Best Start Trial: early intervention physiotherapy to improve motor outcomes in infants at high risk of cerebral palsy or motor delay

Experimental: Best Start Intervention. The essential elements of the experimental intervention include: (i) Physiotherapy Motor Training. Following individualised assessment of the infant, motor goals are discussed with the parents including head control, orientation of movements to the midline and eye-hand co-ordination. From the assessment, the infant’s individual limitations to attaining these goals are explained. Training is designed for the infants individual needs to target goal achievement and to be parent-administered. Experimental care interventions will involve the infant actively and repeatedly practicing movements in response to a parent stimulus or toy that provokes intentional active movement to achieve early motor milestone goals. Emphasis is placed on providing optimal motor learning opportunities without tiring their infant. Parents will be educated on how to read their infants behavioural cues to prevent this. The earliest age infants will commence motor training is 34 weeks GA as this has been identified as a time when infants can comfortably tolerate short periods of motor learning without detriment. Infants will regularly be reassessed to inform the infants motor learning needs. (ii) Parent Coaching in Motor Training: In the NICU and SCN, parents are coached in how to provide short periods (ie 5 minutes maximum three times per day) of motor training in the infants care time ie 30 mins before a feed when nappy changes and other routine cares are performed. Coaching involves helping parents practice activities which illicit motor goals whilst maintaining awareness of their infant’s behavioural cues. Activities will be selected which best suit the parents’ abilities and the infants’ needs. Coaching is therefore parent responsive and aims to support and optimise parent mental health, empowerment and attachment. It is also adapted to the infant’s family’s culture, education and parenting style. Coaching sessions will occur 1-2 times per week as indicated. On discharge home, further parent coaching will be performed by the experimental care physiotherapist. This will occur through home visits, clinic appointments and Skype© sessions on fortnightly – monthly basis as indicated. The duration of motor therapy sessions provided at home initially is three times 10 minutes per day delivered when the infant is alert and awake. By 16 weeks corrected age each of the three sessions will increase from 10 to 20 minutes. Handouts will be provided with photographs, illustrations and instructions to support the therapy content and dosage to be administered by the parent/caregiver. Contacts for the experimental care physiotherapists will be provided to assist with any queries external to coaching times. (iii) Environment Enrichment Strong evidence exists for the provision of environmental enrichment strategies to advance motor development which includes consideration of motor, cognitive, sensory and social domains. Experimental care incorporates each of these aspects as follows with modifications as pertinent between the hospital and home environment: a) Physical environment: provision of physical supports to promote movement eg creating nests, use of a supportive baby chair (Fraser chair) and the use of activities and materials (baby play gym and initial baby toys such as rattles and rings) to entice desired movements b) Cognitive environment: by encouraging early infant problem solving such as hand sucking to functionally self-settle c) Sensory environment: by providing the best background for enhancing motor learning capacity considering timing of therapy delivery with sleep, feeding, oxygen requirements and pain management so that the infant is alert, settled and happily able to best engage. d) Social environment: by coaching parents to be sensitive, responsive and communicative to infant cues. The mechanism of home visits will enable environmental enrichment strategies to be set up in the natural home environment through parent coaching. As this is where the majority of the experimental care interventions will occur, this will enable the translation of practice with is specific, relevant and at the appropriate intensity for the infant to achieve identified motor goals. Prior to discharge home, when the infant is still admitted in the NICU, efforts will be made to enrich the infant’s environment as much as possible within the hospital environment.