Bobath Therapy for Children With Cerebral Palsyv2b

National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

A rapid review of the evidence for the effectiveness of Bobath

therapy for children and adolescents with cerebral palsy

Author: Dr M Webb, Public Health Practitioner

Date: 14/05/08 Version: Version 2b

Status: Approved

Intended Audience: Local Health Boards

Purpose and Summary of Document:Review of the evidence on the effectiveness of NDT/Bobath therapy and alternative treatments for children and adolescents with cerebral palsy to inform LHB commissioning decisions for this treatment. There was a lack of good quality evidence to support the use of NDT/Bobath therapy in children and adolescents with cerebral palsy. Of the available alternative treatments, evidence of effectiveness was only available for exercise programmes focussing on lower extremity muscle strength and /or cardiovascular fitness.

Publication/Distribution: Local Health Board Public Health, Medical and Nurse Directors


Date: 14/05/08 Status: Approved

Version: 2b Page: 1 of 29 Intended Audience: Local Health Boards


CONTENTS

PageExecutive summary 31. Background 42. Aims 43. Research questions 44. Methods 4

4.1 Identifying existing and ongoing research 54.1i Literature searching 5

5. Results 6 5.1 NDT/Bobath therapy 6 5.2 Alternative treatments 8 5. 2i Exercise programmes 8 5.2ii Botulinum toxin 8 5.2iii Acupuncture 9 5.2iv Drug therapy 9 5.2v Surgery 9 5.2vi Speech and language therapy 96 Conclusions 107 References 11Appendix 1 Main search strategy 13Appendix 2 High level search strategy 14Appendix 3 Evidence levels and quality grading 15Appendix 4 Evidence table 16

© 2008 National Public Health Service for WalesMaterial contained in this document may be reproduced without prior

permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to the National Public Health Service for Wales to

be stated.





Executive summary

In the United Kingdom neurodevelopmental therapy (NDT) based on Bobath principles is currently used in many settings with the intent of improving the motor and functional deficits of children and adolescents with cerebral palsy (CP).

Bobath Cymru in Cardiff provides a service to Welsh residents with cerebral palsy and from May 2007 requested an increase in funding from the local health boards. There is a perception that the service is operating without a strong evidence base compared with other conventional therapies for children with CP offered within the National Health Service, although there are acknowledged difficulties in separating out ‘standard’ and Bobath treatments outside purist settings. The aim of the present document is to report the results of a rapid review of the evidence on the clinical and cost effectiveness of NDT/Bobath therapy for children and adolescents with CP.

The major health care databases were searched and high level searching using meta-search engines, other databases and the websites of relevant agencies was also performed to maximise identification of literature.

The searches resulted in 350 documents for NDT/Bobath and cerebral palsy. The abstracts and titles were screened for relevance and 23 articles contributed to this review. Several timely, high quality systematic reviews were identified in the scoping search and these were extensively used to inform the document.

There was good quality evidence (Levels 1 and 2) that did not provide support for the effectiveness of NDT/Bobath therapy for children and adolescents with CP.

It has been suggested that the randomised controlled trial is not an appropriate method to determine the effectiveness of NDT/Bobath therapy because of the problems of heterogeneity of the study population and the techniques used.

Published data on cost effectiveness of NDT/Bobath was not found.

Where alternative treatments are concerned, there was inconsistent evidence for the effectiveness of botulinum toxin A and speech and language therapy and further research is required. Evidence was lacking for acupuncture, rhizotomy and drug treatments and the planned Cochrane reviews on these treatments should provide further data.





1. BackgroundIn the United Kingdom physiotherapists who treat children and adolescents with cerebral palsy (CP) generally use a form of therapy known as neurodevelopmental therapy/treatment (NDT), based on the work of the Bobaths. 1, 2 Bobath therapy aims to influence muscle tone and improve postural alignment by specific handling techniques and attempts to facilitate improved active participation and practice of relevant skills.3 The terms Bobath therapy and NDT are frequently used interchangeably and most practising physiotherapists will adopt some Bobath handling techniques whether working within or outside Bobath settings.

The voluntary sector service to Welsh residents with cerebral palsy is provided by Bobath Cymru, based in Cardiff. Bobath has recently requested increased funding from the local health boards (LHBs) and there are commissioning concerns about this service.4 One of these concerns is the recognition that there is not a strong evidence base for effectiveness and cost effectiveness of Bobath therapy compared with conventional treatment within the National Health Service (NHS). The National Public Health Service (NPHS) was therefore asked to investigate the evidence base for the effectiveness of Bobath therapy and alternative treatments for children and adolescents with cerebral palsy.

