Comparing Two Physical Therapy Schedules for Children with Cerebral Palsy—The ACHIEVE Study [Internet]

Excerpt

Background: Children with cerebral palsy (CP) often receive outpatient physical therapy (PT) services, although the dosing schedule can vary widely depending on the child and the setting. Parents could make more informed choices about their child's therapy schedule if they knew whether a high-intensity (HIP) schedule of therapy was better than or equivalent to a usual model of weekly therapy.

Objectives: The main objective of the ACHIEVE study was to (1) compare the short-term and long-term effects of 2 treatment service delivery models: 1 hour per day, 1× per week for 40 weeks (weekly); and 2 hours every weekday for 2 periods of 10 consecutive weekdays (total of 4 weeks) of a repeated periodic (HIP) bout of outpatient PT. We hypothesized that HIP therapy would result in comparatively greater improvements than would weekly therapy. In addition, we aimed to (2) determine individual differences in (a) children's response to treatment and (b) parent preferences; (3) monitor the progress and variability of motor function; (4) explore patient and family factors associated with treatment response; and (5) identify relationships between the assessment of the child's function by parents and the child's gross motor function as evaluated by professionals.

Methods: We enrolled 100 children aged 2 to 8 years with CP in our study, which took place over a 9-month period. Forty-six participants were randomly assigned to either the weekly or HIP treatment group. Fifty-four participants self-selected their treatment group; this option was added to the study for families that could not commit to accepting either of the schedules. Trained therapists assigned each child a Gross Motor Function Classification System (GMFCS) level and completed baseline and 9-month testing. Testing included the Gross Motor Function Measure-66 (GMFM-66) score (primary outcome measure), as well as secondary measures, including Goal Attainment Scale (GAS) and Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) scores. Parents also completed questionnaires on their children's skills, such as the Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT). We analyzed the participants' scores using a linear mixed model, comparing the weekly and HIP groups in both the randomized and self-selected groups.

Results: Both the weekly and HIP groups improved from baseline to 9 months in both the randomized and self-selected cohorts. At the time of this report, there was a 76% follow-up rate for the primary outcome measure at 9 months. There were no significant differences between the HIP and weekly groups for either cohort on the GMFM-66 (−0.92; 95% CI, −2.83 to 0.98; P = .34). There were also no significant differences between groups on the GAS, Bayley-III, or PEDI-CAT, although all groups improved on these measures over time, with significant main effects for time and clinically meaningful differences. Children with lower GMFCS levels (better function) and higher parent satisfaction with treatment made greater gains in motor function.

Conclusions: HIP and weekly outpatient PT treatments, when provided using the same total number of hours, are likely to produce similar motor outcomes for children aged 2 to 8 years with CP. Parents and therapists can decide which schedule will be more beneficial for an individual child based on their unique personal and family needs.

Limitations: A limitation of this study was a possible lack of power due to attrition during follow-up, which might have limited our ability to detect differences between groups and generalize the results. We may not be able to tell which changes may be due to normal development rather than the interventions, because the interventions were only 9 months long.