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A Review of the Effect of Early Intervention

Programmes on the Devel-,~pmental Status of Very


Preferm, Very Low Birth Weight Infants

Infants who are born prior to forty weeks JOAN COLE


gestation frequently demonstrate a rate of Joan Cole, Ph.D., B.P.T., M.S., M.Ed., is Associate
development which is different from that Professor in the School of Physiotherapy, Curtin
evidenced by their term born peers. This is true University of Technology, Western Australia.
particularly for those infants who have no ab-
normalities which would interfere with their
development but who are both very preterm (of
32 weeks gestation or less) and of very low
weight at birth (1500 grams or less). Stimulation
aimed at overcoming the negative aspects of
preterm birth and enhancing the development
of preterm born infants has been widely recom-
mended. The evidence which supports the idea
of such intervention is conflicting and based on
inconclusive data.
The purpose of this review is to identify those
aspects of early stimulation programmes which
have been of measurable benefit to preterm
born subjects. From this basis it should be
possible to isolate optimal forms of stimulation
to guide those who seek to provide these in-
fants with assistance designed to maximize
their developmental potential.

The ontogenetic progression weight (VLBW), weighing 1500 grams Two points of view are most frequent-
through infancy and childhood of the or less at birth, developmental pro- ly expressed. The rrrst suggests that the
term born infant is well documented gress or status is a matter of interest to infant of short gestation suffers from
and generally proceeds with few devia- - physiotherapists. Such infants are con- sensory deprivation (Field 1980, Katz
tions (prechtl 1981). Knoblock and sidered to be at greater risk for the ap- 1971), the second that overstimulation
Pasamanick (1974) have suggested that pearance of pathologies likely to in- provided by the complex equipment
the behaviours (that is the observable terfere with the emergence of normal surrounding the infant and the
responses displayed by the infant and motor patterns. The increasingly repeated noxious procedures to which
young child) are the manifestations of mature behaviours which characterize the infant is exposed, create a level of
the dynamic processes of change which the development of the term born in- stress which the infant is ill-equipped
the infant experiences as it progresses fant are likely to be slower to emerge in to manage (Campbell 1986, Touwen
towards increasingly more mature very preterm, VLBW infants leading 1980). Both viewpoints have generated
capacities. The evaluation of the to delays in the achievement of com- models of management.
degree to which the infant isattaiQing monly recognized abilities. The programmes designed to offer
the various stages which characterize The discrepancy between the supplemental stimulation have taken
this changing process is an indication behaviours displayed by very preterm, various forms. Not only are different
of the level or status along the VLBW and term born infants, par- types of iilterventionprescribed. but
developmental continuUlilwhich the ticularlyin the early months of life has the time of implementation varies con-
infant has reached. This dYnamic pro- resulted in proposals for various forms siderably. The suggested milWl,gement
cess of change is termed development. of cOmpensatory management. The has been offeredduting the period of
JJirtb before tbecompletion of the absence of tbecyclic stimulation pro- the initial hospitalization or following
full gestational period interrupts the vided by maternal rhythms of sleeping discharge, either as a borne b/liledpro-
usual course .of :development. For and waking, movement and noise has gramme or as areguIar cOnsultation
those infants who are described .asvery directed attention to tbeneed to COn- with a member ofa follow-UPteaJll.
preterm, lhat is those born at 32 weeks sider sensory inputs experienced by the The purpose of theteiew presAA.ted
gestation or less, and of very low birth preterm .bom infants .more carefully. here is to exanUnethe value oftbe