2. Aims

The purpose of the present document is to perform a rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy. The evidence for alternative treatments for CP was also evaluated. The paper did not seek to separately quantify or compare Bobath therapy as a wider holistic social intervention.

3. Research question

What is the evidence that Bobath therapy improves motor and functional outcomes for children and adolescents with cerebral palsy?

4. Methods

The research question in Section 3 was converted to a structured question for searching using the Population, Intervention, Comparison and Outcome (PICO)5 format.





Patient: children and adolescents aged 0 -20i years with a diagnosis of cerebral palsyIntervention: use of Bobath/NDT as a primary interventionComparison: alternative treatments – e.g. conventional physiotherapy/exercise training; botulinum toxin; acupuncture; surgery.Outcome: improved motor function, improved abilities in functional skills, decrease in contractures and/or deformities

4.1 Identifying existing and ongoing research

4.1i Literature searching

Systematic searching: As per the protocol contained in The evidence checklist 6 a scoping search was initially performed to identify major papers on published evidence and refine the final search strategy. For the present overview, search terms contained in the search strategies were used from published reviews and they were kept broad to maximise retrieval of references. The basic search strategy is shown in Appendix 1. The type of literature on NDT/Bobath therapy necessitated the use of a pragmatic approach to searching for evidence in order to achieve production of the review within the short timescales for delivery. It is clear that there had to be a balance between timeliness and rigour and high quality evidence and systematic reviews, meta-analyses, health technology assessments and clinical guidelines were identified first. It should be emphasised that the review is not a systematic review of primary studies.

High level searching: It is well known that the classical databases for medical literature, such as Medline, do not adequately index all relevant literature. The reviewer used validated methods that involved the use of meta-search engines and other databases for ‘high level’ searching to quickly identify relevant evidence. (Appendix 2)

For critical appraisal, the tables recommended for use in the National Institute for Health and Clinical Excellence guideline development methods manual 7

were modified to accept the type of studies identified for cerebral palsy and Bobath therapy. The quality of the evidence was graded using the NICE hierarchy of evidence and the quality checklists. Evidence was rejected if graded as poor quality, apart from where it was of Level 1 type (see Appendix 3 for explanation of evidence grading system) and was highly relevant to the questions. The data relevant to the research question was entered into an evidence table. (Appendix 4) Due to practical limitations a single reviewer performed the final selection, critical appraisal and data extraction.

i Published papers on ‘children’ with CP contained a mix of age ranges and therefore the age range chosen was broad.Author: Dr M Webb, Public Health Practitioner




Inclusion criteria

Search period January 1995 – May 2008Papers in English, German, French or Spanish Interventions relating to Bobath therapy in the treatment of children and adolescents (age range 0-20 years) with cerebral palsy. Randomised controlled trialsSystematic reviewsMeta-analysesGuidelinesObservational studies (where higher quality evidence was not available)

5. Results

The scoping search revealed several key evidence documents and these high quality secondary sources were used to inform this paper. The searches revealed 350 documents for NDT/Bobath therapy and cerebral palsy. A total of 40 citations was downloaded into Reference Manager Software and critically appraised; 23 articles were selected to inform this review.

5.1 NDT/Bobath therapy

The evidence for the effectiveness of NDT/Bobath therapy was scoped by the NPHS in 2007 and there was a lack of good quality evidence to support the effectiveness of such therapy in either stroke or cerebral palsy. 8

A good quality (Level 2++) systematic review of studies where NDT was stated to be the primary intervention was performed by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) in 2001 to inform an AACPDM evidence report. 9 The outcomes considered were motor responses, contractures and deformity, motor development, quantity of therapy, functional limitation/activity, and other domains of child development (cognitive, language, social, emotional etc The authors conclude that although there are still concerns regarding how to effectively measure the effectiveness of NDT in academic studies, it is time to investigate new approaches in therapy that are more effective than NDT in promoting motor and functional improvements in children with CP. A subsequent systematic review (Level 2 ++) with some methodological problems concludes that the evidence for the effectiveness of NDT in children with CP was inconclusive and inconsistent. 10

