention with occupational therapists and physiotherapists, and will depend on the service provider and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing or therapist travel. Equipment and resources may be required depending on the type of early motor intervention program and the complexity of the child’s needs.

Ask service providers if you are eligible for funding to assist with fees, equipment and resources. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

Effective interventions are generally intensive and require a commitment to visit therapists and to complete activities at home.

Cerebral palsy is primarily a motor disorder that results from damage to the developing brain.

A motor disorder may affect:

• Gross motor skills – from rolling, sitting, crawling and walking - through to more advanced skills like running and hopping
• Fine motor skills – from those developed early in an infant’s life, including reaching and grasping, through to more complex hand skills necessary for self-care tasks and play.

One reason for a strong focus on early intervention is what we know about neuroplasticity - the brain’s natural ability to change and adapt.

Understanding neuroplasticity

The first two years of life is a critical period for neuroplasticity, when the brain is most likely to respond to intensive practice of motor activities². Children with cerebral palsy reach 90 per cent of their gross motor potential by the age of five³, and even earlier for those with severe cerebral palsy. Intensive and early therapy that is tailored to the individual needs of an infant or young child is therefore very important for maximising the opportunity for their young brain to adapt and learn.

Experts consider it important to work intensively with infants and young children to take advantage of the crucial early years when the developing brain is particularly responsive to intervention. Early motor intervention ideally begins as soon as a brain injury or developmental concerns are suspected. This might be as early as three months of age for infants who are identified as being at high risk on a General Movements Assessment. This assessment is the most accurate tool for identifying cerebral palsy early in an infant’s life.

A team of health professionals, including paediatric occupational therapists and physiotherapists, will complete a thorough assessment with each child and family to accurately identify and then implement the best intervention. The team and family will also work together to identify goals and decide on a time frame for achieving them.

The second type of assessment is to determine if the intervention is meeting the child’s needs and helping them achieve their goals. Assessments suggested for measuring the outcomes of early motor intervention programs include:

• Gross Motor Function Measure (GMFM) – measures gross motor ability
• Mini-Assisting Hand Assessment (Mini-AHA) or Kids-Assisting Hand Assessment– measures how effectively a child with hemiplegic cerebral palsy uses their affected hand during two-handed play activities
• Pediatric Evaluation of Disability Inventory or Pediatric Evaluation of Disability Computer Aided Test (PEDI-CAT) – measures mobility and daily activities.

We searched the medical, allied health, psychological and educational literature to find research evaluating the outcomes of early motor intervention programs used with infants and children from birth to five years of age.

The search aimed to find the best available evidence (randomised controlled trial (RCTs) or systematic reviews), published since 1984, about whether early motor interventions improve fine or gross motor skills. The search was to find studies where i) all infants in the study were clearly designated at high risk of cerebral palsy or had an established diagnosis of cerebral palsy and ii) all children were birth to five years old when starting the study. Studies of early intervention delivered whilst an infant was in hospital were not included. Studies of infants who were premature or small for gestational age were not included - unless they also had identified brain injuries or absence of fidgety general movements (which is a strong predictor of cerebral palsy in early infancy).

The best available evidence was 11 RCTs evaluating eight different early motor interventions in children from birth to five years old who had cerebral palsy or were at high risk of having cerebral palsy. In addition, we located a systematic review⁴ of the effectiveness of early motor interventions and which included all levels of research designs. Some interventions which are considered early interventions, and some known studies of early interventions may not be discussed below because they did not fit these criteria; or they did not have high level studies (RCTs or systematic reviews) evaluating their outcomes. Such interventions include goal directed training, Vojta and bimanual upper limb therapy.

There are several types of early motor intervention programs, but very few high level studies have been completed to evaluate them. The evidence suggests, however that promising interventions are:

• GAME^5-6
• Infant stimulation for infants with spastic diplegic cerebral palsy^4-7
• Constraint-induced movement therapy⁸ for young children with hemiplegic cerebral palsy
• Treadmill training⁹ for young children at GMFCS Levels I and II

Low quality evidence provided insufficient information about the effects of conductive education¹⁰ and kicking and stepping exercises¹¹ for improving motor outcomes. More good quality research would provide clearer guidance about these interventions and in the meantime, the more promising early motor interventions listed above should be used. Neurodevelopmental therapy^{7, 12-16}, which has been evaluated in several RCTs and has a moderate quality evidence base, appears not to be effective for improving motor skills in young children with cerebral palsy and an alternative intervention should be considered. Other interventions, such as bimanual upper limb therapy, Vojta and goal directed training that exist for the birth to five-year-old age group, do not yet have high level research evaluating their effectiveness⁴.

Research tells us that the brain of the infant and very young child are best able to respond, change and adapt in the first two years of life. We also know from research into older children with cerebral palsy that intensive treatments are more effective than less intensive treatments. Experts, therefore, recommend intensive and early interventions for infants and young children⁴.

