Abstract
Objective. This study aimed to describe the monitoring of treatment fidelity in a pragmatic pediatric rehabilitation trial using the National Institutes of Health Behavior Change Consortium framework, and to identify child and therapist factors that influence treatment fidelity. Methods. Therapists (n = 28) were trained in the key ingredients (1-on-1, functional, goal-directed, motor learning intervention), and study protocol for a comparative effectiveness trial titled: "A Comparison: High Intensity periodic vs Every week therapy in children with cerebral palsy (ACHIEVE)" for children ages 2 to 8 years with cerebral palsy (CP). Therapists were instructed to record every tenth hour of treatment. A subset of recordings were used to monitor treatment fidelity so that each therapist was rated twice using the study-specific ACHIEVE Treatment Fidelity Checklist. Generalized linear mixed effects modeling and logistic regression were used to analyze child and therapist factors related to treatment fidelity. Results. Median treatment fidelity scores were high (>80%). With training, therapist's years of experience and specialty certification do not significantly impact treatment fidelity. There is a trend toward lower treatment fidelity scores for children with communication difficulties, particularly for therapist's use of multi-modal instructions to direct the child in the desired activity. Conclusion. Functional, goal-directed, motor learning intervention can be delivered with high fidelity for children with CP within a busy clinical setting. Motor learning principles may be implemented differently for children with communication difficulties. More research is needed to explore optimal motor learning strategies for these children. Impact. With training, physical therapists can deliver high-fidelity intervention to children with CP across all Gross Motor Function Classification System levels within a busy clinical setting. Therapists may use motor learning principles differently in children with communication delays. Key words: Cerebral Palsy; Motor Control and Motor Learning; Pediatrics; Treatment Fidelity.