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Small Step Program
Evidence reviewed as of before
01-01-2021 Author(s): Ogourtsova, T. (PhD OT); Steven, E. (MSc App OT); Iliopoulos, G. (MSc App OT); & Majnemer, A. (PhD, OT, FCAHS)Share this
intervention:
Small Step
Introduction
The Small Step Program is an early intervention program for infants at risk of developing cerebral palsy (CP) and other neurological disorders. It is an intensive program that uses a variety of elements to provide individualized and goal-directed intervention. There are three distinct foci or areas of development that are targeted: hand use, mobility and communication. Parents are provided training by a skilled therapist to administer the program to their child at home. The Small Step Program can be started as early as 4 months of age.
Accessed on June 29, 2022 from https://www.flintrehab.com/commando-crawling-cerebral-palsy/
The Small Step Program is a goal-centered early intervention program for infants at risk of developing CP and other neurological disorders. It can be used from about 4 months of age. It fosters a close collaboration between the parents and the therapist in order to execute the program and set individualized goals.
The Small Step program has five steps with three focus areas: hand use, mobility, and communication. The hand use and mobility steps are performed twice and communication once. Each step lasts 6 weeks. Therapists train parents to deliver activities at home and provide ongoing coaching during each step.
The Small Step Program has a strong focus on setting goals that are appropriate for a child’s abilities and cognitive level. Goals are set based on what your child will be able to learn as a next step (within each focus). In addition, only activities/toys that interest your child will be chosen to help children initiate actions themselves and practice as much as possible.
The Small Step Program is a home-based, parent led, early intervention program used to stimulate development in 3 different domains: hand use, mobility and communication. It is intended for infants as young as 4 months old that are at high risk of developing neurological disorders like CP.
There is limited research on the effectiveness of the Small Step Program for CP. One known study concluded that the Small Step Program was not more effective than typical infant physiotherapy in improving gross motor function or upper limb use for infants (4-9 months of age) at high risk of CP. However, the study found a bigger improvement in motor development and mobility for the children in the Small Step group who had lower abilities at baseline. In other words, the Small Step was more effective than physiotherapy in helping the most affected children catch up with the rest of the children, in the areas of mobility and motor development, by the end of treatment.
Families should expect initial session(s) with the therapists to set specific goals within each focus area (hand use, mobility, and communication). During goal setting exercises, you will be asked to identify your child’s strengths, self-initiated actions as well as interests (toys, activities) in order to set appropriate and individualized goals for each focus area.
Evaluations for each focus area may be done before and after each “step” (block of 6 weeks) to track progress. Evaluations could take place in a clinic/hospital if special equipment is required.
Parents can expect weekly or bi-weekly coaching and education sessions from the therapists responsible for the specific focus area. These sessions will provide support and training for parents so that treatments at home stay focused on the set goals. Each “step” lasts 6 weeks (a total of 30 weeks).
For each focus (hand use, mobility and communication), a professional with specialization in the area will be assigned to you for coaching purposes. It could be an occupational therapist (for hand use), physiotherapist (for mobility), speech language pathologist (for communication) or any allied professional that has training in these specific areas. However, it is you (the parent) that is responsible for providing the treatment for your child on a daily basis.
The Small Step Program has 5 steps (mobility and hand use performed twice and communication performed once). Each step lasts 6 weeks with weekly or bi-weekly coaching sessions. Parents are expected to provide the treatment for their child on a daily basis, supported by the therapists responsible for the specific focus area. Assessments may need to be completed before and after each step to monitor progress.
The Small Step program is appropriate for infants as young as 4 months old at risk of developing CP as it aims to take advantage of brain plasticity at that age. There is only one recent study examining the Small Step Program’s effectiveness in infants at high risk for CP and other neurological conditions (53% were diagnosed with CP by 2 years of age, GMFCS levels I to V). The study found the Small Step program more effective than typical infant physiotherapy in improving mobility and motor development of the infants with the lowest motor scores at baseline.
More research is required to investigate the effectiveness of this treatment approach for children with or at high risk of CP.
Information on this website is provided for informational purposes only and is not a substitute for professional medical advice.
