Q&A: Identify CP earlier, within 6 months after birth, for greatest therapeutic benefit

A review of research on cerebral palsy from the past decade resulted in varying evidence for “several key principles” that encourage early motor development and leverage “greater potential and brain plasticity” during this period.

The researchers performed this literature review primarily “to inform current research and clinical practice and provide a baseline from which to compare future research on children with CP diagnosed at earlier mean ages and interventions implemented far sooner,” or those implemented in the first years or months of life, they wrote in Developmental Medicine and Child Neurology. They searched four databases for systematic reviews published between 2009 and 2020 and randomized controlled trials published between 2015 and 2020. The investigators aimed to find studies that looked at early motor interventions for infants and children from birth to 3 years who had, or were at risk for, CP.

The search resulted in three systematic reviews encompassing 46 studies, 16 of which included comparison groups, and six randomized controlled trials. Healio Neurology spoke with Diane L. Damiano, PhD, PT, chief of the functional and applied biomechanics section within the rehabilitation medicine department at the NIH Clinical Center, to learn more about the study results.

Healio Neurology: What prompted this research?

Damiano: I am part of a UNICEF/WHO effort to develop a global, evidence-based early intervention program that can be adapted to different settings for children with visual, hearing and neurodevelopmental disorders, such as CP and autism spectrum disorders. We have performed evidence reviews in each of these areas to support this work and these will be part of a special supplement in Developmental Medicine and Child Neurology.

Healio Neurology: What are the specific early vs. late interventions you refer to in the paper?

Damiano: For babies, “intervention” really means working with and coaching the families on strategies to help them promote their child’s development. “Early” used to mean in the first years of life, but neuroscience evidence in animal models suggests that the window of opportunity to ameliorate the brain injury and produce “recovery” of function (eg, hand use) that may not be possible later in development may exist within the first 6 months of life as the spinal interneurons are developing. Very few studies have started this early — but this is about to change dramatically, as we saw in published randomized controlled trial protocols noted at the end of the paper. Early interventions that seem to be most effective include providing an enriched environment that has motor as well as cognitive challenges, intensive goal-directed therapy and intensive upper limb training if the child is favoring one hand significantly over another. The most important thing is that the families focus on these things as part of everyday life — and the child must be an active participant for change to occur.

Healio Neurology: How have these interventions been used over time to treat cerebral palsy?

Damiano: Early intervention has been available for children with CP for decades. Supporting families and helping provide specialized toys and equipment when needed has been done for many years. This helps promote the infant’s development within their capabilities given the brain injury, but it does not really change the prognosis — they still have CP. We want to see if we can do more. To do more, we have to identify the highest-risk children as early as possible and then we have to be able to evaluate whether we are reducing the incidence and severity of CP. This early identification is now possible, according to research from Novak and colleagues, and is being implemented in many places across the world. Australia is the best example because of the national health system where they can make large-scale changes more rapidly than here in the United States, although many are trying to do that here.

Healio Neurology: What did the results of your review demonstrate?

Damiano: The results demonstrate some glimmers of hope, but we are not there yet. We have not demonstrated in human infants what has been possible in animals.

Healio Neurology: How could these findings be relevant for practicing neurologists?

Damiano: Neurologists should be helping to lead the charge for early identification of CP and autism spectrum disorders, where the window of opportunity is likely later in infancy than for motor development. For visual development, the window is in the first weeks of life. The “wait and see” attitude of many practitioners needs to end. If there is a concerning birth history or parents suspect a developmental problem, they need to be more proactive in assessing and following that child.

Healio Neurology: What additional research is needed in this area?

Damiano: Earlier intervention, as is now happening, is important, but the real challenge is how to encourage active movements in babies who have not reached certain developmental capabilities — for example, if they cannot use their hands to reach for or manipulate toys. We may need some innovative strategies, like the smart devices we have tried in our lab, to promote more active movement practice.

Reference:

Damiano DL, et al. Dev Med Child Neurol. 2021;doi:10.1111/dmcn.14855.