A systematic review (Level 1+) of the effects of early intervention on motor development in children with CP or Downs syndrome was published in 2005 11

that included studies of NDT. Eight studies evaluated the effects of NDT or physiotherapy, mainly on the basis of the principles of NDT. Only one study reported a better motor outcome in the experimental group than in the control Author: Dr M Webb, Public Health Practitioner




group. 12 The ‘positive effect’ of this study differed from the other studies in being the only one that compared intensive NDT treatment with less intensive NDT. The other seven studies compared NDT with infant stimulation or with a form of standard care that was not defined further. In six of the seven studies, motor outcome in the NDT group was similar to that of the control group. In the seventh study, motor development was worse in children treated in accordance with the principles of NDT than in children who received an infant stimulation programme. The authors conclude that the studies indicate that NDT during the first years of life does not have a measurable positive effect on motor development.

A 2007 health technology assessment {HTA}, (Level 1++) describing the results of an RCT of additional therapy for children and adolescents with CP also summarises the existing literature on NDT/ Bobath1 and found that the published studies fell into three categories:-

a) comparison of NDT with other therapeutic approaches.

The authors of the HTA conclude that there was a lack of evidence to support the efficacy of any particular physical therapy and that it was difficult to establish the advantages of one particular therapeutic method over another.

b) evaluation of the effectiveness of NDT

Conclusions from the included studies are that there was a lack of valid and objective outcome measures and power calculations. One well designed (Level 1+), but small RCT 13demonstrated that the group that received a programme of infant stimulation followed by NDT progressed more quickly (measured using the Griffiths Development Test) than the group who received NDT alone. There were no significant differences between the groups in the incidence of contractures, or the need for orthopaedic interventions. The result emphasises the importance of measuring outcomes other than locomotion and the inputs from local services.

c) investigation of the nature and intensity of NDT

In spite of the lack of evidence for the effectiveness of NDT/Bobath, many parents and professionals believe that the therapy works for children with CP and that the more sessions the child receives the more effective is the treatment. The HTA again found that the published studies had methodological problems, particularly with sample size and power, lack of controls, sample heterogeneity, confounding and length of follow up. One RCT (Level 1- ) found no benefit of intensive NDT 14 and another RCT (Level 1 - ) found that there was a non significant trend for benefit for the intensive group when additional covariates of age and severity were introduced, not in the primary analysis and the effect was short lived. 15 Another RCT ( Level 1-) reported that the change scores for children in the intensive NDT group were Author: Dr M Webb, Public Health Practitioner




higher than those of the standard group. 16 The statistical methods however, used to analyse the results of this latter trial were not appropriate. The multi-centre RCT 1 ( Level 1++) to evaluate the effect of increasing the frequency of NDT with blinded assessments and a cost effectiveness analysis reported in 2007 demonstrates that there was no evidence that additional physical therapy helped the motor or general development of children with CP. The authors stress that research is required into what is the optimum level of provision, since they suggest that there is a sufficiency of therapy that will be helpful and above that there is no effect. They also raise the possibility that the RCT may not be an appropriate study design when an intervention is focussed on a heterogeneous population such as children with CP.

No studies were found assessing cost effectiveness of NDT/Bobath or physiotherapy. The costs of general services for each child ranged from £250 to £6750 with higher costs associated with more severely impaired children. 1

An RCT comparing a task/content focussed treatment approach with a child focussed treatment approach for children with CP is currently being performed in North America. The rationale behind the design of this trial is the questioning of some therapists of the emphasis on obtaining ‘normality’ with the NDT approach and whether this explores all options for functional success. It may be more important to be able to perform the functional task rather than to attain normal patterns of movement. The trial is due for completion in August 2008. 17

5.2 Alternative treatments

5.2i Exercise programmes

The results of a small RCT (Level 1 - ) of an exercise training program demonstrated an improvement in physical fitness, participation level, and quality of life in children with cerebral palsy when added to standard care. 18

A good quality systematic review (Level 1 +) of all types of exercise programmes for children and adolescents with CP was published in 2008. 19

Only five RCTs investigating the efficacy of exercise training in children with CP could be included and these trials had some methodological problems. However from an evaluation of the available data it appears that children and adolescents with CP may benefit from exercise programmes that focus on lower extremity muscle strength and/or cardiovascular fitness.

