Randomized controlled trial of web-based multimodal therapy for unilateral cerebral palsy to improve occupational performance

Article Reviews
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Read Full Text: Randomized controlled trial of web-based multimodal therapy for unilateral cerebral palsy to improve occupational performance
Journal: Developmental Medicine and Child Neurology
Year Published: 2015
Ranked 84th on our 2015-2020 list of the 100 most influential OT-related articles

Two core problems seem to be driving change to therapy right now.

  1. We’re seeing that it often takes a lot more time to create change in the lives of our patients than is traditionally offered in most clinical settings.
  2. Far too often, we have set our patients up to be passive recipients of our care, versus active partners.

This is where the explosion of web-based approaches and telehealth gets really interesting—they seem to offer a potential part of the solution to these problems.

This week, we looked at a web-based therapy program that was studied in kids with unilateral cerebral palsy (CP). The program shows promise as an adjunct to therapy to increase therapy dosage, and to enhance occupational performance and visual perceptual skills for these kids.

Let’s dive into the details.

Super brief refresher on therapy for unilateral cerebral palsy

Cerebral palsy is the most common childhood physical disability. Children with unilateral cerebral palsy experience difficulty with limb function on one side of the body, which can require ongoing therapy.

High-intensity therapy seems to be required to optimize neuroplasticity, but children frequently only receive limited services.

What has already been studied regarding cerebral palsy, interactive computer play, and therapy?

Therapy delivered by interactive computer play is emerging as a feasible, child-active alternative to standard face-to-face therapy. Here are some of the previous studies done in this area:

The specific web-based therapy program this study is exploring is called Mitii (Move it to improve it). The Mitii has been shown in previous studies to be feasible and increase a sense of agency in kids with CP.

What were the research questions being studied in this trial?

The goal of this randomized control trial was to examine the effects of using Mitii for kids with unilateral CP. The primary hypotheses were that, when compared with standard care, kids who participated in a Mitii program would show:

  • An increase in ADL, motor, and processing skills
  • A decrease in upper limb activity limitations
  • An increase in occupation performance goals
  • An increase in visual perceptual skills

Who participated in this study?

Kids in the study:

102 children participated in this study They all met the following criteria:

How OT was involved:

An experienced OT recruited participants and confirmed inclusion criteria. OTs, PTs, and psychologists collaboratively devised individual programs for participants.

What did the intervention look like?

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Mitii is a muti-modal therapy program that was developed specifically for the home environment. You can see examples of its use on the Mitii website.

Equipment that is required includes:

  • Computer with 6 feet of space in front of it for movement
  • Webcam
  • Green tracking bands
  • Step blocks and balance foam

Training modules

The therapists created individualized programs for each child from 14 training modules. The intent was for the training to be divided into approximately:

  • 40% gross motor activities
  • 60% cognitive/visual perceptual activities combined with upper limb movement

Duration/frequency

The program was intended to be completed 6 days per week for 20 weeks for 20-30 minutes, which would provide a maximum potential dose of 20 hours.

Professional support

Regular contact was maintained with families throughout the study, based on each family’s preferred frequency and mode of contact.

The most common form of contact involved weekly emails/phone calls and video calls every two weeks.

What did care look like for the standard-care group?

The kids who were not in the intervention group typically received consultative sessions with professionals, but no concomitant treatments.

What outcome measures were utilized?

Primary outcome measures included:

Secondary outcome measures included:

What were the results?

The kids in the intervention group participated in the Mitii programming for an average for 32.4 hours.

Interestingly, of the primary outcome measures in the Mitii intervention group, only the dominant (non-imparied) upper limb score on the JTTHF was statistically significantly higher than the control group. The score on the AMPs, the imparied upper limb on the JTTHF, the COPM, and the TVPS-3 all showed a trend toward improvement but were not at the point of clinical significance.

What did the authors conclude/discuss?

The promising trend toward improvement, but overall lack of clinically significant improvements, prompted the authors to conclude that Mitii is recommended as supplementary rehabilitation to goal-directed therapy for kids with unilateral cerebral palsy.

Takeaways for OT practitioners

(These are my personal takeaways, and were not mentioned in the article.)

1.) This study follows our trends of the therapist being in a facilitator/coach role.

Articles like this remind me that the move many therapists are making toward telehealth aligns well with research published prior to COVID-19.

Adding remote coaching and patient monitoring provides many potential benefits for patients with all sorts of diagnoses. Notably in this article, we are reminded that focusing on helping with a home program has the potential to significantly increase dosage of practice beyond what we could offer in the clinic.

2.) Taking on the coach/facilitator role as a therapist has the benefit of increasing a sense of agency for our clients.

One of the biggest shifts we are seeing in health care is acknowledging the importance of giving our patients more agency and ownership over their own health. While I think this has long been a goal of occupational therapy, we are now seeing increased support for this in research—and technology is providing increased opportunities for clients to take ownership of their therapy in the home setting.

3.) We don’t “have all of the answers” quite yet—but we are definitely seeing best-practice trends.

