The effect of an in-patient physiotherapy programme in the neonatal intensive care unit on long-term developmental outcomes of pre-term infants

Abstract

Background: Infants who are born prematurely have enormous odds to overcome. These challenges range from immediately life-saving to long-term developmental outcomes. Pre-term infants are at risk for delay in all developmental areas due to the timing of the maturation of the various bodily systems and their birth. The delay has been shown to have a direct link with the gestational age of the infant, with an earlier gestational age demonstrating a greater risk for developmental delay. This delay ranges from mild learning disabilities to severe and life-long disabilities. There are various early physiotherapy intervention programmes, but they are costly to implement and not easily available in all countries. Additionally, it is not known which components of these programmes are most effective in improving developmental outcomes. Aim of the Study: The aim of this study was to develop and assess the effect of a NICU developmental programme on the developmental outcome of pre-term infants at six, 12 and 18 months. Methodology: The programme development consisted of an expert group panel discussion where the proposed programme was discussed and amended accordingly. This early intervention developmental programme consisted of passive movements and joint compressions, massage and nesting with specific positioning done. These various components were discussed with an expert panel on neonates. The programme was implemented for pre-term infants in one NICU. These infants were the experimental group. A neighbouring hospital NICU was used as the control group. Seventy infants were recruited in each group. These infants were then assessed by a blinded assessor at six, 12 and 18 months corrected age using the Bayley Scales of Infant and Toddler Development III (BSID III) to determine their developmental status. Caregivers signed informed consent for their infants to participate. Ethical clearance for the study was obtained from the University of the Witwatersrand. Data was analysed using Chi-square tests, means, frequencies and ratios and a linear regression analysis was done. Results: The groups were well matched for gestational age. The mean gestational age was 32.80 weeks in the experimental group and 32.50 weeks in the control group (p=0.53). The results of this study showed that the experimental group had an improved developmental status when compared to the control group. This was the result in all developmental areas that the BSID III tests namely, gross and fine motor (p<0.0001 at all testing ages), expressive and receptive communication (p<0.0001 at 12 and 18 months) and cognitive (p<0.001 at six months) developmental areas. At six months the cognitive scaled scores for the experimental group were 9.70 ± 0.95 and 8.50 ± 0.96 for the control group. The six months expressive language scaled scores were 9.80 ± 1.24 for the experimental group and 10.80 ± 1.24 for the control group. The receptive language scaled scores for the experimental group were 10.80 ± 1.24 and the control group 9.90 ± 1.59. The fine motor six month scaled scores for the experimental group were 10.73 ± 1.80 and 10.10 ±1.93 for the control group. The gross motor six months scaled scores for the experimental group were 8.55 ± 1.76 and 7.80 ± 2.20 for the control. At 12 months the cognitive scaled scores for the experimental group were 9.90 ± 0.88 and 9.50 ± 1.19 for the control group. The 12 months expressive language scaled scores were 10.20 ± 1.37 for the experimental group and 9.40 ± 0.89 for the control group. The 12 months scaled receptive language scores for the experimental group were 14.20 ± 1.3 and the control 13.80 ± 0.93. The fine motor, 12 month scaled scores for the experimental group were 10.28 ± 0.98 and 9.00 ± 1.26 for the control group. The gross motor 12 months scaled scores for the experimental group were 10.60 ± 1.37 and 8.50 ± 1.86 for the control. At 18 months the cognitive scaled scores for the experimental group were 10.20 ± 0.99 and 9.30 ± 1.83 for the control group. The 18 months expressive language composite scores were 98.69 ± 5.14 for the experimental group and 95.20 ± 5.10 for the control group. The 18 months receptive language scores for the experimental group were 10.30 ± 0.88 and the control group were 9.50 ± 1.23. The fine motor 18 month composite scores for the experimental group were 10.44 ± 1.18 and 9.00 ± 0.97 for the control group. The linear regression analysis showed that in all three developmental areas the intervention was predictive of the developmental outcome. Factors that were found to be predictive of poorer developmental outcome, at 18 months of age in the control group for motor development, were that of NEC (t=0.01) and gestation (t=0.02). In the language section, the regression showed surfactant (t=0.04) to be the significant factor. In the cognitive section surfactant (t=0.01) and gestational age (t=0.04) to be the factors predictive of poorer developmental outcome. Discussion and Conclusion: This study shows that a developmental intervention consisting of passive movements, joint compression, massage and nesting provided while the infant is in NICU is an effective programme to decrease the risk of developmental delay in this vulnerable population. The results of this study are important as the programme can be implemented into various hospitals with NICUs to aid in the improvement of the morbidity of this population group and the results show that physiotherapy can reduce the burden of disease in this population group by allowing for stimulation during the important brain plasticity phase and decreasing the risk of possible developmental delay. This can be easily implemented into any NICU that has a physiotherapist.