5.2ii Botulinum toxin

Botulinum toxin A (BtA) injections are being used more frequently to treat upper and lower extremity spasticity and hypertonia in children with CP. Two Cochrane reviews (Level 1+) did not find sufficient evidence to support or refute the use of intramuscular injections of BtA as an adjunct to managing the upper or lower limbs in children with spastic cerebral palsy.20 21 Further Author: Dr M Webb, Public Health Practitioner




research incorporating larger sample sizes, rigorous methodology, measurement of upper limb function and functional outcomes is essential.

5.2iii Acupuncture

Acupuncture has been used to treat children and adolescents with CP for more than 20 years. Benefits claimed for acupuncture have included warmer extremities, a decrease in painful spasms, improvement in the use of arms or legs, more restful sleep, improvement in mood and better bowel function. A Cochrane protocol aims to review all RCTs of acupuncture for children with CP. 22

5.2iv Drug therapy

Three drugs diazepam, dantrolene and baclofen have been commonly used to alleviate spasticity in cerebral palsy; and debate remains about their usefulness and there is a Cochrane protocol to assess the absolute, and comparative, efficacy of baclofen, dantrolene and diazepam for spasticity in cerebral palsy.23 Intrathecal baclofen, a much more invasive treatment has been recently introduced and a separate Cochrane protocol will review the evidence for the effectiveness of intrathecal baclofen. 24

5.2v Surgery

A surgical method to reduce spasticity by selective posterior nerve root division was first described in 1913 and reintroduced in the 1970s. Numerous studies with confounding, selection bias, lack of controls and use of variable surgical techniques, and application of subjective outcome measures have reported good results leading to the widespread use of this technique.25 The absence of good evidence to support its efficacy and the lack of information about safety and long term consequences has led to some controversy and the role of this technique, which is expensive and very demanding of the child, family, surgeon and therapist, needs to be justified. 26 There is a Cochrane protocol designed to determine the effectiveness of selective dorsal rhizotomy in the management of children with spastic cerebral palsy. Error: Referencesource not found 5.2vi Speech and language therapy

Firm evidence of the positive effects of speech and language (SLT) for children with cerebral palsy was not demonstrated in a Cochrane review. However, positive trends in communication change were shown. 27 The authors conclude that research is needed to investigate the effectiveness of new and established interventions and their acceptability to families.





6. Conclusions

Despite the widespread use of NDT/Bobath in children and adolescents with CP the existing published evidence, some of which is good quality Level 1, does not provide support for the effectiveness of the NDT/Bobath treatment approach.

Little information was found on service input and costs for children and adolescents with CP who receive NDT/Bobath therapy.

It has been suggested that the RCT may not be an appropriate method to evaluate the effectiveness of NDT/Bobath due to the heterogeneity of children with CP and the use of different treatment strategies. However, one high quality RCT that used additional methodologies to study the effectiveness of intense levels of therapy failed to demonstrate an effect on outcomes.

There was limited evidence for the effectiveness of alternative treatments (exercise programmes; botulinum toxin, medication, acupuncture, surgery, speech and language therapy) used to treat children and adolescents with CP.

There is research in progress that will add to the evidence base for NDT/Bobath and other treatments used for children and adolescents with CP.

The present review has methodological limitations in that, whilst every effort was made to maximise retrieval of relevant references, it is not a systematic review of primary studies and was performed by a single reviewer.

Lack of evidence for effectiveness of Bobath Therapy for cerebral palsy as a healthcare intervention does not preclude consideration of Bobath Therapy as a form of social care.





7. References





Appendix 1 Main search strategy Search terms included subject headings and text words based on: cerebral palsy; neurodevelopmental training; NDT; Bobath therapy; occupational therapy; exercise ( in combination with strength, fitness, working capacity, aerobic power, anaerobic power, endurance, cardiorespiratory physical training or programme); motor intervention; early intervention; surgery; complementary therapy; alternative therapy.

The search terms meta.ab; synthesis.ab; literature.ab; randomized.hw; published.ab; meta-analysis pt; trials.hw; controlled.hw; medline.ab; selection.ab; sources.ab; trials.ab; review.ab; review.pt; articles.ab; reviewed.ab were used to retrieve RCTs, metanalyses and systematic reviews from Medline.





