Developments in Childhood Disability and the F-Words you need to know with Prof. Peter Rosenbaum

Professor of Paediatrics Canada Research Chair in Childhood Disability Co-Founder, CanChild Centre for Childhood Disability Research Timezone Toronto Canada (Ontario)

W-sitting, Botox, walking vs wheelchairs, fixing vs participation, and the inside view on RCTs and Evidence-Based Practice. These are just a few of the hairy topics that came up for discussion as I sat down to talk about childhood disability and the F-words with Professor Peter Rosenbaum. Peter is the co-founder of CanChild, arguably one of the most innovative leaders in childhood disability research, a professor of paediatrics and an amazing human being who is driven to make a difference in the lives of children across the globe. If you don't know what the F-words are in relation to the ICF, this conversation is for you. If you're familiar with the F-words, you're going to love the application of their essence into all aspects of the work we do. Either way, this conversation is filled with wisdom and experience that you don't want to miss. Enjoy.

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For handy links to things we've discussed in this interview, scroll down to the Resources Section at the bottom of the page.

The Podcast: Listen, enjoy, share...

Podcast Highlights

Time Stamps in green

Now vs then 3:10
F-words - 7:00
It kind of made sense but it doesn't work 10:30
The Developmental Part of Developmental Rehab 11:04
Optimal Outcomes 11:23
NDT Intervention Study 13:33
Walking vs Participation 17:30
W-sitting 21:15
F-word 26:32
What do you want to boast about? 33:46
A Shift in Perspective 36:00
SDR & Botox 39:46
Botox & Participation 40:13
Peter's Editorial 42:18
Envisage Study 46:00
Research detracting from clinical practice 47:00
Complimentary And Alternative MedicinesComplementary 49:00
Finding credible information 54:18
GMFCS as an outcome measure 55:21

Article Links:

I've shared the details of the first article in some depth because (a) it's not a free text and (b) it's controversial - so see what you think.

(Full disclosure: I am an NDT trained therapist who highly values NDT as essential training for pediatric therapists >> see "10 Reasons Therapists Do NDT")

1. The Effects of Physical Therapy on Cerebral Palsy

N Engl J Med 1988

Excerpts from the publication:

"Initially, we had projected that a sample of at least 100 infants was necessary for a full evaluation of treatment differences across the entire range of outcomes. Despite aggressive efforts, however, enrollment was less than had been expected... Therefore, the conclusions we report are preliminary."
48 infants (12 - 19 months) enrolled and randomized to either NDT type physiotherapy for 12 months (Group A) or Infant stimulation (age-appropriate gross motor, fine motor, and cognitive games) for 6 months followed by 6 months of NDT type physiotherapy (Group B)
One infant in Group B dropped out of the study after the six-month evaluation. All the other infants completed the study. Both groups had over 90 percent compliance in attending the treatment visits. No infants received other therapies.
Therapy was a clinic-based session once a fortnight for one hour in both groups + a home programme.
- 3/24 infants in Group A could not get to sitting independently and 1 in Group B. These infants received more intensive therapy until they could sit independently (5 days a week up to 20 sessions)
At 6 months
- there was a tendency to favor children in group B walking 10 steps (not statistically significant) and group B did better on cognitive testing (p=0.5)
At 12 months
- Group B children had statistically better walking skills: ie. walking with 1 handheld (P<0.01), walking alone (P = 0.01).
- Cognitive skills were equivalent between groups.
- The scores for lower-extremity deep-tendon and pathologic reflexes showed a statistically significant difference for Group A vs Group B (P = 0.05 and 0.01, respectively). In addition, trends showed more lower-extremity spastic hypertonus in Group A (P = 0.08)
After both 6 and 12 months, the most important determinant of the motor quotient was the motor quotient at the time of enrollment (P<0.0001).

Discussion points

"The positive effects of infant stimulation in this trial may be due to better or broader understanding by the parents of the infants' development and capacities, which may have improved their ability to cope and interact with their infants"
"More frequent contact between therapist and patient may be necessary to make physical therapy more beneficial to infants with cerebral palsy." [ie more than once a fortnight]
"The minor differences between groups observed on neuromotor examination ... may reflect neurologic differences between the groups that were not apparent at the time of enrollment but were manifested clinically only 12 months later because of the infants' neurologic maturation. [sample size was half of what was calculated as adequate for this study]"
"The magnitude of the cognitive difference favoring Group B after 6 months did not persist until the 12-month evaluation... these differences may reflect a practice effect that had diminished by the 12-month evaluation."

Conclusion

"Because of the small size of the sample, the apparent benefit of infant stimulation should be interpreted cautiously. Indeed, the regression analyses showed that motor and mental abilities at the time of enrollment were the most powerful determinants of motor or mental outcome, strongly outweighing any effect of treatment."

My Questions

Does this speak to

> Therapy intensity (is fortnightly effective?)

> The type of therapy (NDT vs generalized infant stimulation?)

> Early Intervention (Is there a window of optimum effectiveness? Does it matter if you start treatment 6 months later in babies and toddlers? Does it matter if you start therapy after 12 months vs before 12 months?)

Therapy Effectiveness

> Did Group B do better - or were they a higher functioning group of children anyway? If so - did Group A catch up on some level or did both groups follow their natural trajectory ie. therapy made no difference to group A or B and they would have achieved their gains regardless.

> Was a combination of therapy + infant stimulation more effective and that's why Group B did better - except they were already better than Group A to start (see conclusion above)

> Can 6 months of standard physiotherapy or a general infant stimulation program change pathological reflexes and spastic hypertonus (that's a rhetorical question)