How reaching for toys could change Cerebral palsy therapy

A USC researcher is hoping to change the way physical therapists treat infants at risk of cerebral palsy by combining cognitive and physical activity.

Photo: Julia Rendelman

By Katharine Gammon, University of Southern California August 21, 2020

Infants who are born early or at low birthweight can be at risk for cerebral palsy, a group of disorders that affect a person’s ability to move and maintain balance and posture, caused by brain damage often before birth.

The standard of care is early intervention, but that can mean a number of different things, said Stacey Dusing, associate professor and director of the Motor Development Lab. “Intervention tends to be very ‘wait and see:’ monitoring how delayed the kids are,” Dusing said. “We are identifying that this is probably not the best practice for kids.” 

Physical therapy for infants typically works in skills like rolling, crawling and walking, Dusing explained. But that’s not the only issue. “Kids don’t move just to move. They move to access the world, to pick up toys, to bang things together,” she explains. She and her research team had the idea to change the interventions to focus on thinking as the primary skill, to weave motor and cognitive learning together.  

Dusing is a co-principal investigator for a new National Institutes of Health grant that will compare interventions for infants with or at high risk of developing cerebral palsy. One group will receive a larger-than-usual dose of traditional physical therapy, which focuses on movement, while the other group receives the same amount of therapy that combines motor skills with cognitive skills, called Sitting Together and Reaching to Play, or START-Play. 

The new study will take place over three sites across the United States, recruiting 150 infants between 8 and 24 months old who have motor delays or early signs of cerebral palsy. The infants will be randomly placed in one of the two groups for 24 visits over a three-month period, with follow-up assessments at three, six, and 12 months after enrollment. Regina Harbourne, a physical therapist and researcher at Duquesne University is the other co-principal investigator. The University of Nebraska-Lincoln is the data management site. The University of Washington and the University of Nebraska Medical Center will also enroll children for the study.

The START-Play (Sitting Together and Reaching to Play) early intervention aims to promote development and readiness to learn in babies with motor delays or challenges. Sitting and reaching skills are critical to early development and help babies explore, interact with others and learn about their world. Photo: Julia Rendelman

“Cognition for free”

In practice, the biggest difference is how therapists use things like toys in the session, Dusing explained: If a therapist is helping a child crawl, she’d typically show the child a toy and then move it further away, to coax the child into extending the movement. But when incorporating cognitive learning alongside movement, a therapist would use the same toy, engage with it, and then encourage the children to do something harder with the toy, like putting the toy inside a container. That way, the child is learning something about how to use the object in addition to how to move. 

Since both interventions focus on movement, Dusing said she expects the infants’ motor skills will be similar at the end of the study — but she expects there will be more improvements in the cognitive skills of the group getting the START-Play therapy. “We describe it as getting cognition for free in this therapy, since we get equal motor gains,” she said. In an earlier study of START-Play, the gains persisted beyond the intervention timeframe. 

The ultimate goal, Dusing explained, is to understand better what type of physical therapy is the most effective for children who have motor delays and cerebral palsy. Dusing has worked as a pediatric physical therapist for 23 years, and one of the biggest questions in the field is what interventions are actually backed with strong evidence. “There are a lot of interventions for young kids that don’t have a lot of evidence behind them,” she said. “We don’t know right now what is effective in these groups, and we want to provide that information to clinicians and parents.”

