Early motor intervention

Last update: 8 Dec 2016

Early motor interventions are recommended for infants and young children with all types and severity of cerebral palsy
The aim of these programs is to improve children’s ability to do things like roll over, sit independently, stand, walk and use their hands for play and learning.

Who is it for?

Early motor intervention is suitable for children with, or at risk of, cerebral palsy and who have the following characteristics:
Type of cerebral palsy : Bilateral cerebral palsy, Diplegia, Hemiplegia, Quadriplegia, Unilateral cerebral palsy

More information about cerebral palsy is contained in the What is CP? section.

Mobility : GMFCS I, GMFCS II, GMFCS III, GMFCS IV, GMFCS V

Gross Motor Function Classification System (GMFCS) – classifies severity of mobility difficulties of children and adolescents with CP.

GMFCS Level I
Walks without limitations in the home and community, climbs stairs and can run and jump, difficulties with speed and coordination.

GMFCS Level II
Walks with limitations, difficulties with long distances and uneven surfaces, uses a railing for climbing stairs, limited running and jumping.

GMFCS Level III
Walks using a hand-held mobility device such as crutches or walking frame, may use wheeled mobility for long distances.

GMFCS Level IV
Usually relies on wheeled mobility with assistance, may use powered mobility, usually needs special seating and assistance with transfers.

GMFCS Level V
Usually transported in a manual wheelchair, requires specialised seating and full assistance for transfers.

See full glossary

Arm ability : MACS I, MACS II, MACS III, MACS IV, MACS V

Manual Ability Classification System (MACS) – classifies severity of upper limb impairment: how children with cerebral palsy use their hands to handle objects in daily activities in the home, school, and community settings.

MACS Level I
Handles objects easily and successfully.

MACS Level II
Handles most objects but with somewhat reduced quality and/or speed of achievement.

MACS Level III
Handles objects with difficulty; needs help to prepare and/or modify activities.

MACS Level IV
Handles a limited selection of easily managed objects in adapted situations.

MACS Level V
Does not handle objects and has severely limited ability to perform even simple actions.

See full glossary

Communication ability : CFCS I, CFCS II, CFCS III, CFCS IV, CFCS V

Communication Function Classification System (CFCS) – classifies severity of everyday communication of people with cerebral palsy.

CFCS Level I
Effective Sender and Receiver with unfamiliar and familiar partners.

CFCS Level II
Effective but slower paced Sender and/or Receiver with unfamiliar and/or familiar partners.

CFCS Level III
Effective Sender and Receiver with familiar partners.

CFCS Level IV
Inconsistent Sender and/or Receiver with familiar partners.

CFCS Level V
Seldom effective Sender and Receiver even with familiar partners.

See full glossary

Movement disorder : Ataxia, Athetosis, Dystonia, Hypotonia, Spasticity

More information about movement disorders can be found on our websites.

Intellectual ability : No intellectual disability, Mild intellectual disability, Moderate intellectual disability, Severe intellectual disability

A person’s thinking skills – ability to understand ideas, learn and solve problems. People with intellectual disability have difficulty with intellectual functioning which may influence learning, communication, social and daily living skills. Intellectual disability may be mild to very severe.

See full glossary

Early motor interventions are delivered by paediatric occupational therapists and physiotherapists.

Cerebral Palsy Alliance offers a specialised service where paediatric occupational therapists and physiotherapists skilled at early intervention with infants and young children complete a comprehensive assessment and help you decide on the best program for you and your child.

Find a Cerebral Palsy Alliance service

Fees will apply for assessment and intervention with occupational therapists and physiotherapists, and will depend on the service provider and the number of sessions needed. Check with the provider whether fees will also apply for development of a home program, report writing or therapist travel. Equipment and resources may be required depending on the type of early motor intervention program and the complexity of the child’s needs.

Ask service providers if you are eligible for funding to assist with fees, equipment and resources. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

Effective interventions are generally intensive and require a commitment to visit therapists and to complete activities at home.

More about early motor intervention

Early motor intervention programs are for infants or young children with cerebral palsy - and those at risk of having cerebral palsy. They are offered to children and their families either early in life or soon after a diagnosis1. These programs aim to improve the gross motor and fine motor skills of infants and young children. It is recommended that children begin these early motor interventions as soon as cerebral palsy is suspected.

Cerebral palsy is primarily a motor disorder that results from damage to the developing brain.

A motor disorder may affect:

  • Gross motor skills – from rolling, sitting, crawling and walking - through to more advanced skills like running and hopping
  • Fine motor skills – from those developed early in an infant’s life, including reaching and grasping, through to more complex hand skills necessary for self-care tasks and play.