The research evidence is just one piece of information to assist in deciding what type of early motor intervention is right for an individual child. Families, caregivers and paediatric therapists will carefully consider the unique goals and needs of each infant and young child with cerebral palsy to determine which program is most suitable. The outcomes should be carefully monitored to check whether the intervention is effective and meeting the goals that were set.

Further information on the findings

GAME is more effective than standard care for motor and cognitive outcomes.

GAME stands for Goals, Activity and Motor Enrichment. This intervention is customised for individual infants and families’ goals and is carried out at home^5-6. Families are coached and supported to actively engage their infant in motor tasks and to enrich the home environment to achieve developmental goals. One RCT⁵ compared GAME with an equal amount of standard care. The results indicated that GAME is more effective for improving motor and cognitive outcomes at 12 months of age. The infants started the study before turning 6 months of age and were at either high risk of cerebral palsy or had a diagnosis of any type of cerebral palsy. GAME is a promising new intervention.

Six months of infant stimulation had better outcomes than an alternate therapy

Infant stimulation involves a series of motor, sensory, cognitive and language tasks of increasing difficulty. One RCT provides moderate quality evidence that six months of infant developmental stimulation results in better motor outcomes than equally intensive neurodevelopmental therapy (NDT, see below)⁷ for children with spastic diplegia. In this study, children with spastic diplegic cerebral palsy, aged 12 months to 19 months, engaged in infant stimulation carried out by parents at home, supported by fortnightly visits to a physiotherapist. Although little high level research has been completed, infant developmental stimulation is a promising intervention.

Constraint-induced movement therapy (CIMT) may help children use their affected hand

CIMT is used with children with hemiplegic cerebral palsy. The unaffected hand is restrained using a mitt, splint or cast, while therapy is completed to improve the use of the affected (hemiplegic) hand. One RCT⁸ provides Low quality evidence that CIMT is more effective than usual care for improving a child’s ability to use the hemiplegic hand in two-handed activities. The intervention involved children aged two and three years old wearing a mitt on their unaffected hand while participating in two hours of therapy per day for two months. Although little high level research has been completed, CIMT is a promising intervention.

Treadmill training combined with physiotherapy may improve independent walking

Treadmill training involves carefully supervised and supported walking on a treadmill. One RCT⁹ provides low quality evidence that treadmill training combined with regular physiotherapy may be more effective for improving independent walking than less intensive regular physiotherapy for nine to 36 month old children with milder cerebral palsy (GMFCS I and II). Treadmill training, in this study, involved walking on a portable treadmill in the home, for an average of 28 minutes per day, six days a week for six weeks. Although little high level research has been completed, treadmill training is a promising intervention.

Neurofacilitation of developmental reaction may improve gross motor skills

One small RCT¹², providing low quality evidence compared neurofacilitation of developmental reaction with equally intensive neurodevelopmental therapy. The former resulted in better gross motor skills than the latter in children with mild to moderate spasticity but unknown types of cerebral palsy. Very little is known about this intervention and it appears only to be used in India.

High intensity kicking and stepping is no better than low intensive physiotherapy

This intervention involves teaching parents to play games to encourage kicking as well as early treadmill stepping. One small RCT¹¹ comparing this intervention to lower intensity physiotherapy provided low quality evidence that there was no difference in motor outcomes between the two interventions with infants at high risk for cerebral palsy. This intervention involved kicking games starting at two months of age and treadmill stepping at home starting at four months. Low quality evidence suggests that the higher intensity kicking and stepping program is no more effective than lower intensity physiotherapy. More good quality research is needed to give us more information about kicking and stepping programs.

No difference between conductive education and neurodevelopmental therapy outcomes

Conductive education is an educational approach, rather than a therapy. Therefore, it is not always classified as an early motor intervention because it addresses a range of other outcomes as well as motor skills. It focuses on several aspects of a child’s development, and includes a motor component. One RCT¹⁰ comprising low quality evidence compared equally intensive conductive education and neurodevelopmental therapy in children aged one to three years old with a range of presentations and severity of cerebral palsy. The study found no difference in gross motor outcomes between the two interventions. More good quality research is required to provide better information about the effect of conductive education on motor skills in this age group. It is important to note that this review only considered motor outcomes and not the other outcomes which conductive education addresses.

Moderate evidence that neurodevelopmental therapy (NDT) is less effective than other equally intensive interventions

Two RCTs^7,12 provided moderate quality evidence that an intervention applied at an equal intensity was more effective for improving gross motor ability than NDT in young children with a range of types and severity of cerebral palsy. Four RCTs^13-16 provided moderate quality evidence that there was no difference in motor outcomes between NDT and a less intensive intervention in children with or at risk of cerebral palsy. For children from birth to five years with, or at risk of, cerebral palsy, moderate quality evidence shows that NDT is no more effective than less intensive interventions and that other equally intensive interventions should be pursued where appropriate.