The Australian Journal of Physiotherapy. Vol. 35, No.3, 1989 131


Early Intervention Programmes

various intervention programmes A later report by Kramer et a1 (1975) radiant heat loss. Equally, the texture
described in the literature with a view of a programme of tactile stimulation ofthe lambswoolmay have been more
to identifying those procedures which administered to 14 infants of less than soothing to theimant, as was the terry
have been reported as being most 38 weeks gestation produced no results toweling covered surrogate mother to
beneficial to the very preterm born of significance. The study defined the the isolated infantjDonkeys in the ex~
infant. intervention as consisting of gentle periments described by Harlow and
stroking offered both before and after Harlow (1966).
Intervention Prior to Hospital feeding for a total of approximately 48 It appears that tactile stimulation in
Discharge minutes per day and extending from the form of stroking of the limbs and
Professionals from several different birth until transfer from an isolette. trunk has not been demonstrably
disciplines have reported on the ef- Immediate effects were measured by beneficial. It could be argued that the
ficacy of particular interventions of- the administration of the Gesell absence of effect may have been
fered within the nursery environment. Developmental Schedule (l{nobloch related to the type of tactile inpqtof-
The majority of the earlier descriptions and Pasaminick 1974) at the time of fered. According to Rood (1962), to
are of programmes which have not transfer to the isolette. At six weeks produce a calming effect, tactile
been based on physiotherapy prin- and three months the BSID (Bayley stimulation should be performed slow-
ciples. Reports detailing the content 1969) was employed to identify group ly with maintained pressure. If the
and effectiveness of intervention differences. No significant differences stroking offeredth infants in either of
designed by physiotherapists tend to between the experimental and the con- these studies was closer to a phasic
have been published more recently. trol group were reported, and weight form of stimulation, it would be an ap-
gain was similar for both groups. The propriate use of this sensory modality.
General Programmes study had intrinsic problems because Equally, this suggestion may explain
Programmes which provide added the subject population was recruited the success of the lambswool mattress
sensory stimulation are described most from seven different nospitalll and, covering. Of course, the decreased ox-
commonly. Simple stimulation of the despite efforts such as time sampling ygen requirement C()uld be sufficient
somatic tactile sensory system by to ensure that the care in each nursery explanation in itself. However, the
means of stroking has not been shown was constant, this represented a major maintained, evenly distributed tactile
to be beneficial (Solkoff et aJ 1969, methodological difficulty. input offered by the lambswool may
Kramer et a1 1975). Stroking which Oile approach to the problem of have produced a more settled infant by
was described as gently rubbing the in- overstimulation of the tactile sensory replacing the intense level of tactile
fant's neck, back and arms every hour mode has been to usea constant stimuli offered by the rougher cotton
for five minutes over a ten day period stimulus such as is provided by a lambs- surface. .
was administered soon after birth by wool mattress cover. Scott and The supplementation of tactile
Solkoff and colleagues (1969) to nor- Richards (1979) examined the effects stimulation with an additional sensory
mally developing infants weighing bet~ on daily weight gain and the amplitude modality has been shown to produce
ween 1190 and 1590 grams. A control and frequency of movement of in- positive clinical effects. However the
group received normal nursery handl- troducing such a change on the 27th statistica1significance of the reported
ing such as feeding, diaper change and post natal day to six symptom free in- resUlts hunot been established con-
routine observations. The startle fants of mean birth weight 1369 grams. clusively. The specific effects of tactile
response, daily weight changes, The mattress was covered alternatively and visual stimulation used both in
temperature, intensity .of cry and with either cotton or lambswool for 24 isolation and in combination were ex~
vig9ur of acCOmpanying movements, hour perlodsover four days. Weight amined in a study reported by Hayes
frequency of urination . and defaeca- gain was significantly greater on the (1980). The low birth weight subjects
tion, and physical development at six days lambswool was used and, at the (LBW, that is infants whose birth
to nine months after discharge from same time, an increased frequency of weight was 2000 grams Or less) in this
hospital were all monitored. Unfor- small amplitude movements .and study were randomly assigned to one
tunately, the small sample size did not decreased frequ.ency of large of three experimental groups and a
permit statistical analysis,andthe amplitude IDOvementwas observed. control group. Infants in the ex-
study provided .oniy subjective indica- None of the other parameters perimental groups experienced a pro-
tions of more rapid weight gain and measured,such as cot temperature, gramme of both visual and tactile
less crying in tne experimental group. bowel motions or amount of milk in- stimulation or only visual and only tac-
At the nine months evaluation, the gested, altered during.the period of the tile supplementary input. The tactile
authors suggested that the experimen- study. The greater weight gain..(a mean stimulation involved stroking for
tal group faired better on the Bayley of 31.5 grams versus 19.6 grams) was periods of up to a total of 90 minutes
Scales of Infant Development (BSID, attributed to several factors. A reduc- per day and the visual stimulus was
Bayley 1969). Again, since no data ed oxygen requirement could have provided by mobiles and bright
were provided, the study 9ffers no in- been associated with the diminished stickers placed around the incubator or
sights into the value of tactile stimula- movement, and the diminished move- erib. Hayes (1980)' indicated that a
tion as a form of intervention .. ment may have contributed toreduGed pOSitive treatment effect related to

