The impact of severity of motor delay, timing of task mastery, and START-play intervention on the development of means-end problem solving in young children.

BACKGROUND: Children with motor delays are at increased risk for delayed means-end problem-solving (MEPS) performance. OBJECTIVES: To evaluate children with motor delays: 1) the impact of motor delay severity and MEPS mastery timing on developmental trajectories of MEPS; and 2) the effectiveness of Sitting Together And Reaching To Play (START-Play) intervention for improving MEPS. METHODS: This represents a secondary analysis from a multi-site randomized controlled trial, with blinded assessors and prospective registration. Children with mild or significant motor delays (n = 112, mean age=10.80, SD=2.59 months at baseline) were randomly assigned to START-Play or usual care early intervention (UC-EI) and assessed at five visits across one year using the Means-End Problem-Solving Assessment Tool that included three 30-second MEPS trials per visit. Task mastery occurred at the first visit the child achieved the highest level of performance in at least two of the three trials. Multilevel analyses evaluated trajectories of MEPS outcomes dependent upon the timing of MEPS mastery, motor delay severity, and intervention group. RESULTS: At baseline, children with mild motor delays demonstrated better MEPS than children with significant delays, but this difference was only observed for children who achieved mastery late. Children with significant delays demonstrated greater improvements in MEPS in the post-intervention phase compared to children with mild delays. No MEPS differences were found between START-Play and UC-EI. CONCLUSION: Motor delay severity and timing of task mastery impacted MEPS trajectories, whereas START-Play intervention did not impact MEPS for children with motor delays. CLINICAL TRIALS REGISTRY IDENTIFIER: NCT02593825 (https://clinicaltrials.gov/ct2/show/NCT02593825).

Sitting Capacity and Performance in Infants with Typical Development and Infants with Motor Delay.

AIMS: Infants with neuromotor disorders demonstrate delays in sitting skills (decreased capacity) and are less likely to maintain independent sitting during play than their peers with typical development (decreased performance). This study aimed to quantify developmental trajectories of sitting capacity and sitting performance in infants with typical development and infants with significant motor delay and to assess whether the relationship between capacity and performance differs between the groups. METHODS: Typically developing infants (n = 35) and infants with significant motor delay (n = 31) were assessed longitudinally over a year following early sitting readiness. The Gross Motor Function Measure (GMFM) Sitting Dimension was used to assess sitting capacity, and a 5-min free play observation was used to assess sitting performance. RESULTS: Both capacity and performance increased at a faster rate initially, with more deceleration across time, in infants with typical development compared to infants with motor delay. At lower GMFM scores, changes in GMFM sitting were associated with larger changes in independent sitting for infants with typical development, and the association between GMFM sitting and independent sitting varied more across GMFM scores for typically developing infants. CONCLUSIONS: Intervention and assessment for infants with motor delay should target both sitting capacity and sitting performance.

Early Mobility and Crawling: Beliefs and Practices of Pediatric Physical Therapists in the United States.

PURPOSE: To characterize beliefs of pediatric physical therapists (PTs) in the United States regarding the role of crawling in infant development and clinical practice. METHODS: Pediatric PTs reported their beliefs about early mobility and crawling, clinical approaches related to early mobility and crawling, and agreement with the removal of crawling from the Centers for Disease Control and Prevention (CDC)'s updated developmental milestone checklists in an online survey. Analyses examined associations between information sources and beliefs, between beliefs and clinical approaches, and between beliefs and CDC update opinions. RESULTS: Most participants believed that crawling was important (92%) and linked to a variety of positive developmental outcomes (71%-99%) and disagreed with its removal from the CDC checklists (79%). Beliefs were linked with clinical approaches focused on promoting crawling and discouraging other forms of mobility. CONCLUSIONS: Further research is needed to determine whether pediatric PTs' beliefs and clinical practices are supported by evidence.

Embedding Play to Enrich Physical Therapy.