Appendix 2 High level search strategy

Agency for Healthcare Research and Quality Chronic Care (AHRQ)Audit CommissionAgency for Quality in Medicine (AZQ)Canadian Coordinating Office for Health Technology Assessment (CCOHTA)Centre for Health Services Research - Population and Health Sciences - University of NewcastleCentre for Reviews & DisseminationClinical EvidenceDepartment of Health Effective Practice & Organisation of Care Group Guidelines International NetworkGoogleGoogle scholarHealth Evidence Bulletin WalesHealth Management Information ConsortiumHealth Technology Assessment ProgrammeKings FundNational Assembly for WalesNational Library for Health ( NLH) – Children’s Health Specialist Library National Guideline ClearinghouseNational Institute for Health and Clinical ExcellenceNational Public Health Service for WalesNHS Centre for Reviews and DisseminationNHS Modernisation AgencyPEDroScottish Intercollegiate Guidelines Network (SIGN)Social Science I CentreSUMSearchTurning Research Into Practice (TRIP) DatabaseUpToDate





Appendix 3 Evidence levels and quality gradingmodified from NICE Guideline Methodology Manual) ref 7

Level of Evidence Type of evidence1++ High-quality meta-analyses,

systematic reviews of RCTs, orRCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of RCTs,or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High-quality systematic reviews of case–control or cohort studies. High-quality case–control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal

2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal

2- Case–control or cohort studies with a high risk of confounding bias, or chance and a significant risk that the relationship is not causal

3 Non-analytic studies (for example, case reports, case series)

4 Expert opinion, formal consensus

Quality grading

++ = good quality+ = fair+/- = fair to poor- = poor





Appendix 4 Evidence tableStudy Population/

settingIntervention/

aimOutcomes Results Comments

italics= reviewers comments

Design Evidence level/

quality

Ade-Hall RA, Moore AP. Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy. Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD001408. DOI: 10.1002/14651858.CD001408.

Children between the ages of 0 and 19 years old with CP who had been treated for lower limb spasticity.

Systematic review of RCTs to determine effectiveness of BtA.

Motorfunction measures including disability rating & gait analysis.Sub-measuresincluded spasticity, range of movement, quality of life, parental opinion and cost effectiveness.

Three eligible studies were found each with small numbers of subjects. One study of twelve ambulant children, compared BtA with injection of a placebo and found non-significant improvementsin gait in the BtA group compared to the placebo group. Two studies compared BtA with the use of casts and there were no significant differences between thegroups in either trial

Poor quality trials with potential for confounding and heterogeneity

Systematic review

1-

+





Study Population/setting

Intervention/aim

Outcomes Results Commentsitalics=

reviewers comments


quality

Blauw-Hospers CH; Hadders-Algra M. A systematic review of the effects of early intervention on motor development. Dev Med Child Neurol 2005; 47:421-32.

Children from 0 to 18 months with Downs syndrome or CP

Systematic review of all types of study to determine the effects of physiotherapy

Motor development assessment tools

34 studies fulfilled the selection criteria. The results showed that NDT does not have a beneficial effect on motor development

Systematic review

2++

+

Bower E; Mitchell D; Burnett M et al. Randomized controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 months. Dev Med Child Neurol 2001; 43: 4–15.

Children with CP aged 3 – 12 years.

A 2 x 2 RCT tocompare the effects of routine amounts of physiotherapy with intensive amounts,

Motor function and performance

56 children with CP; 1 child died. There was no statistically significant difference in scores between intensive and routine amounts of physiotherapy. Adding covariates of age and severity levels produced a trend towards intensive therapy.

Questionable statistical methods.

RCT 1-

+

Brown GA; Burns SA. The efficacy of

Children with neurological

Systematic review of trial

Motor function and general

There were a similar number of

Not restricted to children

Systematic review

2++






Intervention/aim


reviewers comments


quality

neurodevelopmental treatments in children: a systematic review. British Journal of

dysfunction data on the effectiveness of NDT

development. published research studies supporting the benefit of NDT intervention (n=6) compared with no