One high quality RCT (Holmstrom et al., 2019) investigated the effects of a family coaching + home program (focus: mobility, hand use, communication with emphasis on self-initiated actions stimulated by meaningful, motivating, challenging, and playful activities and toys) on gross motor function among infants at high risk for CP (including all types and levels of severity). This high quality RCT randomized infants to receive the Small Step program or typical infant physiotherapy. Gross motor function was assessed using the Gross Motor Function Measure-66 at post-treatment (35 weeks) and follow-up (2 years). No significant between-group differences were found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that the Small Step program (focus: family coaching + home program on mobility, hand use, communication with emphasis on self-initiated actions stimulated by meaningful, motivating, challenging, and playful activities and toys)is not more effective than a comparison intervention (typical infant physiotherapy) in improving gross motor function in infants at high risk for CP.
One high quality RCT (Holmstrom et al., 2019) investigated the effects of a family coaching + home program (focus: mobility, hand use, communication with emphasis on self-initiated actions stimulated by meaningful, motivating, challenging, and playful activities and toys) on mobility among infants at high risk for CP (including all types and levels of severity). This high quality RCT randomized infants to receive the Small Step program or typical infant physiotherapy (TIP). Mobility was assessed using the Pediatric Evaluation of the Disability Inventory (PEDI: Mobility) at follow-up (2 years). A significant between-group difference was found, favoring the Small Step program vs. TIP (note: for infants with low motor development baselines scores).
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that the Small Step program (focus: family coaching + home program on mobility, hand use, communication with emphasis on self-initiated actions stimulated by meaningful, motivating, challenging, and playful activities and toys)is more effective than a comparison intervention (typical infant physiotherapy) in improving mobility in infants at high risk for CP with low motor development baseline scores.
One high quality RCT (Holmstrom et al., 2019) investigated the effects of a family coaching + home program (focus: mobility, hand use, communication with emphasis on self-initiated actions stimulated by meaningful, motivating, challenging, and playful activities and toys) on motor development among infants at high risk for CP (including all types and levels of severity). This high quality RCT randomized infants to receive the Small Step program or typical infant physiotherapy (TIP). Motor development was assessed using the Peabody Developmental Motor Scales at post-treatment (35 weeks) and follow-up (2 years). Significant between-group differences were found at both timepoints, favoring the Small Step program vs. TIP (note: for infants with low motor development baselines scores).
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that the Small Step program (focus: family coaching + home program on mobility, hand use, communication with emphasis on self-initiated actions stimulated by meaningful, motivating, challenging, and playful activities and toys)is more effective than a comparison intervention (typical infant physiotherapy) in improving motor development in infants at high risk for CP and low motor development baseline scores.
One high quality RCT (Holmstrom et al., 2019) investigated the effects of a family coaching + home program (focus: mobility, hand use, communication with emphasis on self-initiated actions stimulated by meaningful, motivating, challenging, and playful activities and toys) on upper extremity use among infants at high risk for CP (including all types and levels of severity). This high quality RCT randomized infants to receive the Small Step program or typical infant physiotherapy. Upper extremity use was assessed using the Hand Assessment for Infants at post-treatment (35 weeks) and follow-up (2 years). No significant between-group differences were found.
Conclusion: There is moderate evidence (Level 1b) from one high quality RCT that the Small Step program (focus: family coaching + home program on mobility, hand use, communication with emphasis on self-initiated actions stimulated by meaningful, motivating, challenging, and playful activities and toys)is not more effective than a comparison intervention (typical infant physiotherapy) in improving upper extremity use in infants at high risk for CP.
References
Holmström, L., Eliasson, A. C., Almeida, R., Furmark, C., Weiland, A. L., Tedroff, K., & Löwing, K. (2019). Efficacy of the Small Step Program in a Randomized Controlled Trial for Infants under 12 Months Old at Risk of Cerebral Palsy (CP) and Other Neurological Disorders. Journal of clinical medicine, 8(7), 1016. https://doi.org/10.3390/jcm8071016
A group of lifelong disorders affecting a person’s movement, coordination, and muscle tone and which are the result of damage to the brain before, during, or shortly after birth.
Gross Motor Functional Classification System. It is a tool used to categorize the gross motor skills of children with cerebral palsy into 5 different levels across 5 age bands. It evaluates the child’s abilities in sitting, walking and wheeled mobility as well as the type of assistive devices needed for mobility. The levels are assigned based on the severity of the limitations, ranging from mild (level I) to severe (level V).
