Running head: HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

A Review of Effects of Home Programs on Children with Cerebral Palsy

Danielle Palmer & Jennifer Unck
Touro University of Nevada

HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

Research Question
In children with Cerebral Palsy, what is the effect of a home program on increasing overall
function compared with no home program within treatment?
Study and Research Question
This study relates directly to our research question. It looked at home programs and
intervention outcomes with children that have Cerebral Palsy (CP). This article looked
specifically at children with spastic hemiplegic cerebral palsy. The article looked to determine if
children with CP benefited from having a home program and family-centered involvement. The
article defines a home program as, Therapeutic activities that the child performs with parental
assistance in the home environment with the goal of achieving desired health outcomes.
(Novac, Cusick, & Lowe, 2007).
Purpose of the Study
The purpose was to identify the effectiveness of a home programs. Home programs are
used with many CP interventions, but there is limited research conducted to evaluate if they help
these individuals.
Research Questions/Hypotheses
This study wanted to determine if home programs help children with CP reach desired
goal outcomes. The researchers believe that occupational therapy home programs make a
positive impact on reaching goals in children with CP.
Literature Review to Justify the Study
The literature review discusses what constitutes a home program and the impact that
home programs can make. It talks about home programs being a common approach in children
with this specific disorder, as well as other disorders. It explains how home programs serve as a

HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

way to get the parent and family members involved, and help them to be more competent in
improving their childs health and development. It discusses CP as a disorder that requires 24
hour care and that home programs can help when providing the care. It explains that
occupational therapists use home programs with CP children and therapists agree that it
optimizes intervention goals. It emphasized why some professionals think home programs are
important in changing new learned skills into functional gains within daily routines. There is no
literature out there that has been conducted specifically on how home programs affects this
certain population to support this. Most therapist choose treatment based on what has been done
in the past, which involves home programs.
Design of the Study and Level of evidence
This study used a single-group pretest--posttest design and is a level 3 of evidence. This
design was chosen for pragmatic reasons. It was stated that there was inherent limitation due to
the lack of control group and the small sample size.
Number of Participants and their Assignment into Groups
There was a total of 20 participants in this study. The researchers choose to only have 20
participants because of the limitations of their resources. The participants were not designated
into groups. Each of the participants participated in the study. They all took a pretest, participated
in the intervention, and then took a post test.
Recruitment and Selection of Participants
The researchers located parents who had children with spastic hemiplegic cerebral palsy.
They specifically looked in Australia and New South Wales. They also put up recruitment
advertisements in 79 specialists offices for cerebral palsy, in 400 pediatric offices, and in the
cerebral palsy newsletter. They put out information to a parent support group of children who

HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

had cerebral palsy as well. From all of this recruitment, the researchers received 89 telephone
calls from people who were interested in participating. Each of these inquiries received a
participant information and consent form through the mail. Of these 89, only 57 met the
inclusion criteria and then were asked to participate in a screening assessment. From those, the
first 20 who met the inclusion criteria and offered to do the screening tests were chosen to
participate in the study.
Description and Variables of Participants
There were many variables within the participants: their ages, home life, diagnosis, and
history of occupational therapy. The participants of the study ranged from 2-7 years of age. All of
the children lived in a house with at least one parent. Sixteen of the participants lived in a house
with both of their parents while four of the participants lived with a single parent. Sixteen of the
participants were boys and four of the participants were girls. Of the participants, eleven had
right-sided hemiplegia, while the other nine had left-sided hemiplegia. All of the participants
could walk without any assistance and could communicate verbally. All of the participants could
sit at a table independently to perform the assessments. Ten of the participants had been involved
in occupational therapy six months before the study began. Also, 6 months before the study,
sixteen of the participants were involved in a home program. Ten of the participants also had
some sort of splint that they wore. Each child engaged in occupations in their everyday life.
Their age depended on what occupations they performed. Fourteen of the participants were in
daycare, while six were in school. There was no mention of the race of the participants.
Measures Administered
Demographic data, clinical profiles, clinical indicators and baseline data were gathered at
the initial session before intervention. An occupational therapist scored videotaped data in

HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

random order as well. Parents of the children provided information and observations to do the
Pediatric Evaluation of Disability Inventory (PEDI) to determine functional independence in
children with disabilities. The Goal Attainment Scaling (GAS) was used to measure clinical
change in goals. Parts of the Quality of Upper Extremity Skills Test (QUEST) were administered
to measure outcomes of dissociated movements and grasp domains. These were videotaped and
scored by a blind rater. Along with these outcome measures, the researchers developed their own
home program log that measured participation of the home program. Minutes per day were
recorded to show how much time was spent on home program activities.
The Intervention
The children and parents were seen on three different occasions by an occupational
therapist for intervention. During the first visit, which lasted an hour and a half, time was taken
to devise a home program and give instructions and training as needed. Splints or casts were
made at this time, if needed. Also, childs strengths, areas of development, demonstrations, and
explanation were discussed to provide clarification with parents. The next visit was one month
out and then followed by a 3 month visit. These visits were for home program support or follow
up sessions that lasted 45 minutes. They allowed parents to ask questions and receive feedback
about activities in the program. This was a time that the therapist could show how to grade the
activities and track the childs improvement for more progress. Post measurements were
administered at 6 months and lasted 45 minutes.
A collaborative approach was taken with parents when establishing goals for the child
with the home program. Parents helped select activities to put in the home program, then the
programs were implemented and evaluations outcomes were measured. Typically the home
programs included a list of therapeutic activities to implement into daily routines with the child.

HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

If splints or casts were used, then they would add this to the home program along with
illustrations to help parent to remember how to put them on.
The Findings
Results from the GAS showed the raw score to be 0 on a scale of -2 meaning most
unfavorable and +2 being most favorable. The t-score at baseline was 29.86 and at follow-up was
50.12, a mean change off 20.26 points. A Wilcoxon rank sum test was used to determine that the
mean scores was significant (p < .000). When looking at the PEDI, the self-care functional skills
mean at baseline was 44.15 out of a possible score of 73. Following intervention it was at a 52.1,
showing a significant mean change of 7.95 points. The caregiver assistance dimension was
analyzed with a t test and indicated it was significant (p < .003). At baseline, the mean was 22.30
and after, it was 27.40. The QUEST results showed a statistically significant change (p < .004),
where the mean baseline was 33.83 of a possible score of 100. The follow-up score was 39.81.
The mean frequency of the home program participation was 0.90 times per day. This means that
the home programs were participated in less than one time per day. They participated in
approximately 27 times per month, but with this, there was no significant outcomes. There was
one significant relationship between the participation in home programs and upper limb quality
of movement measured by the QUEST. The mean duration of participation of home programs in
the 6 months was 13.82 minutes per day. When an outlier was taken out, there was a normal
distribution of 12.27. The overall findings were there was no correlation between home programs
and the GAS, PEDI (functional skills and caregiver assistance scores), and low correlation with
the QUEST.

HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

Hypothesis Support the Findings

Although there were promising numbers between baseline scores and follow-up scores,
there was no statistical significance. These findings do not support the hypothesis but further
research should be done to remove the limitations that were in this study. It showed some keys
factors that could have influenced possible outcome measures.
The Findings and their Relationship to Previous Research
This was the first study conducted on home programs, specifically with children with CP.
Even though the findings were not significant, there was still improvement from the baseline
scores and the follow-up scores. More research needs to be done on this topic to prove that home
programs can make a significant difference in the life of a child with CP.
Clinical Implications
There needs to be more research conducted on home programs with children with CP.
Home programs allow for more participation of family members to be involved with their childs
therapy. If research can prove that home programs can significantly help children with CP, then it
will become more widely used. Right now, there is just no research out there to show benefits of
home programs with CP.
Limitations
The study did not have significant changes but did show some positive results from the
baseline score to the follow-up scores. However, the positive results could have been the
participant matured over those 6 months, or it could have been something with their school or
more family participation. A control group could definitely have helped prove some of the results
but because of pragmatic reasons, this could not be done in this study. Another limitation is that
the sample size was pretty small and could not have caught all of the changes in the participants.

HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

Implications for Future Research

There is no research on CP and home programs. This was the pilot study on this topic.
More research definitely needs to be done. For as much as therapist use home programs with
children with CP, there needs to be a considerable more amount of research conducted on this
topic.
Adequate Sample Size
The sample size is 20 people. That it is a pretty small sample size. The researchers stated
that they could only have this size because of their resources. Overall, more research with larger
sample sizes would provide more findings on this subject. There are so many variables that could
occur in a small sample size.
If no significant difference, Presence of Type II error
There was no significant difference between groups, however there was a significant
difference in mean scores within the tests given. There was no presences of type II error in this
study. Because of the limitations, there is no way of knowing if the failure to detect the effects of
the home program was due to the presences of other outside factors or not.
Presences of a Control or Comparison group
There was no control group. This played into the factors of limitations for the study. If
there was a control group, then they could have compared results to a group that did not receive
the home program intervention. This would have help them to decrease amount of errors and
narrow the chances of other factors.

Administers blind to group assignment, Participants Blind to Group Assignment

HOME PROGRAMS AND CHILDREN WITH CEREBRAL PALSY

The administering of measures was done by an occupational therapist chief investigator

for baseline and follow-up measures. It did not specifically say if the occupational therapist was
blind to the study. The home program participation measure was conducted by a parent or
caregiver and they were not blind to the study. The participants were children between the ages
of 2 to 7 and if they could understand, were not blind or compared with any other group. The
parents were aware because they were logging the hours of home program participation done by
the child.
Account for drop-outs
Due to no drop outs in the study, they were not accounted for. During the 6 months, it
was up to the child and parents to comply with the home programs. Therefore they could have
just not done the home program if they did not want to. When gathering participants initially, the
first 20 children that met the criterion were chosen to participate in the study.
Reliability and Validity, Statistical Analysis
The Pearson product-moment correlations, paired t tests and the Wilcoxon rank sum tests
were used to find the results. The p value was set as p<.05. The research did not report any
reliability or validity for these measures. Also, the researchers did not question their use of these
measures to find the results.
Confounding Factors Influence on the Study
The research did not show any significant results but did show positive results. The study
took place over six months. A confounding factor could be that while in those six months, the
child matured or the parents had more involvement in the childs life which led to this positive
improvement. The home program could have had nothing to do with this improvement.
Major Strengths of this Study

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This study had many strengths. A major strength was its recruiting process. They
recruited a large number of people and then narrowed them down with the internal criteria. This
means they recruited exactly who they wanted to recruit and did not have to make sacrifices
about it. Another strength is that they had three reliable assessments to use to compare their
pretest and their posttest results to see if the findings were significant. Another major strength is
that the parents and the child visited an occupational therapist who came up with the home
program and trained them on how to do it on their own. The therapist also made splints and casts
if the children needed them. This gave the parents and the child adequate information to
successfully conduct the home program at home.
Major weaknesses of the Study
A major weakness of this study is that there was no control group. Having a control group
could have been beneficial for a comparison group. Another weakness is that the study had a
relatively small sample size. The more people in the sample size the better. A weakness is that the
researches only had a log for the parents to complete about the time they completed the home
program each day. Parents could have easily not done the home program and put down on the log
that they had.
How to Use this Article as a Therapist
We would look at this article and see that there was some positive results from the home
programs for children with CP. But the results were not significant. I would also note that it was
a small sample size and that this was a pilot study. Overall, I would try to look up other literature
and research on home programs with diagnoses similar to CP. This study wouldnt change my
mind in providing a home program but, it might help me to have a different perspective on how

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importance of home programs and how they might be used to be more beneficial with familycentered care.
Supports Participation in Occupations and the Field of Occupational Therapy
This article definitely supports the participation in occupations and the field of
occupational therapy. The study focuses on how home programs could benefit children in their
daily occupations. Home programs also help implement more practice on the techniques and
interventions implemented by the occupational therapist. Home programs encourage more active
participation from the parents, and parents play a key role in the success of their child. Home
programs can be a good tool to use for therapist when they only get to see the child for a certain
amount of time per week. More research needs to be conducted on CP and home programs to
gain a better understanding of the effects it has.

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References
Novac, I., Cusick, A., Lowe, K. (2007). A pilot study on the impact of occupational therapy
home programming for young children with cerebral palsy. The American Journal of
Occupational Therapy, 61, 463-468. http://ajot.aota.org/article.aspx?articleid=1866978

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