with CP.+

1 Weindling AM; Cunningham CC; Glenn SM et al. Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial. Health Technol Assess 2007; 11(16). Available at: http://www.ncchta.org/fullmono/mon1116.pdf. [Accessed 1st May 2008]2 Bobath K; Bobath B. The neurodevelopmental treatment In: Scrotton D, ed. Management of the motor disorders of children with cerebral palsy. Oxford: Blackwell Scientific Publications Ltd; 1984. cited in 3 3 Knox V; Lloyd Evans A. Evaluation of the functional effects of a course of Bobath therapy in children with cerebral palsy: a preliminary study. Dev Med Child Neurol 2002; 44: 447- 60.4 Regional Commissioning Support Unit (SE). Scoping brief: Bobath therapy. NPHS 2008; unpublished5 Sackett DL; Richardson WS; Rosenberg W et al. Evidence based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone; 1995.6 National Public Health Service. Evidence checklist. Available at: http://www.nphs.wales.nhs.uk. [Accessed 10th May 2008]7 National Institute for Health and Clinical Excellence. Guideline development methods. Available at: http://www.nice.org.uk. [Accessed 10th May 2008]8 National Public Health Service. Bobath therapy. Cardif:NPHS; 2007. [unpublished]9 Butler C; Darrah J. Effects of neurodevelopmental treatment (NDT) for cerebral palsy; an AACPDM evidence report. Dev Med Child Neurol 2001;43: 778-90.10 Brown GA; Burns SA. The efficacy of neurodevelopmental treatments in children: a systematic review. British Journal of Occupational Therapy 2001; 65:235-44.11 Blauw-Hospers CH; Hadders-Algra M. A systematic review of the effects of early intervention on motor development. Dev Med Child Neurol 2005; 47: 421-32.




http://www.nice.org.uk/

http://www.ncchta.org/fullmono/mon1116.pdf



Intervention/aim


reviewers comments


quality

Occupational Therapy 2001; 65:235-44.

benefit (n=9). The studies that included the use of NDT with paediatric

12 Mayo NE. The effect of physical therapy for children with motor delay and cerebral palsy: a randomized clinical trial. Am J Phys Med Rehabil 1991; 70: 258-67. 13 Palmer FB; Shapiro BK; Wachtel RC et al. The effects of physical therapy on cerebral palsy: a controlled trial in infants with spastic diplegia. NEJM 1988; 318: 803-808.14 Law M; Russell D; Pollock N et al. A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy program for children with cerebral palsy. Developmental Medicine Child Neurology 1997; 39: 664–70.15 Bower E; Mitchell D; Burnett M et al. Randomized controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 months. Dev Med Child Neurol 2001;43: 4–15.16 Tsorlakis N; Evaggelinou C; Grouios G et al. Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsy. Dev Med Child Neurol 2004; 46: 740-45.17 Law M; Darrah J; Pollock N et al. Focus on Function – a randomized controlled trial comparing two rehabilitation interventions for young children with cerebral palsy. BMC Pediatrics 2007; 7:31. Available at: http://www/biomedcentral.com/1471-2431/7/31. [Accessed 12th May 2008]18 Verschuren O. Ketelaar M; Gorter JW et al. Exercise training program in children and adolescents with cerebral palsy: a randomized controlled trial. Arch Pediatr Adolesc Med 2007; 161: 1075-81.19 Verschuren O; Ketelaar M; Takken T et al. Exercise programs for children with cerebral palsy: a systematic review of the literature. Am J Phys Med Rehabil 2008; 87:404-17.20 Ade-Hall RA; Moore AP. Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy. Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD001408. DOI: 10.1002/14651858.CD001408.21 Wasiak J; Hoare B; Wallen M. Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD003469. DOI:




http://www/biomedcentral.com/1471-2431/7/31



Intervention/aim


reviewers comments


quality

subjects diagnosed with CP had inconsistent results regarding the efficacy of NDT

Butler C; Darrah J. Effects of neurodevelopmental treatment (NDT) for cerebral palsy; an AACPDM evidence report. Dev Med Child Neurol 2001;43: 778-90.

Children with CP aged 6 months - 15 years

Systematic review of data on the effectiveness of NDT.

Varied outcomes such as motor function and physiological parameters, social activities.

21 articles were included. NDT was not effective in any of the outcomes measured.

No inclusion of grey literature. Good methodology to minimise bias etc.

Systematic review

2++

++

Howard DC. Anti Children and Systematic Protocol listed

10.1002/14651858.CD003469.pub3.22 Zhang MM; He J; Ai CL. Et al. Acupuncture for children with cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007127. DOI: 10.1002/14651858.CD007127.23 Howard DC. Anti Spastic Medication for Spasticity in Cerebral Palsy. (Protocol) Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD002260. DOI: 10.1002/14651858.CD002260.24 Rice JE; O'Donnell ME. Intrathecal Baclofen for treating spasticity in children with cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004552. DOI: 10.1002/14651858.CD004552.27 Pennington L; Goldbart J; Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003466. DOI: 10.1002/14651858.CD003466.pub2.






