International Clinical Practice Guideline for EI for children 0-2 years at risk for CP

Extracts by Pam Versfeld July 2021

Morgan, C., et al (2021) Early Intervention for Children Aged 0 to 2 Years With or at High Risk of Cerebral Palsy: International Clinical Practice Guideline Based on Systematic Reviews.
JAMA pediatrics, 10.1001/jamapediatrics.2021.0878. Online ahead of print  Abstract

A group of 44 international researchers came together to systematically review the best available evidence about CP-specific early interventions across 9 domains promoting motor function, cognitive skills, communication, eating and drinking, vision, sleep, managing muscle tone, musculoskeletal health, and parental support.

This review led to the formulation of a set of general principles and 28 recommendations for best practice. Below I have copied the the principles and the recommendations that relate to training of motor functions. Please consult the original article for the full set of recommendations and a description of the quality of the research supporting each recommendation.

General Best Practice Guiding Principles

Best practice principles should guide professional interactions and intervention provided to children for all 9 domains.

1 Children diagnosed with or at high risk of CP should be immediately referred for CP-specific and age-specific intervention.

2 Goals should be set that are task-specific and context-specific, at the appropriate level of challenge, and updated regularly.

3 Clinicians should provide coaching and education to increase knowledge and impart support for parents and caregivers.

Clinicians should support parents and caregivers to build parental capacity and expertise, prioritizing a positive parent-child relationship.

Parents’ goals and aspirations must be central to the intervention, with parent participation essential of particular importance is the need for frequent practice of the activities that lead to skilled movement and functional independence. Intervention environments and professional input are not sufficiently frequent to achieve the goals of early intervention programs

Recommendations 

RECOMMENDATION 1.0: Strong (For) Early Intervention

It is best practice to begin intervention at the time of diagnosis of cerebral palsy or “high risk” for cerebral palsy

A precise diagnosis is not necessary as it is sufficient to begin intervention when motor delay or motor system dysfunction is observed. Both clinical and parental concern are sufficient reasons to begin intervention when infants have a “high risk” diagnosis.A precise diagnosis is not necessary as it is sufficient to begin intervention when motor delay or motor system dysfunction is observed. Both clinical and parental concern are sufficient reasons to begin intervention when infants have a “high risk” diagnosis.

RECOMMENDATION 2.0: Strong (For) Task-Specific Motor Training

It is best practice for intervention to include self-discovery of the environment and solutions to overcome movement challenges. Evidence supports the designing of motor tasks that challenge the infant but are achievable, typically including trials with failures but with persistence lead finally to success. The creation of enriched environments can trigger a variety of movement and intense enjoyable practice. Enrichment is supported in both the animal and human literature, indicating small positive effects from moderate to high quality human evidence.

The evidence including 2 systematic review and 9 RCTs is of moderate to high quality but limited in number of subjects included in the studies with infants with CP or high risk of CP as defined in this guide. The recommendation receives support from the rehabilitation literature of older children with CP, adults post stroke, and animals with brain lesions who received enriched environments.

RECOMMENDATION 2.0: Strong (For) Task-Specific Motor Training

It is best practice for intervention to include self-discovery of the environment and solutions to overcome movement challenges. Evidence supports the designing of motor tasks that challenge the infant but are achievable, typically including trials with failures but with persistence lead finally to success. The creation of enriched environments can trigger a variety of movement and intense enjoyable practice. Enrichment is supported in both the animal and human literature, indicating small positive effects from moderate to high quality human evidence.

RECOMMENDATION 4.0: Strong Recommendation (For) Constraint-Induced Movement Therapy (CIMT) or Bimanual

It is best practice to begin CIMT and/or bimanual training as soon as a diagnosis of unilateral CP is made or “high risk” of unilateral CP is determined.

Although the evidence is insufficient at this time, it is not good practice to simply “wait and see” when there are clear clinical symptoms of asymmetrical motor function.RECOMMENDATION 5.0: Strong (For) Cognitive Interventions

It is best practice for infants to receive targeted cognitive interventions since motor impairment can hamper social interactions and exploration of the environment and toys, restricting discovery-based learning

RECOMMENDATION 5.0: Strong (For) Cognitive Interventions

It is best practice for infants to receive targeted cognitive interventions since motor impairment can hamper social interactions and exploration of the environment and toys, restricting discovery-based learning

Evidence from 7 small studies supports the delivery of interventions with a collaboration between parents and therapists. Active engagement of the infant and parent through environmental enrichment and parent

RECOMMENDATION 7.0: Conditional (For) Face-to-Face Nurturing with Vocalizations, Joint Attention and Reciprocal Interaction Interventions

It is best practice for parents to engage their infant face-to-face to talk, sing, show emotion and communicate.

There was no cerebral palsy specific evidence, and recommendations had to be inferred from good practice in typically developing infants.

Very little has been researched or written about promoting the communication abilities of infants with cerebral palsy under 2 years of age, however, general principles for promoting communication in typically developing children are considered good practice.

 

Translating the guideline principles and recommendations into practice 

Solution Focused Task Oriented Movement Therapy Guidelines
 


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