REFERENCES 1. Kirschner B, Guyatt GH. A methodological framework
3. Williams EN, Carroll SG, Reddihough DS, Phillips BA,
5. Bronfenbrenner U. The Ecology of Human Develop-
for assessing health indices. J Chron Dis 1985; 38:
Galea MP. Investigation of the timed ‘up and go’ test in
ment. Experiments by Nature and Design. Cambridge,
27–36.
children. Dev Med Child Neurol 2005; 47: 518–24.
MA: Harvard University Press, 1979.
2. Sackett DL, Rosenberg WM, Gray JAM, Haynes RB,
4. Novak I, McIntyre S, Morgan C, et al. A systematic review
Richardson WS. Evidence based medicine: what it is and
of interventions for children with cerebral palsy: state of
what it isn’t. BMJ, 1996; 312: 71–2.
the evidence. Dev Med Child Neurol 2013; 55: 885–910.
Making it possible – interventions for children with cerebral palsy EVA BECKUNG Department of Physiotherapy and Occupational Therapy, Sahlgrenska University Hospital, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. doi: 10.1111/dmcn.12433 This commentary is on the original article by Bartlett et al.1
What combination of child, family, and service factors explain the change in motor abilities of young children with cerebral palsy (CP)? We all want to know! Bartlett et al. should be complimented for their comprehensive work.1 Analysis of change in motor function over 1 year showed that primary and secondary impairments explained 58% and 75% of the variance in motor function when analyzing determinants of gross motor function in 429 young children with CP. Some considerations. Early childhood is a sensitive period for development, and when children present signs of impaired motor development therapists aim to start interventions even if the value of certain methods and early interventions still are limited, especially in a condition such as CP with its wide variation and complexity. At the onset of the Bartlett study the children were very young, 18 to 60 months of age, and some of them may not have had an ascertainment of the diagnosis of CP at the age of 4 years as recommended by the Surveillance of Cerebral Palsy in Europe, SCPE.2 The classification levels in the Gross Motor Function Classification System (GMFCS) are well known, fairly stable, and extremely useful in the clinic as well as in research. It is a pity that the authors were not able to keep the five levels in the model tested. The children in this study were divided into two groups based on merged GMFCS levels. At 1 year some of the children labeled as being at GMFCS level III might have changed to a milder or a more severe level. In a comprehensive review, Chiarello et al. started building the multivariate model of change used in the paper above.1 A range of factors associated with the
418 Developmental Medicine & Child Neurology 2014, 56: 413–419
motor function in CP was reported.3 Pain in children with CP was not one of the factors. The Study of Participation in Children with CP Living in Europe, (SPARCLE), reported the estimated population prevalence of self-reported pain for children 8 to 12 years of age, in the previous week, to be 60%4 and of young people, 13 to 17 years of age, to be 74%.5 Pain in children with CP is common and needs to be considered also in the very young. Bartlett et al. conclude that motor function in young children with CP is supported by optimizing body structures and function. Fine, but let0 s not forget to put this focus in an activity and participation context. In the model of determinants for gross motor function the intensity of therapy was included. Let us also discuss and evaluate how therapists should contribute. Physiotherapy interventions focusing on children with CP should, according to the literature, be based on a functional and environmental perspective with task-specific functional activity, motor learning processes, and familycentred service, i.e. to enhance motor ability and improve capacity so that the child can perform the tasks necessary to participate actively in everyday life. Larsson et al.6 identified three qualitatively different descriptive categories: 1 Making it possible – a functional-based intervention based on the biopsychosocial health paradigm, and the role of the physiotherapist as collaborative, interacting with the child and family in goal setting, intervention planning, and evaluation. 2 Making it work – an impairment-based intervention built on a mixed health paradigm (biomedical and biopsychosocial), and the role of the physiotherapist as a coach, leading the goal setting, intervention planning, and evaluation, and instructing family members how to carry out physiotherapist-directed orders. 3 Making it normal – an impairment-based intervention built on a biomedical health paradigm, and the role of the physiotherapist as an authoritative expert who determines goals, intervention planning, and evaluation. Let0 s go for 1 – making it possible!
REFERENCES 1. Bartlett DJ, Chiarello LA, McCoy SW, et al. Determi-
motor abilities and engagement in self-care and play of
multicentre European study. Arch Dis Child 2013; 98:
nants of gross motor function of young children with
young children with cerebral palsy. Phys Occup Ther
434–40.
cerebral palsy: a prospective cohort study. Dev Med Child Neurol 2014; 56: 275–82. 2. Smithers-Sheedy H, Badawi N, Blair E, et al. What constitutes cerebral palsy in the twenty-first century? Dev Med Child Neurol 2014; 56: 323–28.
Pediatr 2011; 31: 150–68.
6. Larsson I, Miller M, Liljedahl K, Gard G. Physiothera-
4. Parkinson KN, Gibson L, Dickinson HO, Colver AF. Pain
pists’ experiences of physiotherapy interventions in scien-
in children with cerebral palsy: a cross-sectional multicen-
tific physiotherapy publications focusing on interventions
tre European study. Acta Paediatr 2010; 99: 446–51.
for children with cerebral palsy: a qualitative phenomeno-
5. Parkinson KN, Dickinson HO, Arnaud C, Lyons A,
3. Chiarello LA, Palisano RJ, Bartlett DJ, McCoy SW. A
Colver A, SPARCLE group. Pain in young people aged
multivariate model of determinants of change in gross-
13 to 17 years with cerebral palsy: cross-sectional,
graphic approach. BMC Pediatr 2012; 12: 90.