Play is an active process by which an individual is intrinsically motivated to explore the self, the environment, and/or interactions with another person. For infants and toddlers, engaging in play is essential to support development across multiple domains. Infants and toddlers with or at risk of motor delays may demonstrate differences in play or challenges with engaging in play activities compared to typically developing peers. Pediatric physical therapists often use play as a modality to engage children in therapeutic assessment and interventions. Careful consideration of the design and use of physical therapy that embeds play is needed. Following a 3-day consensus conference and review of the literature, we propose physical therapy that embeds play should consider three components; the child, the environment, and the family. First, engage the child by respecting the child's behavioral state and following the child's lead during play, respect the child's autonomous play initiatives and engagements, use activities across developmental domains, and adapt to the individual child's needs. Second, structure the environment including the toy selection to support using independent movements as a means to engage in play. Allow the child to initiate and sustain play activities. Third, engage families in play by respecting individual family cultures related to play, while also providing information on the value of play as a tool for learning. Partner with families to design an individualized physical therapy routine that scaffolds or advances play using newly emerging motor skills.

Benefits of maternally-administered infant massage for mothers of hospitalized preterm infants: a scoping review.

OBJECTIVES: Infant massage (IM) is a well-studied, safe intervention known to benefit infants born preterm. Less is known about the benefits of maternally-administrated infant massage for mothers of preterm infants who often experience increased rates of anxiety and depression in their infants' first year of life. This scoping review summarizes the extent, nature, and type of evidence linking IM and parent-centered outcomes. METHODS: The Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for scoping reviews (PRISMA-ScR) protocol was followed using three databases: PubMed, Embase, and CINAHL. Thirteen manuscripts evaluating 11 separate study cohorts met pre-specified inclusion criteria. RESULTS: Six primary topics related to the influence of infant massage on parent outcomes emerged: 1) anxiety, 2) perceived stress, 3) depressive symptoms, 4) maternal-infant interaction, 5) maternal satisfaction, and 6) maternal competence. Emerging evidence supports that infant massage, when administered by mothers, benefits mothers of preterm infants by reducing anxiety, stress, and depressive symptoms and improving maternal-infant interactions in the short-term, but there is limited evidence to support its effectiveness on these outcomes in longer periods of follow-up. Based on effect size calculations in small study cohorts, maternally-administered IM may have a moderate to large effect size on maternal perceived stress and depressive symptoms. CONCLUSIONS: Maternally-administered IM may benefit mothers of preterm infants by reducing anxiety, stress, depressive symptoms, and by improving maternal-infant interactions in the short-term. Additional research with larger cohorts and robust design is needed to understand the potential relationship between IM and parental outcomes.

START-Play Physical Therapy Intervention Indirectly Impacts Cognition Through Changes in Early Motor-Based Problem-Solving Skills.

PURPOSE: This study tested whether the Sitting Together and Reaching to Play (START-Play) physical therapy intervention indirectly impacts cognition through changes in perceptual-motor skills in infants with motor delays. METHODS: Participants were 50 infants with motor delays randomly assigned to START-Play plus Usual Care Early Intervention (UC-EI) or UC-EI only. Infants' perceptual-motor and cognitive skills were assessed at baseline and 1.5, 3, 6, and 12 months post-baseline. RESULTS: Short-term changes in sitting, fine motor skills, and motor-based problem-solving, but not reaching, predicted long-term changes in cognition. START-Play indirectly impacted cognition through motor-based problem-solving but not sitting, reaching, or fine motor skills. CONCLUSIONS: This study provided preliminary evidence that early physical therapy interventions that blend activities across developmental domains and are supported by an enriched social context can place infants on more optimal developmental trajectories.

Hand-Arm Bimanual Intensive Training in Virtual Reality: A Feasibility Study.

OBJECTIVE: The aim of the study was to evaluate the feasibility of virtual reality (VR) software built using the core concepts of hand-arm bimanual intensive training (HABIT) for improving upper extremity motor function in children with cerebral palsy (CP). METHODS: Eight children with CP participated in a 10-day, 40-hour HABIT program. Half of the time custom VR software, HABIT-VR was used. The children's motor skills were assessed pre- and postintervention with the Assisting Hand Assessment, Box and Blocks Test, and Nine-Hole Peg Test. RESULTS: The children had significant and clinically relevant changes in the Assisting Hand Assessment and Box and Blocks Test; however, Nine-Hole Peg Test scores did not change with intervention. CONCLUSION: These data suggest that combining traditional HABIT strategies with HABIT-VR games improve upper extremity function and gross motor skills but not fine motor skills.