132 The Australian Journal of Physiotherapy. Vol. 35, No, 3, 1989


Early Intervention Programmes

visual attention was found prior to However, the results need to be viewed beneficial effects found in young rats
discharge from hospital. It was not with caution as the matched control (Thoman and Komer 1971) and term
reported whether this outcome was the group employed in this study was born neonates (Gregg et af 1976,
same for each of the experimental retrospectively selected from infants Korner and Thoman, 1972). The ra-
groups, thus the value of the study in who had been admitted to the same tionale for this form of intervention
isolating the two sensory modalities nursery prior to the birth of those in has been described by Komer (1979) as
was not fully realized. The principal the experimental group, thereby a deficit offsetting model designed to
importance of this investigation was creating some methodological reduce the negative influences of im-
contained in the report of the com- difficulties. mobility and loss of normal, maternal-
parative developmental status of the The financial significance of ly provided stimulation. The use of
participants at three years of stimulation programmes which in- this mode of sensory input has been
chronological age. All the female sub- crease weight gain was identified by frequently reported (Korner et af1975,
jects from all the stimulated groups Field et af (1986) as an important con- Kramer and Pierpont 1976, Edelman
and the control group performed as sideration. These authors examined et af 1982, Komer et af 1983, and
well as a similar cohort of term born the effects of a mixed tactile and Pelletier et af 1985). The stimulation
infants on the McCarthy Scales of kinaestheic programme which was has been provided by the use of a: water
Children's Abilities (McCarthy 1972) tested on 40 infants with a mean filled mattress which can be oscillated
when tested at three years of age. Male weight at birth of 1280 grams, a mean cyclicly. The principal benefits
subjects who had received stimulation gestation of 31 weeks and a mean demonstrated by this form of stimula-
also performed equally as well as their length of stay in the neonatal intensive tion include a reduction in episodes of
term born peers, but unstimulated care unit (NlCU) of 20 days, who were apnoea (Komer et a/1975), improv- an
male subjects were significantly less randomly assigned to either the ex- ed capacity to attend and to pursue
competent. This appears to be the only perimental or the control condition. animate and inanimate auditory and
report of a difference in the influence Significant differences were reported visual stimuli, more mature movement
of stimulation related to the sex of the for several dependent variables. These patterns and a reduced irritability and
infant. included weight gain, the duration of hypertonicity in infants with
The combination of tactile stimula- awake/alert periods, the Neonatal respiratory distress syndrome (Komer
tion with kinaesthetic input was Behavioural Assessment Scale (NBAS, et a/1983). It has been suggested that
reported by Field et af (1986), Rausch Brazelton 1973) and length of the waterbed experience may ~ con-
(1981) and White and LaBarba (1976). hospitalization. As a result of a 15 tribute to the maturation of functional
The short term outcome resulting from minute period of stroking and passive ability which in turn would enable the
the application of massage and passive limb movements repeated over three infants to be more available to ap-
movements to the extremities was consecutive hours for a ten day period, propriate environmental stimulation
selected for investigation by White and the infants in the experimental group (Korner et af 1983). Pelletier et af
La Barba (1976). Twelve normal were discharged an average of six days (1985) reported also that infants placed
preterm infants, aged less than 36 sooner than the control infants. Field on waterbeds following stressful nurs-
weeks and weighing between 1588 and et of (1986) estimated the resultant sav- ing procedures demonstrated more self
2040 grams who came from families of ing as $US6000.00 per infant. calming behaviours and significantly
low socioeconomic status (SES) were Since tactile stimulation in the form fewer signs of stress than controls plac-
enrolled in the study. The programme of stroking has not been proven to be ed on regular incubator mattresses.
was administered for 15 minute beneficial, it is very likely that the However, the significance of this form
periods every honr for four con- positive effects demonstrated by the of stimulation for subsequent
secutive hours over eleven days from mixed tactile and kinesthetic program- developmental status has not been
the time~ the infant was 48 hours old. mes were largely a result of the investigated.
The intervention was judged to be a kinesthetic stimulation, or the increas- An alternative means of delivering
success because of the 13.9CVo increase ed opportunity for movement which vestibular stimulation is through the
in weight demonstrated. Rausch (1981) was provided, incidently ,by the use of ahamIil0ck. Neal .(1975) ex~
evaluated the influence of a daily pro- passive movements performed. amined the differential influence of
gramme which consisted of five However,asRo$s (l!)84) has explain- unposed or self-activated Yestlbular
minutes of passive movements of the ed, no sPecific gwdeliries for the .most stimulation on a group ofprererm in~
limbs preceded and followed by a five effective form of stimulation for either fantsbornbetWeeil 28 and 32 weeks of
minute period of massage, This stUdy of these sensory modalities can be gestation. The infants were placed on
revealed a statistically significant in- identified from the available research hammocks within the ineuba.tot . One
crease in the frequency of bOwel mQ- evidence.
tions, the daily caloric intake and daily $timulationof the vestibularsystetn ~r;:~~~:~~~~=~~tl~~
weight gain of the ex;perimental group as a means of producing short term tions at aconstantrate: a second had
which Rausch (1981) has attributed tQ, benefit in preterm born infants has free slung hammocks which moved in
the effect of the supplementary handl-- been extensively studied. The idea response to the infants' own body
ing programme on vagal stimulation. developed from the results of movement; while those in the third ex-