One reason for a strong focus on early intervention is what we know about neuroplasticity - the brain’s natural ability to change and adapt.

Understanding neuroplasticity

The first two years of life is a critical period for neuroplasticity, when the brain is most likely to respond to intensive practice of motor activities2. Children with cerebral palsy reach 90 per cent of their gross motor potential by the age of five3, and even earlier for those with severe cerebral palsy. Intensive and early therapy that is tailored to the individual needs of an infant or young child is therefore very important for maximising the opportunity for their young brain to adapt and learn.
Experts consider it important to work intensively with infants and young children to take advantage of the crucial early years when the developing brain is particularly responsive to intervention. Early motor intervention ideally begins as soon as a brain injury or developmental concerns are suspected. This might be as early as three months of age for infants who are identified as being at high risk on a General Movements Assessment. This assessment is the most accurate tool for identifying cerebral palsy early in an infant’s life.

Assessments

There are two types of assessment required when participating in an early motor intervention program.

A team of health professionals, including paediatric occupational therapists and physiotherapists, will complete a thorough assessment with each child and family to accurately identify and then implement the best intervention. The team and family will also work together to identify goals and decide on a time frame for achieving them.

The second type of assessment is to determine if the intervention is meeting the child’s needs and helping them achieve their goals. Assessments suggested for measuring the outcomes of early motor intervention programs include:

Best available research evidence

We searched the medical, allied health, psychological and educational literature to find research evaluating the outcomes of early motor intervention programs used with infants and children from birth to five years of age.
The search aimed to find the best available evidence (randomised controlled trial (RCTs) or systematic reviews), published since 1984, about whether early motor interventions improve fine or gross motor skills. The search was to find studies where i) all infants in the study were clearly designated at high risk of cerebral palsy or had an established diagnosis of cerebral palsy and ii) all children were birth to five years old when starting the study. Studies of early intervention delivered whilst an infant was in hospital were not included. Studies of infants who were premature or small for gestational age were not included - unless they also had identified brain injuries or absence of fidgety general movements (which is a strong predictor of cerebral palsy in early infancy).

The best available evidence was 11 RCTs evaluating eight different early motor interventions in children from birth to five years old who had cerebral palsy or were at high risk of having cerebral palsy. In addition, we located a systematic review4 of the effectiveness of early motor interventions and which included all levels of research designs. Some interventions which are considered early interventions, and some known studies of early interventions may not be discussed below because they did not fit these criteria; or they did not have high level studies (RCTs or systematic reviews) evaluating their outcomes. Such interventions include goal directed training, Vojta and bimanual upper limb therapy.

There are several types of early motor intervention programs, but very few high level studies have been completed to evaluate them. The evidence suggests, however that promising interventions are:

  • GAME5-6
  • Infant stimulation for infants with spastic diplegic cerebral palsy4-7
  • Constraint-induced movement therapy8 for young children with hemiplegic cerebral palsy
  • Treadmill training9 for young children at GMFCS Levels I and II

Low quality evidence provided insufficient information about the effects of conductive education10 and kicking and stepping exercises11 for improving motor outcomes. More good quality research would provide clearer guidance about these interventions and in the meantime, the more promising early motor interventions listed above should be used. Neurodevelopmental therapy7, 12-16, which has been evaluated in several RCTs and has a moderate quality evidence base, appears not to be effective for improving motor skills in young children with cerebral palsy and an alternative intervention should be considered. Other interventions, such as bimanual upper limb therapy, Vojta and goal directed training that exist for the birth to five-year-old age group, do not yet have high level research evaluating their effectiveness4.

Research tells us that the brain of the infant and very young child are best able to respond, change and adapt in the first two years of life. We also know from research into older children with cerebral palsy that intensive treatments are more effective than less intensive treatments. Experts, therefore, recommend intensive and early interventions for infants and young children4.

The research evidence is just one piece of information to assist in deciding what type of early motor intervention is right for an individual child. Families, caregivers and paediatric therapists will carefully consider the unique goals and needs of each infant and young child with cerebral palsy to determine which program is most suitable. The outcomes should be carefully monitored to check whether the intervention is effective and meeting the goals that were set.

Further information on the findings

GAME is more effective than standard care for motor and cognitive outcomes.