The Effect of START-Play Intervention on Reaching-Related Exploratory Behaviors in Children with Neuromotor Delays: A Secondary Analysis of a Randomized Controlled Trial.

AIMS: Children with neuromotor delays are at risk for reaching and object exploration impairments, which may negatively affect their cognitive development and daily activity performance. This study evaluated the effectiveness of the Sitting Together And Reaching To Play (START-Play) intervention on reaching-related exploratory behaviors in children with neuromotor delays. METHODS: In this randomized controlled clinical trial, 112 children (Mean = 10.80, SD = 2.59 months old at baseline) with motor delays were randomly assigned to receive START-Play intervention or usual care-early intervention. Performance for ten reaching-related exploratory behaviors was assessed at baseline and 1.5, 3, 6, 12 months post-baseline. Piecewise linear mixed-effects modeling was used to evaluate short- and long-term effects of the intervention. RESULTS: Benefits of START-Play were observed for children with significant motor delays, but not for those with mild delays. START-Play was especially beneficial for children with significant motor delays who demonstrated early mastery in the reaching assessment (i.e., object contact ≥65% of the time within 3 months after baseline); these children showed greater improvements in manual, visual, and multimodal exploration, as well as intensity of exploration across time. CONCLUSIONS: START-Play advanced the performance of reaching-related exploratory behaviors in children with significant motor delays.

"Learn the Signs. Act Early.": Updates and Implications for Physical Therapists.

PURPOSE: In early 2022, the Centers for Disease Control and Prevention (CDC) updated their developmental surveillance milestone checklists. The purpose of this article is to clarify and interpret the updates from a physical therapist perspective and to discuss implications of the new milestones for physical therapists. SUMMARY OF KEY POINTS: The CDC's updated checklists provide clear, consistent, easy to use, and evidence-based developmental milestones to prompt discussion with families. The new checklists do not represent a lowering of standards and will likely increase, not decrease, referrals for screening, evaluation, and services. Crawling has been removed from the milestone checklists, as the current evidence suggests that crawling is highly variable and not essential for development. CONCLUSIONS AND RECOMMENDATIONS FOR CLINICAL PRACTICE: The updated milestone checklists will facilitate bringing vital services to children who need them. Physical therapists should support our primary care colleagues in implementing this useful program.

Object Permanence and the Relationship to Sitting Development in Infants With Motor Delays.

PURPOSE: This study examines object permanence development in infants with motor delays (MD) compared with infants with typical development (TD) and in relation to sitting skill. METHODS: Fifty-six infants with MD (mean age = 10 months) and 36 with TD (mean age = 5.7 months) were assessed at baseline and then at 1.5, 3, and 6 months postbaseline. A scale was developed to measure object permanence (Object Permanence Scale [OPS]), and the Gross Motor Function Measure sitting subsection (GMFM-SS), and the Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III) were administered. RESULTS: Interrater reliability of the OPS was excellent and correlation between the OPS and Bayley-III cognitive scores was moderately positive. Compared with TD, infants with MD were delayed in development of object permanence but demonstrated increased understanding over time and as sitting skills improved. CONCLUSION: In children with MD, object permanence, as quantified by the OPS, emerges in conjunction with sitting skill.

The Effect of Early-Life Seizures on Cognitive and Motor Development: A Case Series.