The Australian Journal of Physiotherapy. Vol. 35, No.3, 1989 1a3


Early Intervention Programmes

perimental group were placed in sta- ding Segal (1972) suggested that the When the infants graduated to an open
tionary hammacks and the control provision of supplementary auditory crib, the mobile toy was hung at eye
group of subjects received normal stimulation to preterm bQrn infants level and the 'en face' position was
care. The size of the sample (five in resulted in a greater degree of adaptive employed during feeding and combin-
each group) precluded useful analysis, responsiveness at the equivalent of 36 ed with stroking, rocking and singing.
butsome indication of benefit was sug- weeks of gestation!ll age. Katz (1971) Infants in the experimental group
gested by Neal (1975). While positive also found that infants exposed to the demonstrated superior performance
benefits of the use .of hamm()Cks to auditory stimulus showed more mature on the interactive items of the NBAS
provide vestibular stimulatian have development of the central nervous (Brazelton 1973) at .discharge and,at
not been demonstrated adequately, system on reaching 36 weeks of gesta- six months, a higher, psychomotor
this form of postJu'al support hils been tion!ll age than control infants. development index (PDI) and mental
found to have no adverse effect on Multimodal stimulation program- development index (MOl) on the BSID
VLBW infants (Bottos et a/1985). me!! based on a Piagetian model of (Bayley 1969). However, the non-
the combination of aural stimula- dev.elopment also have prQven random assignment and possible ex-
tion in the form of a simulated heart popular. Such stimulation has been perimentor bias could have con-
beat with vestibular activatian provid- evaluated by Brown et 01 (1980) in a tributed to the observed benefits.
ed by an Qscillating water bed, has not nursery b!l.Sed programme for preterm . Apart from the efforts to influence
been found to demonstrate additianal infants of soci81ly disadvantaged sensory motor performance directly,
effects (Barnard 1973, Barnard and mothers. The 41 infants fitted the law Widmayer and Field (1981) have em-
Bee 1983, Kramer and Pierpoint 1976). birth weight description (re weighed phasised the contribution which parent
Significant differences in weight gain, 2000 grams or less at birth) and were education may play in enhancing
head circumference and biparietal randQmly assigned among three ex- subsequent developmental status and
skull diameter were reparted by perimental groups. A control group .of parent':'infant interactions. Widmayer
Kramer and Pierpoint (1976) in infants a further 26 infants was included also and Field (1981) invited mothers of in-
exposedtQ these du!ll farms of but these subject!! were nQt randQmly fants assigned to.an experimental
stimulation. An increase in periods of assigned. Infants in the' experimental group to be present during the ad-
quiet sleep and developmental maturi- groups received visual, auditory, ministration of the NBAS (Brazelton
ty was found by Barnard (1973) using kinesthetic and tactile stimuIatiQn ad- 1973) prior 19 discharge. These in-
similar stimuli. Since these differenceS ministered either by nursing staff, by vestigators then carried out repeated
were very like those previously the infant's mother or by both, while assessment of the experimental and
reported for the use of the water bed routine nursery care wasptovided for control group infants at one, four and
alone, it is difficult to suggest that the the infants in the control group. twelve months of age. The opportunity
aural stimulus augmented the Weight gain and the NBAS (Brazeltan to observe the routine pre discharge
intervention. 1973) at discharge from hospital, the testing and significant effects. this
Investigations of the value of Home Observation for the Measure- was made evident' by the subsequent
llu~tory stimulation alone have pro- ment of the Environment (HOME, superiQr motor performance .of the in-
duced equivocal results. One attempt Caldwell and Bradley 1979) at nine fantsand the increased .amountof
by Malloy (1979) to compare the effect months and the BSm (Bayley 1969) at face-to-face parent-infant interactions
of a taperetording of a mother'.s voice twelve months of age were recorded. of the experimental subjects .and their
with one of a classical lullaby provided No significant short or long term ef- mothers recorded at the follow-up
no useful information. The study ap- fects of the stimulation were found for assessments. Widmayer and Field
peared to bave been weUplanned, but any Qf the dependent variables. (1981) concluded that the early ex-
the first measure,at discharge, yielded Superior performance as a result of posure of the mother to the range of
no usable data, and the Bsm (Bayley a multimodal programme of stimula- capabilities of the infant (as revealed in
1969) administerecl at . WQ.e months of tion administered in hospital has been the course Qf evaluation observed)
age showed no significant difference reported by Leib et al (1980). Fourteen significantly raised the mother's expec-
between the lD,ean~forD;l<lllce oJ the infants made up the experimental tations of the infant's responSeS and
stimulated .and the noihstimt$~ed group and 14 subsequently born ina affectedpost.,discharge parent-infant
group. Earlier studies by Katz, (1971) fants formed a control group. All interactions in a positive manner.
and Segal (1972) botlJ. examined theJn- 'Yeighecl between 1200 and 1800 grams
fluence of daily .exposure to a at birth and bad no abnormalities. the Physiotherapy ProgranUnes
taperecording of the maternal voice. programme was presented in two A variety of programmes of
The results reported by Segal (1972) forms and ac\Ininistered by the nursing physiotherapy intervention during the
demonstrated that exposure to the staff. During the period the infants period of hospitalization have been
auditory stimulus increased the rate of spent is an isolette, a brightly coloured described, but few conclusions concer-
change of the cardiac response to other mobile toy WlUl p~ in the iso~te ning their efficacy can be drawn from
aural' stimulation when measured at 36 and during gavage feedings each infant the published reports. Campbell
weeks of post conceptual age in the ex- was subjected to soothing and stroking (1974), in a programme for preterm
perim~ntalgroup. Based upon this f'm- of the' extermities, trunk and face. .and term born infants with

