Therapy Dosing in Pediatrics

We recently finished another round of our increasingly popular Volunteer Orientation Course. As part of the final assignment members were tasked to write an original piece of work to share with the profession, the contributions were of the highest quality. Below is the great piece of work written by Meaghan Rieke.

Dosing therapy services for children with disabilities presents unique challenges for patients and families, physical therapists, and other health care professionals. However, efforts should be made to adhere to evidence-based recommendations about appropriate dosing for children and their families. Providing services with optimal dosing ensures that physical therapists are providing the greatest value to patients and families while avoiding the potential for burn out among patients and families. Therapists must be willing to modify dosing in order to provide patient-centered care. A one size fits all approach of providing weekly therapy services throughout a child’s lifespan limits a therapist’s ability to tailor therapy services to each child and family.

Dosing of physical therapy services includes the frequency (number of sessions per week and number of weeks), intensity, time (per session), and type of intervention. Dosing schedules can include: intensive (3-11 sessions per week), weekly or bimonthly, periodic (monthly or less often), or consultative (episodic or when needed). When selecting optimal dosing, therapists should consider the child’s ability to participate in therapy and benefit from therapy, whether or not the child is in a critical period for skill progression or regression, the amount of clinical decision making required from a therapist, and the level of support the patient has in working towards functional goals. More intensive dosing of therapy services is appropriate for patients who;

  1. are likely to rapidly progress or regress as a result of therapy services (or lack thereof),
  2. are in a critical period for skill development,
  3. require a therapy program that requires the clinical decision making of a therapist (program cannot be safely performed by a caregiver),
  4. require significant support to achieve functional goals.

Recent research shows that dosing recommendations are impacted by a variety of factors including age, diagnosis, severity level, setting of therapy services, and insurance coverage. A retrospective cross-sectional study of the medical records of 425 individuals with cerebral palsy yielded a multifactorial model that accounted for 19% of the variability in physical therapy dosing.3 The factors included GMFCS level, age, and type of insurance. Individuals classified as GMFCS level III received the highest amount of physical therapy and individuals classified as GMFCS level II, III, or IV received significantly more therapy compared to GMFCS level V. Individuals 5 years or younger received significantly more therapy compared to individuals in the >12-18 years old group. The ability of the multifactorial model to account for only 19% of variability in physical therapy dosing suggests that further research is needed to determine additional factors that should be considered in selecting appropriate therapy dosage such as motivation, readiness to learn, and personal or family characteristics.

A study examining the medical records of 80 children and adolescents with traumatic brain injury that received care in an inpatient rehabilitation facility found a relationship between number of therapy units provided and likelihood of reaching the minimal clinically important difference (MCID) on the Pediatric Evaluation of Disability Inventory (PEDI) between admission and discharge. Children who reached the MCID on the PEDI received a significantly greater intensity of physical therapy services compared to children who did not reach the MCID. The odds ratio showed that children were 2.5 times more likely to achieve the MCID on the PEDI for every additional unit of 15 minutes of therapy per day (95% CI 1.45-4.50).

Physical therapists must consider the lifelong impacts of a child’s diagnosis, the child’s age, the developmental process, and personal factors impacting the child and family when recommending appropriate dosing parameters. Additional research is needed to provide therapists with guidelines and recommendations for optimal dosing parameters based on factors impacting both the child and family. To ensure we are providing the maximum value to our patients, therapy intensity should be modulated to take advantage of critical periods in a child’s development and time periods during which patients and families demonstrate a readiness for change.