PURPOSE: This case series documents developmental changes over time and in response to a novel intervention, Sitting Together and Reaching to Play (START-Play), in children with early-life seizures. METHODS: Thirteen children with early-life seizures were included from a subset of participants in the START-Play multisite, randomized controlled trial. Seven received 3 months of twice weekly START-Play intervention; 6 continued with usual care early intervention. Bayley Scales of Infant Development-III (Cognitive Composite), Gross Motor Function Measure-66 Item Set, Assessment of Problem-Solving in Play, and reaching assessments were administered at baseline, 3, 6, and 12 months postbaseline. Change scores are reported at 3 and 12 months postbaseline. RESULTS: Over time, plateau or decline was noted in standardized cognition measures; motor development improved or was stable. Children receiving START-Play showed positive trends in problem-solving (71.4%) and reaching behaviors (57.2%). CONCLUSIONS: Interventions such as START-Play that combine motor and cognitive constructs may benefit children with early-life seizures.

The SIT-PT Trial Protocol: A Dose-Matched Randomized Clinical Trial Comparing 2 Physical Therapist Interventions for Infants and Toddlers With Cerebral Palsy.

OBJECTIVE: Although early intervention for infants at risk for cerebral palsy is routinely recommended, the content of intervention is poorly described, varies widely, and has mixed supporting evidence. The purpose of this study was to compare efficacy of 2 interventions grounded in differing domains of the International Classification of Functioning, Disability and Health on developmental outcomes of infants with or at high risk of cerebral palsy. METHODS: Infants who meet inclusion criteria will be randomized into either Sitting Together and Reaching To Play or Movement, Orientation, Repetition, Exercise Physical Therapy groups. Both groups will receive intervention twice weekly for 3 months and follow-up at 3, 6, 9, and 12 months from baseline. The primary objectives compare changes over time and between groups in sitting, gross motor, and cognitive development. The setting is the infant's home unless the caregiver requests otherwise. One hundred and fifty infants between 8 and 24 months of age will be enrolled in 3 geographically, racially, and ethnically diverse sites: Los Angeles, California; Omaha, Nebraska; and Seattle, Washington. Enrolled infants will demonstrate motor delays, emerging sitting skills, and signs of neurologic impairment. Sitting Together and Reaching To Play targets activities including sitting, reaching, and motor-based problem solving to improve global development. In contrast, Movement, Orientation, Repetition, Exercise Physical Therapy focuses on strengthening and musculoskeletal alignment while encouraging repeated movement practice. Outcome measures include the Gross Motor Function Measure, Bayley Scales of Infant Development-IV, Assessment of Problem Solving in Play, and a Parent Child Interaction assessment. Enrolled children will maintain usual intervention services due to ethical concerns with intervention withdrawal. IMPACT: This will be the first study, to our knowledge, comparing efficacy of early physical therapy with dose-matched interventions and well-defined key principles. The outcomes will inform selection of key principle of intervention in this population.

Effect of the START-Play Physical Therapy Intervention on Cognitive Skills Depends on Caregiver-Provided Learning Opportunities.

AIMS: This study evaluated whether caregiver-provided learning opportunities moderated the effect of START-Play physical therapy intervention on the cognitive skills of young children with neuromotor delays, and whether START-Play impacted caregiver-provided learning opportunities over time. METHODS: One hundred and twelve children with neuromotor delays (7-16 months) participated in a multisite randomized clinical trial evaluating the efficacy of START-Play. Children were assessed at baseline and 3 (post intervention), 6, and 12 months post baseline. Cognition was scored from the Bayley Scales of Infant & Toddler Development, Third Edition, cognitive scale. The proportion of time caregivers spent providing learning opportunities was coded from a 5-minute caregiver-child free play interaction. RESULTS: Baseline caregiver-provided learning opportunities moderated the 3- and 12-month effects of START-Play on cognition. Cognitive gains due to START-Play were more pronounced for children whose caregivers provided more learning opportunities. START-Play did not impact caregiver-provided learning opportunities over time. CONCLUSIONS: START-Play may have a lasting effect on children's cognition, but this effect is contingent on caregivers providing their child with ample opportunities to practice cognitive skills. Strategies for improving caregivers' uptake and transfer of START-Play principles to their daily routines should be evaluated. TRIAL REGISTRATION: ClinicalTrials.gov NCT02593825.

The Influence of Maternal Cognitions Upon Motor Development in Infants Born Preterm: A Scoping Review.