134 The Australian Journal of Physiotherapy. Vol. 35, No.3, 1989


Early Intervention Programmes

neurological dysfunction, inclnded offered in isolation auditory stimula- were randomly assigned toeithet an
faciUtation of sncking as an ex- tionusing the maternal voice is useful .experimental or a control grpup.
ploratoryand adaptive as well as but other forms of sensory stimulation Mothers of infants in the .c,Xperimental
alimentary response, visual stimula- appear to produce equivocal out- group were trained in theadministra-
tion to promote fixation, auditory comes. When combined with move- tion of the programme prior to the
discrimination, prehension through ment of the passive infant the in- discharge of their infants from
palmar stimulation and intersensory fluence of both auditory and tactile hospital. Mothers of the control group
integration through activities which stimuli have been shown to be received' only normal discharge infor-
combined various aspects of the enhanced. mation. Stimulation was offered to the
programme. experimental infants for 15 minutes
Other examples such as the Good Intervention In the Post four times per day for 30 days beginn-
Start Programme from the Texas Discharge Period ing on the day after discharge froiD
Chlldren'sHospital described by Oes- Less interest has been displaYed in hospital. During theeXperbnental
mond et (II (1980) and those outlined the provision of long-term program- period, public health nurses visited the
by Anderson and' Auster-Liebhaber mes,operating in the period following homes of the experimental groups
(1984), Murphy (1984) and Sweeney discharge. This is not sUfPrisingcon- regularly, adding a dimension of con-
(1985), .provide some of the details of sidering the cost of providing services cern which was not offered to the con-
the scope of physiotherapy interven- to the population within the trol group thereby confounding the
tion and follow-up programmes in- widespread community. The interven- report of a positive outcome. At four
tended to assist preterm infants and tions which have been reported in the months the experimental group show-
their families. While developmental post discharge period have been ed improved weight grun, earlier ac-
measures usually are repeated designed by a number of different quisition of the Landau and labyrin-
throughout the preschool years for the health professionals. thine righting reactions on the head
infants serviced by such programmes, Scarr-Salapatek (1973) described an and superior performance on the PDI
no attempt to measure the benefits of early regime of this nature. This and MDI of the BSID (Bayley 1969).
thservices offered have been author employed a multiinodal Intervention over a longer duration
reported. stimulation programme incorporating based upon a Piagetian model has been
campbell (1986), Fetters (1986) and visual, tactile and kinesthetic stimuli reported by Resnick et al (1987). These
Wilhelm (1984) have all discussed the administered both in hospital and authors have reported on aprpspective
objectives which nursery centered through weekly visits to the infant's two year follow-up study of the in-
physiotherapy programmes for home until the child was one year of fluence of a multidisciplinary, parent
pretermbom infants should address. age. Infants in the experimental group centred, intervention programme on
Both Campbell (1986) and Fetters were reported to show enhanced the developmental status of preterm
(1986) have identified a number of develomental status at both four weeks infants at 12 and 24 months of age.
models upon which the intervention and twelve months of age when com- TWo hundred and fifty-five infants
may be based. Reports of evaluation pared with the control group. born between 1979 and~ 1981 were
of these models are beginning to pro- However, relatively few of the control assigned to either an intervention or a
vide valuable information to group were available for the twelve control group on an alternate basis at
physiotherapists. The immediate in- month evaluation which limited the 24 hours after birth. Mean birth weight
fhlenceofintervention in the nursery author's ability to draw firiDconchi- for the intervention group was 1411
on the motor behaviours displayed by sions from the study results. grams and gestational ilgewas 31.5
preterm infants has been described by More recent reports suggest that in- weeks. The control group did not dif-
Pelletier et al (1985) while Sweeney terest is growing in the need to under- fer significantly on these par/UIJ;eters.
(1983) has discussed the physiological stand the value of continuing stimula- The control group (131 subjects)
cost to the preterm infant of the use of tion programmes. Despite the lack of received routine in-nurserycate and
hydrotherapy. Both of these reports evidence to support the use of tactile participated in routine follOW-Up
indicated that motor performance was stimulation derived from nursery bas- assessment. Infants in the intervention
improved in the short term. ed programmes, it has been suggested group (124 subjects) were nursed on a
to be beneficial when applied in the water mattress, provided with visual
Conclusions post discharge period (Rice 1979). The stimulation and were given twice daily
In summa;y, it seems that preterm Rice Infant Sensorimotor Stimulation developmental activity sessions, each
born infants do derive benefit from treatment is described as consisting of of 20 minutes duration. Parents were
stimulation during the period of their ten minutes of massage in a instructed in the application of the
hospitalization. The form ofstimula- cephalocaudal distribution with five most appropriate activities for their
tion which has been shown most con- minutes of subsequent holding and own children and were required to ad-
sistently to be of benefit is one in cuddling oUhe infant (Rice 1979). For minister the programme with further
which movement is provided, ac- evaluative PUfPOSes,theprogramme assistance provided as appropriate.
tivating either the vestibular or was tested by its author on 30 infants The se$$ions consisted of full body
kinesthetic sensory modalities. When of less than 37 weeks gestation who mass'age, passive movements,

