Research on the effectiveness of physiotherapy to improve function in children with cerebral palsy generally has focused on the development and evaluation of the specific methodologies of a physical therapy (PT) program. Reports of the results of these evaluations have generally given inconclusive results, often because of the inadequacy of either research design or of the method used to evaluate outcome. Other studies have addressed the effectiveness of extended periods of intense physiotherapy. Again, the reported results were usually inconclusive; however, the study was often complicated by the unwelcome demands of an extended program of intensive therapy on the family and the children leading to their poor cooperation and compliance.

It has been suggested that a treatment program which included short periods of intensive therapy separated by rest periods might address this problem. An intermittent program of intense therapy and rest periods might be particularly important for younger children or for those with more severe impairments.

Johanne Trahan and her colleague conducted a pilot study to test this possibility¹. Children received intensive physical therapy 4 times a week for 4 weeks, followed by an 8 week rest period. This sequence was then repeated a second time ( a total of 24 weeks). The results were compared to those in the same children who had previously received a conventional schedule of physical therapy (2 times a week for 8-20 weeks). The physical therapy was administered by the child's treating physiotherapist using a neurodevelopmental approach (Mayston, 1990). All children also received occupational therapy focusing on upper extremity function. When the child was in the 'rest phrase', all OT and PT treatments were discontinued. The parents were given advice about home 'practice', but the advice did not include a specific home program of OT and PT.

The results of the pilot study were that four treatments per week over a four week period were well tolerated. There was then a rest period of 8 weeks. A second session of four treatments per week over a four week period were again well tolerated.

The program led to improvements in motor function which were maintained during the rest period. The author states: 'a regime that is intensive enough without being tiring and one that provides practice conditions for consolidating motor skills learned during the intensive therapy period may best optimize motor training'.

Comment:
Most conventional physiotherapy and occupational therapy programs in this country offer therapy 1-2 times a week with encouragement to continue therapy at home. Most conventional programs in this country have not set a specific period of time (duration); the time is often governed by economics or availability.

A number of physiotherapy programs developed in Europe use innovative methods and are also intensive programs of many hours/week for 4-6 weeks. Parents report improved outcomes in function from these intensive programs. Is it the innovative method? The intensity and duration of therapy? Or both? Ms. Trahan and her colleague utilize a conventional method of therapy with a program of increased intensity. Her results indicate improved performance when compared to utilizing the same therapy less intensely.

The results of this study are both encouraging and provocative. It indicates that the intensity of therapy may be the critical issue; if not THE critical issue, apparently one of importance. The results justify an in-depth study utilizing more specific inclusion-exclusion criteria, randomization of patients and 'blinded' evaluators. Also, another important issue remains: for whom is intensive therapy useful: everyone with an impairment? Persons with specific impairments? Is a maximum result achieved after one series? Two series? Many series? The 'who' is as important as the 'how'.

Experts in physiotherapy are now acquiring the research skills necessary for carefully designed research evaluations of the methods and timing used in clinical practice. We look forward to the results of their endeavors.

¹ Trahan J et. Malouin F. (2002) Intermittent Intensive Physiotherapy in Children with Cerebral Palsy: A Pilot Study DMCN 4:233-239