Goal-directed therapy for children with cerebral palsy

Abstract

The overall aims of the thesis were to study the effects of goal-directed therapy (GDT) in children with cerebral palsy (CP) in an ecological setting, using the ICF-CY as a frame of reference, and to determine the reliability of the selective motor control (SMC) scale. Measures included in this thesis were represented in the domains of body function/structure and activity and participation. A specific interest was directed towards the SMC scale, since associations with gross motor activity have previously been detected. During the past few decades, the aim with therapy for children with CP has gradually moved from normalisation to activity and participation in meaningful life situations. Modern theories of motor development, motor control and motor learning support a treatment philosophy in which children with CP are encouraged to actively search for optimal strategies to accomplish meaningful activities and are given optimal possibilities to practice in their everyday environments. Today emphasis is also made to actively include the family. There is now growing evidence in support of GDT, even though there is a variation in the therapy setting, the level of child/family s involvement in choosing the goals and the therapy duration. A specific interest were if GDT could give beneficial effects in comparison to Activity focused therapy (AT), what the long-term effects on gross motor capacity and goal attainment were and if body functions measures (SMC, Passive Range of Motion (PROM) and Modified Ashworth Scale (MAS)) were affected after GDT.

The inter-rater reliability of the SMC scale was evaluated by three assessors who simultaneously and independently scored the child s ability to dorsiflex the ankle. A consecutive sample of 40 children with CP, 3-16 years and in GMFCS I-V, was examined. The results revealed fair/good to strong inter-rater reliability. The test-retest reliability was achieved through a second examination of 29 children at a different occasion. Weighted Kappa statistics revealed strong test-retest reliability.

Comparison of GDT and AT was completed, with respect to everyday activities and gross motor capacity. Habilitation centres recruited 44 children, 1-6 years, 25 boys, GMFCS I-IV, MACS I-V, 27 bilateral CP and 17 unilateral CP. Focus with therapy in the GDT group (n=22) was directed towards individualized family selected goals with participation in group training, while focus in therapy in the AT group (n=22) was directed towards generalized aims with individualized therapy sessions. Evaluations after 12 weeks revealed significantly higher improvements in the GDT group in comparison to the AT group in both everyday activities and gross motor capacity.

Longitudinal investigation of gross motor capacity (GMFM-66) and goal attainment (GAS) in children receiving GDT (n=22) was accomplished by repeated assessments before, during and after a 12 week period of GDT. In addition, evaluations of SMC, PROM and MAS were completed before and after therapy. The assessments of gross motor capacity before GDT were stable. During and after the 12 weeks therapy, gross motor capacity improved significantly, whereas the long-term follow-up assessments did not reveal any further improvement. The goals were gradually reached to or above the expected level at the end of therapy. The long-term follow-up assessments demonstrated a gradual progress towards higher performance, with no further change in gross motor capacity. No changes in SMC, PROM or MAS were detected.

Explorations of relationships between family selected goals and scores on standardized measures were performed using the ICF-CY as a classification system. The 110 goals from children participating in GDT were used. The meaningful concept of the expected level in the goals were coded and linked to the ICF-CY. The children s baseline assessments and change scores from standardized measures were used to explore the relationships. All GAS-goals were classified in the Activity and Participation domain within ICF-CY. The number of GAS-goals in the Mobility chapter and in the Self-Care chapter correlated to baseline scores in standardized measures. The change scores in standardized measures correlated to goal attainment in the Mobility chapter and in the Self-Care chapter.

Beneficial effects in gross motor capacity and everyday activity were detected after GDT. The SMC scale demonstrated moderate to strong reliability.