The Australian Journal of Physiotherapy. Vol. 35, No.3, 1989 135


Early Intervention Programmes

prefeeding oral stimulation, playing of trol group ma:y have been responsible neurodevelopmental score determinecl.
tap.e recordings of altUJDan heartbeat for the more advantageous outcomes. by the authors. Those making up the
and classical music and' procedures normalgfoup had a neurodevelopmen.
described as 'bonding interactions'. Physiotherapy Programmes tal scoreoi' less than four and those in
All activites were offered when the in- Support for the findings of Resnick the high risk group scorecl between
fants were in a suitably responsive et af (1987) has come from the results four and twelve. The infants, whether
state. Prior to discharge, activities for of another study based upon similar classed as normal or a.t risk, were then
the early home management of the principles (O'Reilly et aJ 1986). One alternately assigned to either an in-
stimulation progranune were identified hundred and two VLBW infants were tervention or a nonintervention
and taught to the mother in the same 'randomly assigned to one of two ex- subgroup. Apart from the
way as before. perimental groups or to a control preponderance of families of lower
group. the first group received an in- s'ES in the at risk group,the groups
Following discharge each child in dividualised intervention programme
the interventi()n programme received did not differ significantly in other
which was taught to the paa;ents. respects.
bimonthly visits from an early Parents were encouraged to work with
childhoo!i development specialist who Unfortunately, the study was con-
their infants ona daily basis during the founded from the beginning because
pfovide!l information about the use of
period of hospitaIizationand follow- infants With seoresof greater than ten
appropriate items from a sequential up. Support was provided by twice
developmental curriculum described as on the neurodevelopmental test were
consisting of 400 items. These items
monthly contacts with the research all assigned to the high risk interven-
team. The second group received an tion grotip. They were considered to be
were in seven deVelopmental
categories, .personal-social. visual;
eqJlaI amount of interest from the neurologically impaired and therefore
researchers, but it was of a generalised could not be denied the intervention.
auditory, language, memory, percep- nature and no activity programme was
tual motor and, physical. Counselling, Additionally, as the study progressed,
instigated. The control group received any infant not in an intervention group
referral or similar needs of the family routine care. found to have shown deterioration
were met also ~y the home visitor. No Stepwise regression analysis using a subsequently, was reassigned. The
method of controlling for the absence priori selected predictors of outcome authors do not make it clear, but it ap-
of this repeated home based service to demonstrated tbatat nine months of
the nonexperimental familieS was pears that the results of such infants
adjustecl. age ll!l7o of the variability of were not included in the analysis of the
reported. the POI and 31070 of the variability of outcome measures.
An independent routine follow-up the MOl of the BSID(Bayley 1969) Treatment consisted of neuro-
using the PDI ancl. MOl of the BSID could be attributed to group member- developmental therapy (NOT) as
(Bayley 19(9) was carried out on all ship. While more of the variability described by B.Bobath (1967) and K.
subjects wbo returned for assessment could be accounted for by other fac- Bobath (1980) and was administered in
at one and two years of adjusted age. tors (ethnic grouping, 30Ofo of the monthly 45 minute sessions in .a
. At the one ye~ assessment. there were MDt, composite post natal factors hospital outpatient setting by
('7 subjectsl'emaining in the interven- . score; 30% of thePDI), this statistical- therapists certifjed in the use of this
tion group and 66 in the control group. ly significant finding does indicate that form of treatment. Parents were given
At the two year vi~it 27 and 26 subjects if the experimental design includes a a home programme also, consisting of
were assessed inJbe respective groups. control for the effect ofinterest by the a dai,ly formal treatment session and
A significant difference in the in- research team, the intervention pro- the inclusion of desirable movement
cidence of develOpmental delay in the gramme can be cl.emonstrated to have patterns for daily activities. The treat-
two groups was' noted. The control an important influence on the infant's ment showed no significant effect for
grOUp was found !o have a significant- subsequent developmental status. either the normal or at risk groups on
ly greater percentage of infants who Programmes based on neuro- repeated neurodevelopmental assess~
displayed developmental delay (18070 developmental therapy treatment 'ment (at six, nine and twelve months
versus 4Ofo at 12 mOnths and 26Ofover- models of intervention have been less of age) or the Developmental Quotient
sus 4070 at 24 months). A beneficial ef- successful. Goodman et at (1985) or any of tbe subscl:lle scores of the
fect which appeared to increase as the reported the outcome of a monthly Griffiths' Mental Development Scale
children grew older' was reported in physiotherapy. visit, combined with a (GMDS, Griffiths 1954); From the
tlJis study. Tile increased developmen- home programme carried out by results reported it mustpe concluded
tl:ll advantage of the experililental parents. Criteria fot admission to the tbat an/lpptoachto intervention cen-
group OVer the contiol group with in- study included birth weight of less than tred upon regular, hospital based,
creasing age is a JlltenQlIl~oD. which 17PO gtamsaild gestation of less than NJ>T treatment supportedbya parent
has been reported elsew~ere (Ramey et 34 weeks. The .subject population con- administered .daily home treatment
at 1984). It is difficult, however, to sistec1ofBO infants who were ~tted programme; .was not successful in im-
assess the extent to which the addi- to the study at three mQnthSof ad.. proving performance on either a
tional interestsJIown in theexp,edmen- justedage. lnfant$ were classitied !il,S measu~e of neurological development
tat group and not offered to the con- 'normali or'.at risk' on th.e baSis ora ora measuteof general developmental