Source USC Division of Biokinesiology and Physical Therapy via Medical Xpress


1. Experiences Build Brain Architecture. The basic architecture of the brain is constructed through a process that begins early in life and continues into adulthood. Simpler circuits come first and more complex brain circuits build on them later. Genes provide the basic blueprint, but experiences influence how or whether genes are expressed. Together, they shape the quality of brain architecture and establish either a sturdy or a fragile foundation for all of the learning, health, and behavior that follow. Plasticity, or the ability for the brain to reorganize and adapt, is greatest in the first years of life and decreases with age.
This video is part one of a three-part series titled “Three Core Concepts in Early Development” from the Center and the National Scientific Council on the Developing Child at Harvard University. The series depicts how advances in neuroscience, molecular biology, and genomics now give us a much better understanding of how early experiences are built into our bodies and brains, for better or for worse. Healthy development in the early years provides the building blocks for educational achievement, economic productivity, responsible citizenship, lifelong health, strong communities, and successful parenting of the next generation. Youtube Sep 29, 2011
2. Serve & Return Interaction Shapes Brain Circuitry. One of the most essential experiences in shaping the architecture of the developing brain is “serve and return” interaction between children and significant adults in their lives. Young children naturally reach out for interaction through babbling, facial expressions, and gestures, and adults respond with the same kind of vocalizing and gesturing back at them. This back-and-forth process is fundamental to the wiring of the brain, especially in the earliest years. Youtube Sep 29, 2011
3. Toxic Stress Derails Healthy Development. Learning how to cope with adversity is an important part of healthy development. While moderate, short-lived stress responses in the body can promote growth, toxic stress is the strong, unrelieved activation of the body’s stress management system in the absence of protective adult support. Without caring adults to buffer children, the unrelenting stress caused by extreme poverty, neglect, abuse, or severe maternal depression can weaken the architecture of the developing brain, with long-term consequences for learning, behavior, and both physical and mental health. Youtube Sep 29, 2011
  Further reading

START-Play Consortium. What Really Works in Intervention? Using Fidelity Measures to Support Optimal Outcomes, An M, Dusing SC, Harbourne RT, Sheridan SM. Phys Ther. 2020 May 18;100(5):757-765. doi: 10.1093/ptj/pzaa006.

Sitting skill and the emergence of arms-free sitting affects the frequency of object looking and exploration, Marcinowski EC, Tripathi T, Hsu LY, Westcott McCoy S, Dusing SC. Dev Psychobiol. 2019 Nov;61(7):1035-1047. doi: 10.1002/dev.21854. Epub 2019 Apr 22.

A Physical Therapy Intervention to Advance Cognitive and Motor Skills: A Single Subject Study of a Young Child With Cerebral Palsy, Dusing SC, Harbourne RT, Lobo MA, Westcott-McCoy S, Bovaird JA, Kane AE, Syed G, Marcinowski EC, Koziol NA, Brown SE. Pediatr Phys Ther. 2019 Oct;31(4):347-352. doi: 10.1097/PEP.0000000000000635.

Assessing the Validity and Reliability of a New Video Goniometer App for Measuring Joint Angles in Adults and Children, Cunha AB, Babik I, Harbourne R, Cochran NJ, Stankus J, Szucs K, Lobo MA. Arch Phys Med Rehabil. 2020 Feb;101(2):275-282. doi: 10.1016/j.apmr.2019.07.008. Epub 2019 Aug 26.

Sitting Together And Reaching To Play (START-Play): Protocol for a Multisite Randomized Controlled Efficacy Trial on Intervention for Infants With Neuromotor Disorders, Harbourne RT, Dusing SC, Lobo MA, Westcott-McCoy S, Bovaird J, Sheridan S, Galloway JC, Chang HJ, Hsu LY, Koziol N, Marcinowski EC, Babik I. Phys Ther. 2018 Jun 1;98(6):494-502. doi: 10.1093/ptj/pzy033.

Validity and reliability of the developmental assessment screening scale, Singh A, Squires J, Yeh CJ, Heo KH, Bian H. J Family Med Prim Care. 2016 Jan-Mar;5(1):124-8. doi: 10.4103/2249-4863.184636. Full text

Grounding early intervention: physical therapy cannot just be about motor skills anymore, Lobo MA, Harbourne RT, Dusing SC, McCoy SW. Phys Ther. 2013 Jan;93(1):94-103. doi: 10.2522/ptj.20120158. Epub 2012 Sep 20. Full text

Also see
Fralin Biomedical Research Institute, partners pioneer nation’s first pediatric rehabilitation resource center Virginia Tech
Play-Based Study Seeks To Help Developmentally Delayed Babies Reach Important Milestones Pittsburgh NPR
UD researchers test intervention program for infants with poor motor skills Delaware Public Media
Physical therapy program offers help for infants with delayed skills Virginia Commonwealth University

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