PURPOSE: This scoping review summarizes the extent, nature, and type of evidence linking broadly defined maternal cognitions to motor outcomes in infants born preterm. Maternal cognitions are beliefs, perceptions, or psychosocial attributes that inform parenting practices. METHODS: Arksey and O'Malley's 5-step method was applied. Thirteen articles between 1980 and November 2019 met inclusion criteria. RESULTS: Two key themes emerged with infants born preterm: (1) quality of the social and physical caregiving environment influence developmental outcomes with implications for motor development; and (2) complex interactions between environmental factors, prematurity-related biomedical risks, and maternal cognitions contribute to eventual motor outcomes. CONCLUSION: Further research is needed to understand how maternal cognitions either scaffold or constrain early motor opportunities for infants born preterm and at risk for motor delays. WHAT THIS ADDS TO THE EVIDENCE: This review summarizes studies that explore potential links between maternal cognitions and motor development in infants born preterm.

START-Play Physical Therapy Intervention Impacts Motor and Cognitive Outcomes in Infants With Neuromotor Disorders: A Multisite Randomized Clinical Trial.

OBJECTIVE: Our objective was to evaluate the efficacy of the Sitting Together and Reaching to Play (START-Play) intervention in young infants with neuromotor disorders. METHOD: This randomized controlled trial compared usual care early intervention (UC-EI) with START-Play plus UC-EI. Analyses included 112 infants with motor delay (55 UC-EI, 57 START-Play) recruited at 7 to 16 months of age across 5 sites. START-Play included twice-weekly home visits with the infant and caregiver for 12 weeks provided by physical therapists trained in the START-Play intervention; UC-EI was not disrupted. Outcome measures were the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley); the Gross Motor Function Measure; reaching frequency; and the Assessment of Problem Solving in Play (APSP). Comparisons for the full group as well as separate comparisons for infants with mild motor delay and infants with significant motor delay were conducted. Piecewise linear mixed modeling estimated short- and long-term effects. RESULTS: For infants with significant motor delay, positive effects of START-Play were observed at 3 months for Bayley cognition, Bayley fine motor, and APSP and at 12 months for Bayley fine motor and reaching frequency outcomes. For infants with mild motor delay, positive effects of START-Play for the Bayley receptive communication outcome were found. For the UC-EI group, the only difference between groups was a positive effect for the APSP outcome, observed at 3 months. CONCLUSION: START-Play may advance reaching, problem solving, cognitive, and fine motor skills for young infants with significant motor delay over UC-EI in the short term. START-Play in addition to UC-EI may not improve motor/cognitive outcomes for infants with milder motor delays over and above usual care. IMPACT: Concepts of embodied cognition, applied to early intervention in the START-Play intervention, may serve to advance cognition and motor skills in young infants with significant motor delays over usual care early intervention. LAY SUMMARY: If you have a young infant with significant delays in motor skills, your physical therapist can work with you to develop play opportunities to enhance your child's problem solving, such as that used in the START-Play intervention, in addition to usual care to help your child advance cognitive and motor skills.

Sitting Matters! Differences Between Sitters and Nonsitters at 6 Months' Adjusted Age in Infants At-Risk and Born Preterm.

PURPOSE: Sitting delays in infants born preterm compound cognitive and language deficits. This retrospective study examines differences in prematurity-related risk and compares developmental outcomes between sitters and nonsitters at 6 months' adjusted age. METHODS: A total of 105 graduates of the neonatal intensive care unit met inclusion criteria. Infant demographic and medical risk profiles and 6-month Bayley Scales of Infant Development-3rd edition (BSID-III) cognitive and language scores were retrieved. Infants who sat with hands free greater than 60 seconds were classified as "sitters." RESULTS: Sixty-nine percent of the sample were nonsitters and were born earlier, had lower birth weights, were chronologically older at follow-up, and spent more days with respiratory support. BSID-III scores were significantly higher in sitters but did not differ by gender, multiple birth, head ultrasound results, payment type, or race/ethnicity. CONCLUSION: Sitting abilities at 6 months' adjusted age are associated with prematurity risk factors. Cognitive and language scores differ significantly between sitters and nonsitters.