Intervention/aim


reviewers comments


quality

Spastic Medication for Spasticity in Cerebral Palsy. (Protocol) Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD002260. DOI: 10.1002/14651858.CD002260.

adults with CP

review to assess the absolute, and comparative, efficacy of baclofen, dantrolene and diazepam for spasticity in cerebral palsy..

in 2000, why no publication?

Knox V; Lloyd Evans A. Evaluation of the functional effects of a course of Bobath therapy in children with cerebral palsy: a preliminary study. Dev Med Child Neurol 2002; 44: 447-60.

Children with CP aged 2- 12 years

Preliminary study to evaluate of the functional effects of Bobath therapy.

Motor function; mobility; self care and social function. Parents and therapists perceptions of change.

20 children were recruited but only 15 children were enrolled for a 6 week course of therapy. Participants demonstrated a significant improvement in scores for motor function (p=0.001); self care skills ( p=0.086) and

Small numbers with high risk for bias. Preliminary study but no follow up publication was identified.

Case series

3

+






Intervention/aim


reviewers comments


quality

caregiver assistance ( p=0.012)

Law M; Russell D; Pollock N et al. A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy program for children with cerebral palsy. Dev Med Child Neurol 1997;39: 664–70.

Children with CP aged 18 months – 4 years

RCT to compare the effectiveness of intensive NDT and casting with regular OT programme

Hand function, secondary outcomes were upper limb movement and parents’ perception of improvement

50 children completed the study. There were no significant differences in outcomes between the groups.

Insufficient details of randomisation process

RCT 1-

+

Law M; Darrah J; Pollock N et al. Focus on function – a randomized controlled trial comparing two rehabilitation interventions for young children with

Children with CP aged 1 – 5 years.

RCT to compare a task /content focussed treatment approach with a child focussed treatment.

Motor function, disability measures, QOL

Planned to recruit 220 children.

Trial finished 2007. Publication ?

RCT ?






Intervention/aim


reviewers comments


quality

cerebral palsy. BMC Pediatrics 2007; 7:31.

Mayo NE. The effect of physical therapy for children with motor delay and cerebral palsy: a randomized clinical trial. Am J Phys Med Rehabil 1991; 70: 258-67.

Children with CP aged 0 – 18 months

RCT to determine the effectiveness of intensive versus regular physiotherapy.

Motor function The average proportional change in aggregate motor development for the 17 infants on the weekly (intensive) regimen was substantially better than that for the 12 on the monthly (basic) regimen, after adjusting for the child's age. A statistical test led to an equivalent of a Student's t = 3.49, which with 24 df was associated with P = 0.0019 (two-sided).

Insufficient details of randomisation. Problems with methodology.

RCT 1-

+/-

Narayanan U, Howard A. Selective

Children with CP

Systematic review to

Protocol listed 2001.






Intervention/aim


reviewers comments


quality

dorsal rhizotomy in the management of children with spastic cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD003360. DOI: 10.1002/14651858.CD003360.

determine the effectiveness of selective dorsal rhizotomy in the management of children with spastic cerebral palsy.

Palmer FB; Shapiro BK; Wachtel RC et al. The effects of physical therapy on cerebral palsy: a controlled trial in infants with spastic diplegia. NEJM 1988; 318: 803-8.

Children with CP aged 12 – 19 months.

RCT to evaluate the effectiveness of either 12 months (Gp A) of physical therapy or 6 months of physical therapy preceded by 6 months (Gp B) of infant stimulation

Motor quotient, motor ability, and mental quotient

48 children were studied. After six months, the infants in Gp A had a lower mean motor quotient than those in Gp B (49.1 vs. 58.1, P = 0.02) and were less likely to walk (12 vs. 35 percent, P = 0.07). These differences persisted after 12 months of therapy

Well designed trial but with small numbers

RCT 1+

+






Intervention/aim


reviewers comments


quality

[NDT] . (47.9 vs. 63.3, P less than 0.01, and 36 vs. 73 percent, P = 0.01, respectively)

Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003466. DOI: 10.1002/14651858.CD003466.pub2.

Children with CP

Systematic review to determine the effectiveness of SLT that focuses on the child or their familiar communication partners, as measured by change ininteraction patterns.• To determine if individual types of SLT intervention are more effective than

Eleven studies were included in the review. Seven studies evaluated treatment given directly to children, four investigated the effectsof training for communication partners. No conclusions could be made about the effectiveness of SLT due to methodological problems with the studies.