GAME stands for Goals, Activity and Motor Enrichment. This intervention is customised for individual infants and families’ goals and is carried out at home5-6. Families are coached and supported to actively engage their infant in motor tasks and to enrich the home environment to achieve developmental goals. One RCT5 compared GAME with an equal amount of standard care. The results indicated that GAME is more effective for improving motor and cognitive outcomes at 12 months of age. The infants started the study before turning 6 months of age and were at either high risk of cerebral palsy or had a diagnosis of any type of cerebral palsy. GAME is a promising new intervention.

Six months of infant stimulation had better outcomes than an alternate therapy

Infant stimulation involves a series of motor, sensory, cognitive and language tasks of increasing difficulty. One RCT provides moderate quality evidence that six months of infant developmental stimulation results in better motor outcomes than equally intensive neurodevelopmental therapy (NDT, see below)7 for children with spastic diplegia. In this study, children with spastic diplegic cerebral palsy, aged 12 months to 19 months, engaged in infant stimulation carried out by parents at home, supported by fortnightly visits to a physiotherapist. Although little high level research has been completed, infant developmental stimulation is a promising intervention.

Constraint-induced movement therapy (CIMT) may help children use their affected hand

CIMT is used with children with hemiplegic cerebral palsy. The unaffected hand is restrained using a mitt, splint or cast, while therapy is completed to improve the use of the affected (hemiplegic) hand. One RCT8 provides Low quality evidence that CIMT is more effective than usual care for improving a child’s ability to use the hemiplegic hand in two-handed activities. The intervention involved children aged two and three years old wearing a mitt on their unaffected hand while participating in two hours of therapy per day for two months. Although little high level research has been completed, CIMT is a promising intervention.

Treadmill training combined with physiotherapy may improve independent walking

Treadmill training involves carefully supervised and supported walking on a treadmill. One RCT9 provides low quality evidence that treadmill training combined with regular physiotherapy may be more effective for improving independent walking than less intensive regular physiotherapy for nine to 36 month old children with milder cerebral palsy (GMFCS I and II). Treadmill training, in this study, involved walking on a portable treadmill in the home, for an average of 28 minutes per day, six days a week for six weeks. Although little high level research has been completed, treadmill training is a promising intervention.

Neurofacilitation of developmental reaction may improve gross motor skills

One small RCT12, providing low quality evidence compared neurofacilitation of developmental reaction with equally intensive neurodevelopmental therapy. The former resulted in better gross motor skills than the latter in children with mild to moderate spasticity but unknown types of cerebral palsy. Very little is known about this intervention and it appears only to be used in India.

High intensity kicking and stepping is no better than low intensive physiotherapy

This intervention involves teaching parents to play games to encourage kicking as well as early treadmill stepping. One small RCT11 comparing this intervention to lower intensity physiotherapy provided low quality evidence that there was no difference in motor outcomes between the two interventions with infants at high risk for cerebral palsy. This intervention involved kicking games starting at two months of age and treadmill stepping at home starting at four months. Low quality evidence suggests that the higher intensity kicking and stepping program is no more effective than lower intensity physiotherapy. More good quality research is needed to give us more information about kicking and stepping programs.

No difference between conductive education and neurodevelopmental therapy outcomes

Conductive education is an educational approach, rather than a therapy. Therefore, it is not always classified as an early motor intervention because it addresses a range of other outcomes as well as motor skills. It focuses on several aspects of a child’s development, and includes a motor component. One RCT10 comprising low quality evidence compared equally intensive conductive education and neurodevelopmental therapy in children aged one to three years old with a range of presentations and severity of cerebral palsy. The study found no difference in gross motor outcomes between the two interventions. More good quality research is required to provide better information about the effect of conductive education on motor skills in this age group. It is important to note that this review only considered motor outcomes and not the other outcomes which conductive education addresses.

Moderate evidence that neurodevelopmental therapy (NDT) is less effective than other equally intensive interventions

Two RCTs7,12 provided moderate quality evidence that an intervention applied at an equal intensity was more effective for improving gross motor ability than NDT in young children with a range of types and severity of cerebral palsy. Four RCTs13-16 provided moderate quality evidence that there was no difference in motor outcomes between NDT and a less intensive intervention in children with or at risk of cerebral palsy. For children from birth to five years with, or at risk of, cerebral palsy, moderate quality evidence shows that NDT is no more effective than less intensive interventions and that other equally intensive interventions should be pursued where appropriate.