This article did not make me feel like we should all run out and license Mitii for all of our CP patients. (Though if it feels like the right fit, there seems to be enough promise to support its use as a supplement to therapy.)

But, what feels more important is the reminder this article provides about best practices for caring for cerebral palsy (and many other diagnoses we work with). The authors remind us in the conclusion that current evidence for child-active therapy supports therapy that is:

  • Goal-directed
  • Task-specific and
  • Involves high-dose repetition to stimulate exercise-dependent therapy

And, it will be interesting to see the supportive adjuncts to therapy that are developed to help us achieve this goal!

(Possibly) Earn CEUs/PDUs for reading this article.

Many of you can receive continuing education credits for reading this article. Here’s a form to help you do it, along with information to help you understand who qualifies.

And, here’s the full APA citation you many need:

James, S., Ziviani, J., Ware, R. S., & Boyd, R. N. (2015). Randomized controlled trial of web-based multimodal therapy for unilateral cerebral palsy to improve occupational performance. Developmental Medicine & Child Neurology, 57(6), 530–538. doi: 10.1111/dmcn.12705

What questions/thoughts does this article raise for you?

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Having never done tele therapy until 6 weeks ago I was very leery that it would be effective, especially with my CP patients. I don’t think anything can replace 1:1 intervention with a skilled therapist. The Mitii sounds like a interesting home program. I wonder if there had been more time with the OT than every other week if the results would have been better. I often do “forced use” intensives with my patients that involve restriction of uninvolved hand. I think the Mitii would be a nice addition to this as it would be engaging to the child. The struggle during these intensives is finding motivating ways to get children to use the arm that isn’t repetitive and boring. The Mittii would be great for that.

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There is so much to be valued in 1:1 intervention with a skilled therapist; however, I am intrigued with the potential impact of telehealth that allows for the patient and his/her family to play more of an active role as the therapist takes on more of a coach/facilitator. It would be interesting to see if this encouraged increased compliance and completion of the home exercise program as compared to clinic visits.

Even with the return to in person 1:1 skilled intervention, I feel like this article provides good take aways for therapists to think about how to engage families and have patients take more responsibility for their therapy as well as providing information, resources, Accountability, and specific home exercise programs for patients to use at home that would increase interaction and participation for the patient and family. Great thought provoking article!

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Interesting article! I feel very excited as a practitioner about the technologies being created that have the potential to meaningfully impact a child with CP and other disabilities! I do feel however at this point Mitii is definitely a fun complement to goal-directed intervention as the authors concluded. I also thought if these kids are already participating in school, therapy and other leisure pursuits how feasible is six days per week even if it is only 20- 30 minutes (not including set up, check-ins etc)?. Further, the COVID-19 pandemic in NYC has unveiled the sheer number of kids here who do not have access to an internet connection or laptop/tablet in their home environment. I am sure this is seen throughout the globe. Nevertheless, the research is innovative and there are many important takeaways to consider!

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Hi @tara! I’m so glad you brought up internet access. I’ve been curious about numbers, and it looks like only 75% of American adults have high speed broadband in their home. And, the 25% of those who don’t may be the households who would most benefit from our services.

I definitely see the likelihood of even more people around the globe gaining internet access over the next decade, and the technology of tele-health improving dramatically, but I agree that internet access is a huge limitation right now!

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Thanks Sarah!! Interesting statistic. I think close to 330,000 students (30ish%) in NYC public schools didn’t have access to electronic devices in their home. And yes most likely those are the kids that would reap the greatest benefits.

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I love your takeaways from the article. Through my experience with telehealth thus far (with kids who have various diagnoses), I see many benefits, but of course there is no replacement for the interaction and relationship building that occurs in person. Ideally, I think it’d be great to see kids/families in person in the clinic 1-2x/month for check-ins, education, proper physical instruction & to ensure appropriate alignment, etc. The other visits would be comprised of virtual resources, such as the Mitii, in conjunction with a virtual telehealth consultation as well. That way, the foundation for the personal relationship is laid and reinforced in the clinic, while the skills are continuing to be built upon in the home, with the therapist available virtually.

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I very much agree with @tabitha that this could be a great way to add onto therapy. Especially as so many kids these days opt to play a game on a device over what we’d consider more traditional play that we know helps develop needed skills. I see this article and movement towards web-based multi-modal therapy as a great jumping point to see more OTs partnering with engineers and web designers to create games in the online sphere to enable more consistent learning and follow-through at home. And, hopefully once community spaces are reopened, allow for families to access these through libraries and other community organizations to mitigate costs and some other barriers that’ve been discussed above.

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Like @Emily_PolovickMoulds, I completely agree with you Tabitha about preserving and finding the balance between in person interactions and virtual ones. I’ve been thinking on a very high level about the importance of balancing human connection and efficiency. This seems like this will be a challenge we will be facing not only in our therapy practices, but in many aspects of our lives.

I listened to a podcast with the former surgeon general of the US, and he was talking about healing power of connection. This topic of connection is one that I’m definitely interested in diving into deeper.