Morgan C, Darrah J, Gordon AM, Harbourne R, Spittle A, Johnson R, Fetters L. Effectiveness of motor interventions in infants with cerebral palsy: a systematic review. Dev Med Child Neurol. 2016 Sep;58(9):900-9.    https://onlinelibrary.wiley.com/doi/full/10.1111/dmcn.13105

Thirty-four studies met the inclusion criteria, including 10 randomized controlled trials. Studies varied in quality, interventions, and participant inclusion criteria. Neurodevelopmental therapy was the most common intervention investigated either as the experimental or control assignment. The two interventions that had a moderate to large effect on motor outcomes (Cohen's effect size>0.7) had the common themes of child-initiated movement, environment modification/enrichment, and task-specific training.

Hadders-Algra M, Boxum AG, Hielkema T, Hamer EG. Effect of early intervention in infants at very high risk of cerebral palsy: a systematic review. Dev Med Child Neurol. 2017    https://onlinelibrary.wiley.com/doi/full/10.1111/dmcn.13331

Thirteen papers met the inclusion criteria. Seven studies with moderate to high methodological quality were analysed in detail; they evaluated neurodevelopmental treatment only (n=2), multisensory stimulation (n=1), developmental stimulation (n=2), and multifaceted interventions consisting of a mix of developmental stimulation, support of parent–infant interaction, and neurodevelopmental treatment (n=2). The heterogeneity precluded conclusions. Yet, two suggestions emerged: (1) dosing may be critical for effectiveness; (2) multifaceted intervention may offer best opportunities for child and family.

Finch-Edmondson, M., Morgan, C., Hunt, R. W., & Novak, I. (2019). Emergent Prophylactic, Reparative and Restorative Brain Interventions for Infants Born Preterm With Cerebral Palsy. Frontiers in physiology, 10, 5.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360173/

Boyd, R. N., Ziviani, J., Sakzewski, L., Novak, I., Badawi, N., Pannek, K., … Rose, S. (2017). REACH: study protocol of a randomised trial of rehabilitation very early in congenital hemiplegia. BMJ open, 7(9), e017204. doi:10.1136/bmjopen-2017-017204

Cortical reorganisation after an early brain lesion: a critical window

For infants with early brain lesions, there are important phases of sensorimotor reorganisation in the first year with two main types of brain reorganisation.

• Ipsilesional reorganisation (ie, reorganisation within spared cortical tissue of the damaged hemisphere) allows the damaged motor cortex to become reconnected to the spinal cord, as observed in adults following stroke.
• Contralesional reorganisation (ie, reorganisation in the undamaged cortex) occurs when existing ipsilateral motor projections remain intact instead of becoming retracted within the first months of life.

This alternate type of reorganisation occurs in very early brain lesions and can lead to severe motor impairment due to dissociation of the primary sensory and motor pathways..

It is proposed that the first 3–6 months following an asymmetric brain lesion provides a critical opportunity for interventions to influence lateralisation of the corticospinal (CS) pathways.When sparing of the CS tract is present, early intervention may shape cortical reorganisation and improve outcomes.

Spittle AJ, Morgan C, Olsen JE, Novak I, Cheong JLY. Early Diagnosis and Treatment of Cerebral Palsy in Children with a History of Preterm Birth. Clin Perinatol. 2018 Sep;45(3):409-420.

Infants born preterm are at increased risk of cerebral palsy (CP), with the risk increasing with decreasing gestational age. Although preterm children are at increased risk of CP compared with their term-born peers, most preterm children do not have CP and thus, it is important to have a standardized process for detecting those children at high risk of CP early. A combination of clinical history, neuroimaging, and physical examination is recommended to ensure early, accurate diagnosis. Early detection of CP is essential for timely early intervention to optimize outcomes for children and their families.

Novak I, McIntyre S, Morgan C, Campbell L, Dark L, Morton N, Stumbles E, Wilson SA, Goldsmith S. A systematic review of interventions for children with cerebral palsy: state of the evidence. Dev Med Child Neurol. 2013 Oct;55(10):885-910.

https://onlinelibrary.wiley.com/doi/full/10.1111/dmcn.12246

Overall, 166 articles met the inclusion criteria (74% systematic reviews) across 64 discrete interventions seeking 131 outcomes. Of the outcomes assessed, 16% (21 out of 131) were graded 'do it' (green go); 58% (76 out of 131) 'probably do it' (yellow measure); 20% (26 out of 131) 'probably do not do it' (yellow measure); and 6% (8 out of 131) 'do not do it' (red stop). Green interventions included anticonvulsants, bimanual training, botulinum toxin, bisphosphonates, casting, constraint-induced movement therapy, context-focused therapy, diazepam, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care, and selective dorsal rhizotomy. Most (70%) evidence for intervention was lower level (yellow) while 6% was ineffective (red).

