Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial

OBJECTIVES: To investigate whether, in the short and medium term, additional support by (a) a physiotherapy assistant improved physical function in young children with spastic cerebral palsy and (b) a family support worker improved family functioning. DESIGN: This was a multi-centre randomised controlled trial (RCT) with blinded assessments and a cost-effectiveness analysis. The children studied had spastic cerebral palsy that was the consequence of perinatal adversity. All were less than 4 years old on entry to the study. SETTING: In the child development centre and in the home. PARTICIPANTS: Seventy-six families completed the intervention period. Forty-three families were reassessed 6 months after the end of the intervention and 34 of these after a further 6-month period. INTERVENTIONS: Randomisation was to: (a) a group who received extra physiotherapy from a physiotherapy assistant; (b) a group who received standard physiotherapy; and (c) a group where the child received standard physiotherapy and the family was also visited by a family support worker. Children in all groups continued to receive standard physiotherapy in addition to the study interventions. MAIN OUTCOME MEASURES: The child outcome measures were motor functioning, developmental status and adaptive functioning. The family outcome measures were self-reported maternal stress, level of family needs and parental satisfaction. RESULTS: There was no evidence that additional physical therapy for 1 hour per week for 6 months by a physiotherapy assistant improved any child outcome measure in the short or medium term. Intervention by a family support worker did not have a clinically significant effect on parental stress or family needs. Over the 6-month period the total cost of services for each child ranged from 250 pounds to 6750 pounds, with higher costs associated with children with more severe impairments. No significant relationship was found between measures of intensity of services received by the children and families and the main outcome measures. Low-functioning children, in terms of both motor and cognitive function, were more likely to receive more services in terms of range and frequency. Parents generally reported high satisfaction ratings after all interventions and some stated that the interventions had benefited the child and/or the family. There was therefore a discrepancy between the perceptions of these parents and the objective, quantitative measurements. The family support workers identified a small number of families who were experiencing considerable family problems, but who had not been referred for appropriate support by any other agency. CONCLUSIONS: The findings of this study provide support for the current literature that there was no evidence that additional intervention (in this case by a physiotherapy assistant or family support worker) helped the motor or general development of young children with spastic cerebral palsy. Nor was there any quantitative evidence that providing extra family support helped levels of parental stress and family needs. The implication was that the provision of extra physical therapy does not necessarily improve the motor function of a young child with cerebral palsy and additional family support should not automatically be assumed to be beneficial. In addition, no significant association was found between the intensity of the local services provided and any outcome measure, other than a slight association with lowered family needs. The provision of local services was related to the severity of the child's impairments and not to family difficulties. A small group of families with complex family problems needed more service input. There was a wide range in the costs of services. Research is needed to examine what 'sufficient' levels of provision or therapy might be for which children and which families. A time series of different levels of input and outcomes would provide valuable information for practitioners. It is also recommended that future assessments of therapies of this type adopt a similar multifaceted approach, which is likely to be more suitable than a simple RCT for the evaluation of clinical interventions where the effects are complex. The most appropriate measures of outcome should be used, including assessment of provision of information and emotional support for families.