More is More:  Children with Cerebral Palsy and TBIs Need Time and Repetition to Learn New Skills
By Melissa McGinnis, PT, MPT

As a pediatric Physical Therapist, I feel that our goals for treating children who have gross motor disorders, such as cerebral palsy and traumatic brain injuries, should be to teach new and lasting functional skills that lead to more independence.  According to research published by PT scholars Shumway-Cook & Woolacott (1995), “learning” is defined as the formation of new synaptic connections in the brain, and we learn through practice and repetition.   Yet, most children do not have enough time in the traditional therapy settings to accumulate enough strength to carry out new skills, let alone learn them.  

If your child has a non-progressive gross motor disorder you may already be familiar with the educational model of physical therapy, which is usually 20-minutes to 30-minutes of therapy once a week.  You may also have taken your child to an outpatient physical therapy clinic and they received a little more PT, maybe 1 or 2 hours per week.  Your insurance company may even tell you that if your child is getting therapy during school they don’t need other therapies since the state is providing it for them.  However, the two therapy models have different goals.  The school therapists are using an "educational model" of therapy, i.e., “therapy that focuses on intervention to improve the student’s ability to learn and function in the school environment.” In the Medical Model, therapy “focuses on treatment to alleviate or cure specific underlying medical pathologies.”  [Handbook for Occupational and and Physical Therapy Services in the Publc Schools of Virginia].  

In an emerging third model of therapy delivery service – Intensive Physical Therapy – the goal is to create new and functional skills through time and repetition leading to greater mobility or independence.  How are new skills created?  Primarily, it is by increasing the therapy time to gain strength since weakness is a major hindrance in children with gross motor disorders* [*Sahrmann & Norton, 1977, and Damiano & Vaughan, et al, 1995, and Damiano & Abel, 1998, and Kramer & MacPhail, 1994, Darcy & Hauber, 2001, and Morton et al, 2005].  How do they learn the new skills?  By allowing them enough time to practice their new skills through repetition.  

In the Intensive Physical Therapy model, the child is in therapy a minimum of 6 hours per week for a 3-month period (72 hours in 3-months), to a maximum of 20 hours of therapy for 4-weeks straight (80 hours over 1 month).  The patient is learning NEW functional skills that they have never been able to do before, like going from a wheelchair to using a walker, or going from using crutches to walking independently. It is not meant to replace school or traditional out-patient therapy; to the contrary, it is best used as a complement to traditional models of treatment. Traditional physical therapists will help to maintain function and strength and are an important collaborator in the child’s overall progress.

“Suit therapy” is sometimes, but not always, part of an intensive therapy setting.  A therapy suit is a snug-fitting device that the child wears up to two hours during their four-hour therapy session.  It has a series of bungee-like cords and Velcro straps that can be adjusted to create more or less resistance and will help align the child’s body as they go through their physical therapy activities.  These activities are wide and varied, depending on the goals for the child.  For example, if the goal is to teach a child who uses crutches to walk independently, then the child may wear the therapy suit during gait training, strengthening and balance activities.  If a more involved child is learning how to roll over to get a toy, then the suit would be used more on floor activities and core strengthening activities.  For some children, the therapy suit would not be beneficial and may be medically contraindicated, which is why it is very important that intensive therapy and suit therapy be administered in a clinical setting and overseen by a physician.

Trahan and Malouin published an often-cited study on Intermittent Intensive Physiotherapy in children with CP that concluded “sequences of short intensive therapy periods alternating with longer rest periods seem to optimize the effects of motor training.” The UK’s Dr. Eva Bower, et al, has published several successive studies concluding that Intensive physiotherapy did produce improvement in the Gross Motor Function Measure (GMFM) scores.  Yet, insurance and state Medicaid programs like Children’s Special Health Care Services in Michigan (CSHCS) are slow to reimburse new methods equitably.  While Euro-Peds is a hospital-based clinic and accepts many insurances as well as CSHCS, other newer intensive therapy clinics may not be considered a provider of services by insurers.  Through persistent presentation of research pointing to the need to reconsider how physical therapy is organized, perhaps one day Intensive Physical therapy will no longer be considered “alternative,” but one of the standards of care for children with gross motor disorders.