Date of literature searches: July 2016

  1. Shonkoff, J. P., & Meisels, S. J. (2000). Handbook of early childhood intervention (2nd ed.). New York, NY: Cambridge University Press.
  2. Johnston, M. (2009). Plasticity in the developing brain: Implications for rehabilitation. Developmental Disabilities Research Reviews, 15, 94-101.
  3. Rosenbaum, P., Walter, S., Hanna, S., Palisano, R., Russell, D., Raina, P., . . . Galuppi, B. (2002). Prognosis for gross motor function in cerebral palsy: Creation of motor development curves. Journal of the American Medical Association, 288(11), 1357-1363.
  4. Morgan, C., Darrah, J., Gordon, A. M., Harbourne, R., Spittle, A., Johnson, R., & Fetters, L. (2016). Effectiveness of motor interventions in infants with cerebral palsy: a systematic review [with consumer summary]. Developmental Medicine and Child Neurology 2016 Mar 29:Epub ahead of print. See abstract
  5. Morgan, C., Novak, I., Dale, R. C., Guzzetta, A., & Badawi, N. (2016). Single blind randomised controlled trial of GAME (Goals – Activity – Motor Enrichment) in infants at high risk of cerebral palsy. Research in developmental disabilities, 55, 256-267. See abstract
  6. Morgan, C. J., Novak, I., Dale, R. C., & Badawi, N. (2014). Optimizing the motor outcomes of infants at high risk of cerebral palsy: A pilot randomized controlled trial. Developmental Medicine and Child Neurology, 56, 96-97.
  7. Palmer, F. B., Shapiro, B. K., Wachtel, R. C., Allen, M. C., Hiller, J. E., Harryman, S. E., . . . Capute, A. J. (1988). The effects of physical therapy on cerebral palsy. A controlled trial in infants with spastic diplegia. The New England Journal of Medicine, 318(13), 803-808. See abstract
  8. Eliasson, A. C., Shaw, K., Berg, E., & Krumlinde-Sundholm, L. (2011). An ecological approach of Constraint Induced Movement Therapy for 2-3-year-old children: A randomized control trial. Research in Developmental Disabilities, 32(6), 2820-2828. See abstract
  9. Mattern-Baxter, K., McNeil, S., & Mansoor, J. K. (2013). Effects of home-based locomotor treadmill training on Gross Motor Function in young children with Cerebral Palsy: A quasi-randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 94(11), 2061-2067.
  10. Reddihough, D. S., King, J., Coleman, G., & Catanese, T. (1998). Efficacy of programmes based on Conductive Education for young children with cerebral palsy. Developmental Medicine and Child Neurology, 40(11), 763-770.
  11. Campbell, S. K., Gaebler-Spira, D., Zawacki, L., Clark, A., Boynewicz, K., Deregnier, R. A., . . . Zhou, X. J. (2012). Effects on motor development of kicking and stepping exercise in preterm infants with periventricular brain injury: A pilot study. Journal of Pediatric Rehabilitation Medicine, 5(1), 15-27.
  12. Batra, M., Sharma, V. P., Batra, V., Malik, G. K., & Pandey, R. M. (2012). Neurofacilitation of Developmental Reaction (NFDR) approach: A practice framework for integration/modification of early motor behavior (primitive reflexes) in cerebral palsy. Indian Journal of Pediatrics, 79(5), 659-663. doi: 10.1007/s12098-011-0545-3. See abstract
  13. Law, M., Russell, D., Pollock, N., Rosenbaum, P., Walter, S., & King, G. (1997). A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy program for children with cerebral palsy. Developmental Medicine & Child Neurology, 39(10), 664-670.
  14. Ohgi, S., Fukuda, M., Akiyama, T., & Gima, H. (2004). Effect of an early intervention programme on low birthweight infants with cerebral injuries. Journal of Paediatrics and Child Health, 40(12), 689-695. See abstract
  15. Weindling, A. M., Cunningham, C. C., Glenn, S. M., Edwards, R. T., & Reeves, D. J. (2007). Additional therapy for young children with spastic cerebral palsy: A randomised controlled trial. Health Technology Assessment, 11(16), 1-71.
  16. Weindling, A. M., Hallam, P., Gregg, J., Klenka, H., Rosenbloom, L., & Hutton, J. L. (1996). A randomized controlled trial of early physiotherapy for high-risk infants. Acta Paediatrica, 85(9), 1107-1111. See abstract
Find out about CP Check-Up™

Cerebral Palsy Alliance offers a service called CP Check-Up™ which provides ongoing surveillance of the health and well-being of our clients aged 0-18 years.
The information on this page was developed using the best research evidence combined with the expertise of clinicians and people with cerebral palsy and their families. It is provided to help people with cerebral palsy, their families and caregivers, clinicians and service providers make decisions about suitable interventions. This information is intended to support, but not replace, information exchanged, and decisions made, between people with cerebral palsy, their families and health professionals.