Poor quality studies

Systematic review

1-

+






Intervention/aim


reviewers comments


quality

others in changing interaction patterns.

Rice JE, O'Donnell ME. Intrathecal Baclofen for treating spasticity in children with cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004552. DOI: 10.1002/14651858.CD004552.

Children with CP

Systematic review to determine the effectiveness of intrathecal baclofen in treating spasticity in children with CP.

Tsorlakis N; Evaggelinou C; Grouios G et al. Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsy. Dev Med Child

Children with CP aged 3 – 14 years

RCT to determine the effect of intensive NDT compared with regular schedules.

Motor function 34 children were randomised to intensive NDT (5/week) or regular NDT (2/week). Motor function improved in both groups. Children receiving intensive

Inappropriate statistical methods. ANCOVA not used. Authors conclusions not supported by results.

RCT 1-

+/-






Intervention/aim


reviewers comments


quality

Neurol 2004; 46: 740-45.

NDT performed better ( p<0.05) that regular NDT group.

Verschuren O; Ketelaar M; Gorter JW et al. Exercise training program in children and adolescents with cerebral palsy: a randomized controlled trial. Arch Pediatr Adolesc Med 2007; 161: 1075-81.

Children and adolescents with CP aged 7 – 18 years

RCT to determine the effect of an exercise training programme

Aerobic and anaerobic capacity

86 children were randomly assigned to an exercise training programme or no training. A significant training effect was found for aerobic (P < .001) and anaerobic capacity (P = .004). A significant effect was also found for agility (P < .001), muscle strength (P < .001), and athletic competence (P = .005).

RCT 1-

+

Verschuren O; Ketelaar M; Takken T et al. Exercise programs for children with cerebral palsy: a

Children with CP aged 6 – 20 years

Systematic review of the literature on the effectiveness

5 trials on children with CP met the inclusion criteria. The results suggest that exercise

Some trials had methodological problems.

Systematic review

1+






Intervention/aim


reviewers comments


quality

systematic review of the literature. Am J Phys Med Rehabil 2008; 87:404-417.

of exercise programmes

programmes that focus on lower extremity muscle strength and /or cardiovascular fitness may be of benefit.

+

Wasiak J, Hoare B, Wallen M. Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD003469. DOI: 10.1002/14651858.CD003469.pub3.

Children with CP

Systematic review to assess the effectiveness of intramuscular BtA injections as an adjunct to managing the upper limb in children with spastic CP.

Motor outcomes

2 trials were included. The results from the 2 trials were inconsistent and no conclusions can be made

Systematic review

1+

+

Weindling AM; Cunningham CC; Glenn SM et al. Additional therapy for

Children aged < 3 years.

Multicentred RCT to determine whether

Motor function; developmental status;

79 families started the intervention and 76 completed the 6 month intervention.

Well designed trial with adequate details of

RCT 1++






Intervention/aim


reviewers comments


quality

young children with spastic cerebral palsy: a randomised controlled trial. Health Technol Assess 2007; 11(16).

additional support for children with CP and their falilies improves outcomes

adaptive functioning; parent satisfaction.

Participants were randomised to 3 interventions :-1. CG= routine physiotherapy and support2. PAG = one extra session physiotherapy3. FSWG = weekly home visits from a family social worker.Follow up was at 12 and 18 months. The detailed analyses of found no significant effect of extra intervention in the form of physiotherapy or extra social worker input. .

methodology. Qualitative studies were also performed.

+

Zhang MM, He J, Ai CL, Li J. Acupuncture

Children with CP

Systematic review to






Intervention/aim


reviewers comments


quality

for children with cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007127. DOI: 10.1002/14651858.CD007127

determine the efficacy and safety of acupuncture therapy for children with CP including spastic cerebral palsy, athetoid cerebral palsy and ataxic cerebral palsy

25 Narayanan U; Howard A. Selective dorsal rhizotomy in the management of children with spastic cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD003360. DOI: 10.1002/14651858.CD003360.26 Landau WM, Hunt CC. Dorsal rhizotomy, a treatment of unproven efficacy [comment] [see comments]. J Child Neurol 1990;5:174-8. Cited in 22




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Bobath Therapy for Children With Cerebral Palsyv2b

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