Optimizing Therapy Intensity and Treatment Sequencing for Children with Spastic Cerebral Palsy: A Randomised Crossover Trial in Zambia.

Faith  Mwelwa Muma; Geoffrey  Moyo; Loveness Anila Nkhata

doi:10.51168/sjhrafrica.v7i3.2457

Authors

Faith Mwelwa Muma University of Zambia, Department of Physiotherapy, School of Health Sciences, Lusaka, Zambia
Geoffrey Moyo University of Zambia, Department of Physiotherapy, School of Health Sciences, Lusaka, Zambia
Loveness Anila Nkhata University of Zambia, Department of Physiotherapy, School of Health Sciences, Lusaka, Zambia

DOI:

https://doi.org/10.51168/sjhrafrica.v7i3.2457

Keywords:

cerebral palsy, physiotherapy, therapy intensity, treatment sequencing, neurorehabilitation, spasticity, low-resource settings, motor function, dose-response

Abstract

Background:

Spastic cerebral palsy (SCP) is the most prevalent cerebral palsy subtype, causing significant long-term motor disability. Optimal therapy intensity and treatment sequencing remain poorly understood, particularly in African low-resource settings.

Objectives:

This study aimed to: (1) compare treatment effects of Standard versus Higher-Intensity physiotherapy protocols on spasticity, motor function, and goal attainment in children with SCP; and (2) examine whether treatment sequencing (Higher-Intensity-first versus Standard-first) influences cumulative treatment effectiveness.

Method:

A randomised, assessor-blinded AB/BA crossover trial enrolled 30 children aged 3 months to 4 years with SCP at a tertiary hospital in Zambia. Participants received a Standard Protocol (2 sessions/week × 40 minutes) and Higher-Intensity Protocol (3 sessions/week × 60 minutes), each for 12 weeks with a 2-week washout. Sequence allocation was randomised. Outcomes included spasticity (Modified Ashworth Scale), gross motor function (GMFM-88), and goal attainment (Goal Attainment Scaling).

Results:

The Higher-Intensity Protocol produced significantly superior outcomes across all measures: greater spasticity reduction (mean difference 1.0–1.1 points, p<0.001), GMFM improvement (+24.8±5.2% vs +12.1±4.1%, p<0.001), and goal attainment (median +1.5 vs +0.5, p<0.001). Treatment sequencing significantly influenced cumulative outcomes, with Higher-Intensity-first children showing 13–15% greater overall improvement (p<0.015). No significant carryover effects were detected (p=0.67).

Conclusion:

Higher-intensity physiotherapy produces clinically and statistically superior outcomes in children with SCP. An initial 'burst' therapy approach followed by maintenance protocols represents an evidence-based strategy for resource-constrained settings.

Recommendations:

Clinicians should prioritise higher-intensity physiotherapy in early treatment phases, supplemented by structured caregiver-assisted home routines. Policymakers should consider 'burst' therapy models to optimise outcomes within limited healthcare resources.

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