Change the environment, not the child

(Press-News.org) Hamilton, ON (August 16, 2011) -- A successful new rehabilitation approach to treating children with cerebral palsy puts its focus on where a child lives and plays, not just improving the child's balance, posture and movement skills.

Called a "context-focused intervention", McMaster University and the University of Alberta researchers report in a new study this approach is just as beneficial as traditional child-focused therapy, offering parents an additional treatment option for their child.

The McMaster study, in conjunction with researchers at the University of Alberta's Faculty of Rehabilitation Medicine and Alberta Health Services in Calgary, is the first randomized trial to examine the effects of therapy focused on changing a child's task or environment, not the child. It appeared in the July issue of the medical journal Developmental Medicine and Child Neurology.

Context-focused and child-focused therapies were evaluated in a randomized controlled trial of 128 children with cerebral palsy ranging in age from one year to almost six year old. The children, from 19 different rehabilitation centres in Ontario and Alberta, received one of the two approaches for six months. Therapy was provided by occupational therapists and physical therapists. Between assessments at six and nine months, they returned to their regular therapy schedule.

Researchers found that while both groups improved significantly over the study, there were "no significant differences in daily functioning" between the two treatment groups, reported lead author Mary Law, professor in McMaster's School of Rehabilitation Science and co-founder of the university's CanChild Centre for Childhood Disability Research.

Cerebral palsy is caused by damage in the brain before or just after birth that results in problems with muscle tone and movement, and impacts ability to perform everyday activities. More than 50,000 Canadians have cerebral palsy, which occurs in about two of 1,000 babies.

During the study, parents in both groups received general information and education about their child's disability as well as specific strategies to practice at home.

In the child-focused approach, therapists identified the underlying impairment – tone, posture, range of motion – and provided therapy to improve the child's skills and abilities.

Emphasis in the context therapy approach was on changing the task or environment. For example, one parent's goal was for their child to finger-feed himself Cheerios independently. The therapist experimented with putting peanut butter on the tips of his fingers so that the Cheerios would stick to it. The child was successful in one intervention session, even though he did not have the fine grasp to pick them up without it. Having experienced success, the child went on to be able to finger feed Cheerios by himself.

"This study provides evidence that each intervention approach yields equivalent important change after a six-month intervention," Law said. "We also found no difference between the therapy approaches for the outcome of parent empowerment."

If both approaches are equally effective, Law said therapists and families are able to discuss the treatment approach that best fits the intervention goals for their child and their family situation.

Law is co-author in a second article in the same journal, describing the context-focused approach with lead author Johanna Darrah, a professor of physical therapy in the Faculty of Rehabilitation Medicine at the University of Alberta. Darrah said the experience with context therapy was positive: "The benefits of working in the child's natural environment were striking."

Darrah added researchers found this approach was more challenging with children who have a severe disability, as some therapists felt that by not providing hands-on treatment, the approach is not true therapy. However, the study found that the context approach was equally effective for children with mild or severe cerebral palsy.

### The study was supported by a grant from the National Institutes of Health in the United States and the Alberta Centre for Child Family and Community Research. Mary Law holds the John and Margaret Lillie Chair in Childhood Disability Research.