136 The Australian Journal of Physiotherapy. Vol. 35, No.3, 1989


Early Intervention Programmes

status. This negative finding could be variables recorded on admission to the stimulation of the kinesthetic and/or
related to the age at which the in- study. The analysis of variance statistic vestibular sensory systems provided by
tervention was commenced, to the was employed to assess the role of the movement are of positive benefit to the
treatment model upon which the in- physical therapy programme on the Pleterm born infant, it is possible to
tervention was based or to the depen- prevention or minimization of han- identify other factors which contribute
dent variables selected to measure the dicap. Neither the three-way (Group to the usefulness of such regimes. Suc-
effect of the programme. X Optimality Score X Birth Weight) cess appears to be more likely if the
A similar treatment model adopted nor either of the two-way (Group X programme is parent centred, that is if
by Piper et af (1986) was equally un- Optimality Score, Group X Birth it involves the parents in the ad-
successful in improving performance Weight) interactions were significant ministration of the stimulation, and if
in preterm infants on a number of and none of the main effects yielded the regime is based on a model which is
dependent variables measuring significant results. not treatment related. This last point is
developmental outcome. One hundred Unfortunately, the interpretation of important as physiotherapists working
and thirty-four infants in two risk the results is somewhat difficult. While in NICUs are becoming increasingly
categories (VLBW, or all infants who the report includes the mean values of involved in offering prophylactic treat-
had experienced birth asphyxia, all the dependent variables for the ex- ment intervention for infants con-
seizures or central nervous system perimental and control groups, stan- sidered to be at high risk for later
dysfunction with one abnormal elec- dard deviations are omitted and the movement dysfunction.
troencephalographic recording) were magnitude of the within group
recruited from two NICUs in Mon- variability is therefore unknown. This Research Problems in Interven-
treal. Balanced, block randomization, variably is likely to be quite large since tion Studies
achieved by categorizing the subjects the twelve month neurological assess- Other critical reviews of intervention
according to three birth weight ment indicates that ten of the subjects studies which report the effects of pro-
categories 750 grams, 750 to 1500 (seven in the experimental group and grammes directed towards enhancing
grams and> 1500 grams) and optimal three in the control group) were frank- the developmental status of preterm
neurological status as described by ly abnormal. Also, since some infants born infants have been presented by
Prechtl (1977), were used to assign the in the control group who demonstrated Campbell (1983), Cornell and Gott-
subjects to one of two groups. The developmental delay appear to have fried (1976), Field (1980), Masi (1979),
groups received either a standard received physical therapy on referral to Ross (1984) and Schaefer et af (1980).
follow-up programme consisting of other agencies, it is not entirely correct Criticism of early intervention pro-
routine developmental assessments or to claim that physiotherapy interven- grammes is common and, it would ap-
physiotherapy based upon the NDT tion was confined to the experimental pear, not unjustified. Cornell and Got-
model proposed by the Bobaths group. It can only be said that the tfried (1976) were the first to question
(Bobath B 1967, Bobath K 1980). NDT programme as offered in the the value of the wide range of stimula-
Treatment was commenced as the study was not experienced by the con- tion programmes being advocated for
infants reached term and continued trol group. neonatal intensive care management.
until twelve months of adjusted age. The study is of major significance to In addition to the problems of research
Infants were seen weekly for one hour . the debate over whether NDT as a design and methodology identified by
by a physiotherapist certified in the physiotherapy treatment technique these authors, the lack of knowledge
practice of NDT during the first three contributes to improved developmen- of the course of development in the
months of the programme and once tal performance. However, the failure preterm infant and the conflicting
