Children with cerebral palsy (CP) benefit from functional interventions that seek to improve levels of activity and participation in their daily environments. Excellent new study provides clinical practice guidelines for patient activities and participation. International Classification of Functioning, Disability and Health (ICF) to families and therapists, addressing which interventions are effective and evidence-based. The study, Interventions to improve physical function in children and young people with cerebral palsy: international clinical practice guidelineThey evaluated systematic reviews (or other supporting evidence when no systematic review was available) to draw up a list of good practice recommendations and evidence-based practice recommendations.
Good practice recommendations (1 to 9)
The nine Good Practice Recommendations are based on clinical reasoning and decision making and apply to questions outside the scope of available systematic reviews. These consider the preferences of the child and family, the environment and the economic situation, in order to appropriately implement the evidence to obtain better results. The recommendations are the following:
- The objectives must be chosen by the client.
- Clinicians must determine factors that limit goal achievement.
- The intervention must directly target the goals chosen by the child.
- The intervention must be pleasant and motivating for the child.
- Goal practice should occur within the child’s home or community environment.
- Intervention by parents is a key component of any intervention.
- Children, young people and parents must remain the decision makers at all times.
- Sufficient practice is necessary to achieve functional goals.
- A team approach should be used to establish goals and intervention regimens.
Evidence-based practice recommendations (10-13)
A multidisciplinary panel using the GRADE Evidence-to-Decision framework developed the four Evidence-Based Practice Recommendations after rigorous examination of relevant interventions and the evidence supporting them. The process included deciding for or against a recommendation (benefit versus harm) and then indicating the strength of the recommendation (strong or conditional). The recommendations are the following:
- Gross motor function and mobility (children with cerebral palsy, GMFCS levels I-IV)
There is a strong recommendation for task-based contextual mobility practice and a high certainty of harm without intervention.
The most effective means to improve walking speed and distance is to practice walking. Treadmill training can increase the dosage of walking practice, and overground walking training has better results when practiced in a child’s everyday environment.
Children in GMFCS levels IV and V show greater improvement in ambulation distance when walking on the ground compared to treadmill practice.
Gross motor function should be practiced as a complete task, although partial practice can be a stepping stone.
For children in GMFCS levels III and IV, adaptive equipment, environmental adaptations, and technology support progress toward functional goals, independence, and inclusion.
- Use of the hand in functional activities.
There is a strong recommendation, based on low to high certainty evidence, to improve hand use through comprehensive task practice with a task-oriented approach.
CIMT and bimanual therapy (HABIT/HABIT-ILE) are effective approaches for intended clinical presentations, and both should be followed by comprehensive practice (no restrictions after CIMT).
- Personal care
There is a strong recommendation, based on a high certainty of harm if no intervention, for self-care goals. Again, these should be practiced with a task-specific approach, using adaptive equipment to assist in their achievement.
- Leisure
This is a conditional recommendation with a lower certainty of evidence. However, most people would choose to participate in leisure activities regardless. Leisure activities are best pursued with a goal-oriented approach and focusing on overcoming barriers to participation.
Reading the entire article is certainly time well spent, as each evidence-based recommendation comes with intervention- and population-specific details. It is fantastic to see so much evidence supporting a task-based contextual approach to improving the activities and participation of children with disabilities. And of course, as this is the first clinical practice guideline to describe physical and occupational therapy interventions for children with cerebral palsy based on ICF activities and levels of participation, it is a very welcome addition to the pediatric literature.
