Tuesday, 6 November 2012

WHAT'S INTENSIVE TRAINING WHEN IT'S AT HOME?

Home, I think, is Sweden
 
I first heard of Intensive Training as an apparent treatment approach when I used to have close contact with the development of conductive services in Norway. The expression 'Intensive Training' was coming up in conversation in ways that suggested that this was not simply a casual use of language but a 'something', a particular means of intervention. Intrigued, I enquired further and, in so far as I recall, was told that Intensive Training was a system being worked out by therapists in neighbouring Sweden in specific response to Conductive Education, adopting particularly what the Swedish therapists regarded as one of CE's cardinal features, that it is 'intensive'.
 
Intensive?
 
This is not of course the only context in which one may come across the word 'intensive 'to describe Conductive Education. One often see it on the websites of CE centres and centers to describe what they do – sometimes even stated this as 'intensive therapy'.
 
This casual and unthinking use of the word is long-standing but is not what concerns me here. It used, by the way, really to irritate the late Mária Hári, who would remark tetchily –

People say that Conductive Education is 'intensive' for the children. That is wrong. Conductive Education should not be not intensive for the children, only for the conductors.

(Note that at that time the word 'intensive' was being levelled at as a criticism.)

Training?

The word träning (rendered into English as 'training') is frequently used in Norwegian and Swedish, and I think in Danish too, to refer both to Conductive Education and to therapy. I have never been able to discover whether it bears the same rather negative connotations in those languages as it can in English.
(I do not think, however, that native English-speakers would ever call CE 'training'.)
'Intensive training' seems to have all become a bit of a muddle. In some of the Swedish press reports that one was seeing a couple of weeks ago, the term intensiv trening was used at times to refer particularly to an indigenous way of delivering therapy ('intensively'), at other times as a generic term to cover CE, and at times for both together. Pity the poor politicians.

What is Intensive Training?
There seems a considerable body of information now on line about intensiv träning. Here is a recent power-point presentation that looks that it might offer a well-grounded overview. On the other hand, those in a position to be much closer to the topic might regard it as less satisfactory. This is how it begins

Introduction
  1. What is Intensive Therapy?
  • 45-60 hours of therapy over 3-4 weeks (typically 3-4 hours each day)
  • Some clinics use a 2-week method to improve tolerance
  • 2-4 sessions each year are recommended
  • It uses strength-training combined with repetitive movements to improve functional mobility
  • The sessions are broken up into 2 phases: preparatory and secondary
  • All participant are given a home exercise program to maintain the results
  • It can include occupational therapy and speech therapy as well
What it isn't
  • More hours of standard PT and OT
  • Many types of therapy jammed into one session
See the rest of this presentation at:

http://www.slideshare.net/sdeaton1/intensive-power-point

Is this what was intended to replace a conductive service in Stockholm county. Such specific detail was not a matter for public debate, on either side of the disputed contract.
 
Head to head
 
Whatever the origin of Intensive Training, and the range and nature of what is currently covered by this term in Scandinavia, in October it came publicly head to head with CE. The dispute surfaced and was played out publicly at the level of service-contracts and politics. The 'researchers', however,  have been there for some time. I have known of two published English-language studies, there may be more.
 
Evidence-base buffs might enjoy these two studies, both in English:
 
Stiller, C, Marcoux B, Olson R. (2003) The effect of conductive education, intensive therapy, and special education services on motor skills in children with cerebral palsy. Physical and Occupational Therapy in Pediatrics, vol. 23, no 3, pp. 31-50.
 
PURPOSE: The purpose of this study was to compare the effects of intensive therapy, conductive education, and special education on function in 19 children with cerebral palsy.
 
METHODS: Subjects participated in a five-week program of conductive education, intensive therapy, or special education. Professionals, blinded to group assignment, administered the Pediatric Evaluation of Disability Inventory (PEDI), the Gross Motor Function Measure (GMFM), and the Fine Motor Scale of the Peabody Developmental Motor Scales before and after intervention. Professionals providing treatment and parents completed a survey about their perceptions of change in the children.
 
RESULTS: ANOVA showed no statistically significant differences between groups before or after treatment. Using t-tests, statistically significant within group changes were found only for the intensive therapy group on the PEDI Self-care and Social Function scales and the Crawling and Kneeling scale of the GMFM. Individual changes from pre- to post-test were also examined and are discussed. Surveys revealed that both parents and professionals perceived improvement in all children.
 
CONCLUSIONS: Greatest improvements were noted in the group receiving intensive therapy, with children in all groups showing some improvement in function.
P. E. Ödman, P. E., Öberg, B. E. (2006) Effectiveness and expectations of intensive training: A comparison between child and youth rehabilitation and conductive education, Disability and Rehabilitation, vol. 28, no 9 . pp 561-570
 
Objective. To compare the effectiveness of two intensive training-programmes from a professional and parent perspective. To describe and compare the type of expectations of the two intensive training programmes with the self-reported individualized goals.
 
Design. Quasi-experimental with two groups.

Setting and intervention. Traditional health care and conductive education.

Patients and their parents. Fifty-four children with cerebral palsy, 3–16 years old.

Methods. Data included a self-reported individualized goal measure (SRIGM), before and after the ITP. Individualized goals were classified according to the International Classification of Functioning (ICF). Clinical measures (CM) included repeated measures with Gross Motor Function Measure (GMFM) and Pediatric Evaluation of Disability Inventory—Functional Skills (PEDI-FS).

Results. Twenty-eight parents out of 54 perceived a clinically significant improvement on the SRIGM with no significant difference between the training programmes. Most individualized goals were formulated in the domain of Mobility (115 out of 248) and Neuromusculoskeletal and movement-related functions (64 out of 248 goals) of ICF in both training programmes. There was no difference in the proportion of improvement measured with SRIGM compared to the CM, if an improvement in any dimension in GMFM or domain in PEDI FS was counted.

Conclusion. There were no major differences in outcome and expectations between the training programmes. Parents' expectations were mainly directed towards improvement in prerequisites of motor function and mobility skills. The SRIGM confirmed the outcome on the CM.

http://informahealthcare.com/doi/abs/10.1080/00222930500218821
 
Research and politics
 
Together, as stated, these two studies indicate that comparative outcome evaluation has found no resounding advantage in favour of the outcome of Conductive Education over Intensive Therapy, or vice versa, when both are delivered within the habilitering model and given the specific situations reported, at least using the particular outcome measures reported here.
 
Is it surprising that such comparative outcome evaluation ('research') did not receive some sort of prominence during the recent tussle between CE and intensiv trening? Or is it not ?
 
Just in case, though, perhaps Swedish CE-people should be examining the two comparative studies cited here, along with any more that I have missed, and taking good academic advice about possible arguments. Then I guess that they already have. If this Swedish business comes back into prominence, it could prove instructive for us all.

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1 Comments:

Anonymous Andrew said...

I just noticed this:

'Move & Walk offers intensive training...'

http://www.movewalk.se/Engelska/AboutMoveWalk.aspx

As I said, pity the politicians, never mind Jo Public.

Thursday, 8 November 2012 at 17:31:00 GMT  

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