every two weeks thereafter. Half the of the study to yield a significant Birth views of the needs of the infant and its
treatment session was devoted to in- Weight X Groups Interaction family were considered by Cornell and
tervention by the therapist and the demonstrates only that an intervention Gottfried (1976) to be factors which
other half to parent instruction in the programme which is essentially contributed to the often contradictory
implementation of a programme to be hospital centred and based upon a reports being generated. An evaluation
carried out at home on a daily basis. model designed for the treatment of of nursery intervention programmes
To aid compliance, parents were asked movement dysfunction will be unsuc- for preterm infants in which tactile or
to record the daily use of the pro- cessful in improving developmental kinesthetic stimulation was employed
gramme in a notebook provided for outcome in VLBW infants. It may was undertaken by Ross (1984). Of
the purpose. highlight also the need to examine those identified, few were considered
The success of the programme was more closely the methods employed to by this author to meet the criteria for
measured by several different tests ad- assess developmental status when of- valid research and absence of adequate
ministered at twelve months of ad- fering a programme intended to rationale or consistent parameters for
justed age. Results of 115 infants were enhance sensory motor performance. the implementation of the programmes
available for final analysis. No signifi- described, was a notable feature.
cant difference between the experimen- Conclusions Simeonsson et af (1982) reviewed 27
tal and control group was found on In addition to suggesting that in- research reports of a range of interven-
any of the 25 pre and peri natal tervention programmes which include tion programmes. They divided the ex-

The Australian Journal of Physiotherapy. Vol. 35, No.3, 1989 137


Early Intervention Programmes

amples .cited into Jour groups based on (1979) as being most enhanced by discharge and be equally SUccessful.
the degree of rigour of the intervention. . Whether it must then be continued un-
methodology employed. The studies til the infant is older is also unclear. A
could be classed as retrospective, pro- Summary further question unanswered by the in-
spective with no control group; pro- Very pretei'm, VLBW infants who vestigations reported here relates to the
spective with coIitrolgroup but lacking survive must overcome many medical long term benefits of earlyinterven-
random assignment and prospective and psychosocial problems which have tion. Does the effort expended during
with random assignment to the in- the potential to exert negative in- the first months of extrauterine life
tervention versus no intervention con- fluenceson their subsequent make a difference to the child's
ditions. While the review does not deal developmental status. Efforts to develOpmental stattIs in the pre-school
specifically with intervention program- minimise the adverse effects which ap- and early school years? The number of
mes for the preterm infant, the finding pear to be a consequence of preterm unanswered questions raised in review-
that few met the requirements of basic birth have led health professionals in a ing the value of intervention program-
research design and appropriate number of differing fields to promote mes fot preterminfattts, indicates the
statistical analySes is relevant to the the value of specific intervention pro- need for further and inore rigorous in-
present discussion. grammes. Despite the fact that the vestigation of this area of early infant
In an attempt to understand the con- stimulation presented in such pro- development. However, it is apparent
trary viewpoints being expressed by grammes has been energetically pur- that some forms of intervention are of
studies Which described intervention sued, the value of the programmes value; Physiotherapists should be
for preterm infants, Field (1980) ex- promoted has not been established; guided therefore by these fmdings
amined the type of stimulation It is evident from the intervention when planning programmes for the
presented in each of the programmes programmes described in this review, very preterm, VLBW infant.
reviewed. Sheooncluded that the that the problems of insufficient sub-
variation in results reported coUld be ject: numbers, lack of cOntrols, absenCe References
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