Evidence based

Evidence based practice is an ethical obligation of health professionals for the utilisation of what is often public resources or funding that aims to maximise clinical or health benefits whilst minimising harm.[3]

Practices that are informed by the evidence comes from research and are underpinned by good quality science. This means that interventions provided are the most effective in achieving the desired outcomes. Where high-quality evidence is not available, it is then essential that interventions offered are still underpinned by the evidence base.[3, 4] 

It is important to know that evidence-based practices are not prescriptive in nature. Rather, it is the integration of the best available research evidence, combined with clinical expertise as well as the values and goals of the individual that is receiving the services (Figure 1.0 below).

Over the last decade in particular, researchers in child health have been working to develop guidelines to identify the most effective interventions available. Researchers have been working with families to identify areas of importance and where efforts should be placed to develop new interventions.[6]

The guiding papers to highlight evidence-based interventions in child health were published in 2013 with another revision in 2020. Both of these papers systematically and objectively evaluated the body of evidence as is currently stands in the area of cerebral palsy.[4, 7]

The results were presented by using a traffic light system with “green” light interventions suggesting that we should ‘do it’ because there is strong evidence to support its effectiveness, “yellow” light interventions which suggest that we can ‘probably do it’ and finally, “red light” interventions or stop and ‘do not do it’ because evidence has shown that they are ineffective.[4] (Figure 4.0)

When it comes to motor interventions (i.e., approaches that improve motor skills such as gross motor or fine motor skills) there are some clear principles that have been shown to be the most effective. This relates to the principles of neuroplasticity and the “F-word” framework.[5, 8] When adopting an evidence-based approach, it is vital that we use interventions that have the greatest odds of achieving motor skills.[9] At the core, interventions need to be:

• Motivating and engaging – in a child’s world, this does mean it needs to be fun! The more engaging and motivating the intervention, the more attention the child is paying to it and this is crucial in learning new skills and establishing neuroplastic changes.[4]

• Task-specific practice that is rewarding and enjoyable – to develop new skills, practice needs to be meaningful to the child and the family. If it is meaningful, it will produce spontaneous and regular practice (both in and out of the therapy setting) and this is a wonderful strategy for getting greater intensity and repetition.[4, 9]

These approaches tend to be more “hands-off” in nature. The role of the therapist is less about holding, positioning, aligning and more about setting up the environment and using equipment. This way, it is more about movements that are initiated by children. Child initiated problem solving and child initiated movement is the key to establishing the motor circuitry for neuroplastic changes.[4] In fact, excessive external sensory input has been seen to disrupt this process.[10]

The most current and up to date approach focuses on meaningful activities and participation in daily life. Approaches that focus on what we call “body structure and function” of the ICF framework (Figure 2.0) are less effective in achieving and improving daily, meaningful skills that are needed to be part of the community and to participate in life. As such, researchers and scientists are able to confidently say that these approaches should be “discontinued based on current evidence.”[11] 

These approaches include techniques known as neurodevelopmental therapy (or NDT), Vojta, Cuevas-Medek (or CME) and Dynamic Movement Intervention (or DMI). The basis of these approaches depart from what we know is effective in improving motor outcomes. As such, the decision for us as researchers, scientists and clinicians at Healthy Strides is to not provide these techniques because there are evidence-based interventions that have better odds or greater possibilities of achieving motor outcomes in children. 

This decision is not based on a personal objection by any means. It is guided by the current state of the evidence and highlights the reasoning for Healthy Strides’ core value of providing only evidence-based approaches so that we have the greatest odds of achieving outcomes. This approach optimises the opportunities for children to spend more time out of a therapy setting, and more time in the world with their friends, family and attend school.

There is more published research in the area of cerebral palsy because it is the most common cause of physical disability in childhood.[12] However, we know that the development of new motor skills and the framework for developing interventions (the ‘F-words’) is not diagnostic specific – in fact it relates to all of us! [8, 13]. In the absence of diagnostic specific interventions, we can still apply the active ingredients of effective motor interventions that relate to cerebral palsy. 

What is hugely important is that information about interventions is provided to enable families to make an informed choice. Only families know their own circumstances, their child and what works for them so there is never any judgement about the choices that families make. At the core, families just need to be able to make a choice based on the most relevant information available. An informed choice is ultimately a good choice!