Commentaries
419
3. Williams EN, Carroll SG, Reddihough DS, Phillips BA,
5. Bronfenbrenner U. The Ecology of Human Develop-
for assessing health indices. J Chron Dis 1985; 38:
Galea MP. Investigation of the timed ‘up and go’ test in
ment. Experiments by Nature and Design. Cambridge,
27–36.
children. Dev Med Child Neurol 2005; 47: 518–24.
MA: Harvard University Press, 1979.
2. Sackett DL, Rosenberg WM, Gray JAM, Haynes RB,
4. Novak I, McIntyre S, Morgan C, et al. A systematic review
Richardson WS. Evidence based medicine: what it is and
of interventions for children with cerebral palsy: state of
what it isn’t. BMJ, 1996; 312: 71–2.
the evidence. Dev Med Child Neurol 2013; 55: 885–910.
Making it possible – interventions for children with cerebral palsy EVA BECKUNG Department of Physiotherapy and Occupational Therapy, Sahlgrenska University Hospital, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. doi: 10.1111/dmcn.12433 This commentary is on the original article by Bartlett et al.1
What combination of child, family, and service factors explain the change in motor abilities of young children with cerebral palsy (CP)? We all want to know! Bartlett et al. should be complimented for their comprehensive work.1 Analysis of change in motor function over 1 year showed that primary and secondary impairments explained 58% and 75% of the variance in motor function when analyzing determinants of gross motor function in 429 young children with CP. Some considerations. Early childhood is a sensitive period for development, and when children present signs of impaired motor development therapists aim to start interventions even if the value of certain methods and early interventions still are limited, especially in a condition such as CP with its wide variation and complexity. At the onset of the Bartlett study the children were very young, 18 to 60 months of age, and some of them may not have had an ascertainment of the diagnosis of CP at the age of 4 years as recommended by the Surveillance of Cerebral Palsy in Europe, SCPE.2 The classification levels in the Gross Motor Function Classification System (GMFCS) are well known, fairly stable, and extremely useful in the clinic as well as in research. It is a pity that the authors were not able to keep the five levels in the model tested. The children in this study were divided into two groups based on merged GMFCS levels. At 1 year some of the children labeled as being at GMFCS level III might have changed to a milder or a more severe level. In a comprehensive review, Chiarello et al. started building the multivariate model of change used in the paper above.1 A range of factors associated with the
418 Developmental Medicine & Child Neurology 2014, 56: 413–419
motor function in CP was reported.3 Pain in children with CP was not one of the factors. The Study of Participation in Children with CP Living in Europe, (SPARCLE), reported the estimated population prevalence of self-reported pain for children 8 to 12 years of age, in the previous week, to be 60%4 and of young people, 13 to 17 years of age, to be 74%.5 Pain in children with CP is common and needs to be considered also in the very young. Bartlett et al. conclude that motor function in young children with CP is supported by optimizing body structures and function. Fine, but let0 s not forget to put this focus in an activity and participation context. In the model of determinants for gross motor function the intensity of therapy was included. Let us also discuss and evaluate how therapists should contribute. Physiotherapy interventions focusing on children with CP should, according to the literature, be based on a functional and environmental perspective with task-specific functional activity, motor learning processes, and familycentred service, i.e. to enhance motor ability and improve capacity so that the child can perform the tasks necessary to participate actively in everyday life. Larsson et al.6 identified three qualitatively different descriptive categories: 1 Making it possible – a functional-based intervention based on the biopsychosocial health paradigm, and the role of the physiotherapist as collaborative, interacting with the child and family in goal setting, intervention planning, and evaluation. 2 Making it work – an impairment-based intervention built on a mixed health paradigm (biomedical and biopsychosocial), and the role of the physiotherapist as a coach, leading the goal setting, intervention planning, and evaluation, and instructing family members how to carry out physiotherapist-directed orders. 3 Making it normal – an impairment-based intervention built on a biomedical health paradigm, and the role of the physiotherapist as an authoritative expert who determines goals, intervention planning, and evaluation. Let0 s go for 1 – making it possible!
REFERENCES 1. Bartlett DJ, Chiarello LA, McCoy SW, et al. Determi-
motor abilities and engagement in self-care and play of
multicentre European study. Arch Dis Child 2013; 98:
nants of gross motor function of young children with
young children with cerebral palsy. Phys Occup Ther
434–40.
cerebral palsy: a prospective cohort study. Dev Med Child Neurol 2014; 56: 275–82. 2. Smithers-Sheedy H, Badawi N, Blair E, et al. What constitutes cerebral palsy in the twenty-first century? Dev Med Child Neurol 2014; 56: 323–28.
Pediatr 2011; 31: 150–68.
6. Larsson I, Miller M, Liljedahl K, Gard G. Physiothera-
4. Parkinson KN, Gibson L, Dickinson HO, Colver AF. Pain
pists’ experiences of physiotherapy interventions in scien-
in children with cerebral palsy: a cross-sectional multicen-
tific physiotherapy publications focusing on interventions
tre European study. Acta Paediatr 2010; 99: 446–51.
for children with cerebral palsy: a qualitative phenomeno-
5. Parkinson KN, Dickinson HO, Arnaud C, Lyons A,
3. Chiarello LA, Palisano RJ, Bartlett DJ, McCoy SW. A
Colver A, SPARCLE group. Pain in young people aged
multivariate model of determinants of change in gross-
13 to 17 years with cerebral palsy: cross-sectional,
graphic approach. BMC Pediatr 2012; 12: 90.
Commentaries
419