Based upon the best available evidence, standard care for children with CP should include the following suite of interventions options (where the interventions would address the family's goals):

(1) casting for improving ankle range of motion for weight bearing and/or walking;

2) hip surveillance for maintaining hip joint integrity;

(3) bimanual training, constraint‐induced movement therapy, context‐focused therapy, goal‐directed/functional training, and/or home programmes for improving motor activities or self‐care function;

(4) BoNT, diazepam, or selective dorsal rhizotomy for spasticity management;

(5) fitness training for aerobic fitness;

(6) pressure care for reducing the risk of ulcers;

(7) bisphosphonates for improving bone mineral density; and

(8) anticonvulsants for managing seizures.

When delivering interventions to children with CP, it is paramount that clinicians choose evidence‐based interventions at the activities and participation level that hone the child's strengths and reflect their interests and motivations, and ultimately seek to help children live an inclusive and contented life.

However, when choosing interventions at the body structure and functions level, the primary purpose is to mitigate the natural history of CP (such as hip dislocation) and the probable physical decline from secondary impairments,118 rather than trying to fix the condition. We must also remain mindful that conflicts can arise between what families hope for and what the evidence suggests will be helpful or is realistically possible.202 Part of being truly family centred is to act as an information resource to the family, which will include honest and open disclosure about prognosis using evidence‐based tools to guide these difficult conversations.203 

Similarly, designing services based upon goals set by the family 5, 64 is best practice and can also help to set the scene for discussing what is realistic and possible from intervention.

Novak I, Honan I.​ Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review. Aust Occup Ther J. 2019 Jun;66(3):258-273.

https://onlinelibrary.wiley.com/doi/full/10.1111/1440-1630.12573

Thirty percent of the indications assessed (n = 40/135) were graded 'do it' (Green Go); 56% (75/135) 'probably do it' (Yellow Measure); 10% (n = 14/135) 'probably don't do it' (Yellow Measure); and 4% (n = 6/135) 'don't do it' (Red Stop).

Green lights were: Behavioural Interventions; Bimanual; Coaching; Cognitive Cog-Fun & CAPS; CO-OP; CIMT; CIMT plus Bimanual; Context-Focused; Ditto; Early Intervention (ABA, Developmental Care); Family Centred Care; Feeding interventions; Goal Directed Training; Handwriting Task-Specific Practice; Home Programs; Joint Attention; Mental Health Interventions; occupational therapy after toxin; Kinesiotape; Pain Management; Parent Education; PECS; Positioning; Pressure Care; Social Skills Training; Treadmill Training and Weight Loss 'Mighty Moves'.

Evidence supports 40 intervention indications, with the greatest number at the activities-level of the International Classification of Function.

Yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions could be discontinued because effective alternatives existed.

SR authors have concluded that NDT/Bobath and SI rarely confer motor gains superior to no intervention, but the RCTs contain so many methodological flaws that recommendations for use or discontinuation of use within practice cannot be made with certainty (Boyd & Hays, 2001; Brown & Burns, 2001; Case‐Smith & Arbesman, 2008; Case‐Smith et al., 2013; Case‐Smith et al., 2014; Lang et al., 2012; May‐Benson & Koomar, 2010; Novak et al., 2013; Sakzewski et al., 2009, 2013; Steultjens et al., 2004; Watling & Hauer, 2015; Weaver, 2015). Some therapists have interpreted the uncertainty of the NDT/Bobath and SI systematic evidence as justification of continuance, whereas others in the profession recommend discontinuance because of the growing body of ‘top‐down’ evidence that offer effective alternatives (Rodger et al., 2006). A Bobath expert has recommended that the common‐sense way forward for the profession is to choose interventions that promote activity and participation outcomes (Mayston, 2016) and to use consistent language to describe intervention options. For example, describing interventions by clear uniform terminology (i.e. ‘splitting’) might be more helpful than ‘clumping’ interventions into expanded NDT/Bobath umbrella terms.

Morgan C, Honan I, Allsop A, Novak I, Badawi N. Psychometric Properties of Assessments of Cognition in Infants With Cerebral Palsy or Motor Impairment: A Systematic Review. J Pediatr Psychol. 2019 Mar 1;44(2):238-252.

The Mayes Motor-Free Compilation, Fagan Test of Infant Intelligence, and Bayley-III Low Motor/Vision have predictive and/or discriminative utility in this population. The Mullen Scales of Early Learning was the only tool with psychometric research available examining responsivity to change.

CONCLUSIONS: Assessment tools with low-motor/motor-free accommodations have greater accuracy in estimating cognitive abilities of infants with motor impairment than conventional norm-referenced tests. There, however, remains a significant paucity of research in this area.