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1
ACKNOWLEDGEMENT
First of all, I would like to kneel thanking ALLAH, The most
merciful who provided me with patience to achieve this work and graces
that I could never be able to account.
I would like to express my deep gratitude and faithful thanks to
Prof. Dr. Elham Elsayed Salem, for the continuous supervision, endless
patience and encouragement throughout the whole work.
I would like to express my deep thanks to Prof Dr. Eman Abd
Elraaouf Mohammed for his great effort, continuous guidance and
support for me. No words will describe the greatest support, patience and
real love from my kind parents.
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Effect of neurodevelopmental treatment in children with spastic
cerebral palsy (A Systematic Review) / Mahmoud samir mohamed.
Supervisors: Prof. Dr. Elham Elsayed Salem, Professor in the
Department of Physical Therapy for Growth and Development Disorder
in Children and its Surgery, Faculty of Physical Therapy, Cairo
University; prof. Dr. Eman Abd Elraaouf Mohammed, Professor in the
pediatric Department, Faculty of Medicine, Cairo University; Master
Thesis, 2012.
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ABSTRACT
Objective: The aim of this work was to systematically review the studies
which assess the effects of neurodevelopmental treatment on children
with spastic cerebral palsy. Methods: Systematic review of all published
studies with all research designs except expert opinions. A search was
made in Medline, Cochrane library, PEDro and Google scholar; from the
earliest date to February 2012.Intervention: Neurodevelopmental
treatment programs performed by the physical therapist in children
diagnosed as cerebral palsy with age between births to eighteen years.
Outcome measures: Activities of daily living, gross motor function,
sitting posture control and mechanical efficiency. Results: Only 5
studies met the inclusion criteria. Meta-analysis could be done and the
current level of evidence to support the effectiveness of
neurodevelopmental treatment in children with spastic CP remains not
sufficient. As according to this review there is no support enough to use
NDT for children with cerebral palsy except only in intensive form of
treatment is used to improve gross motor function and sitting posture
control. Conclusion: The current level of evidence to support the
effectiveness of neurodevelopmental treatment on children with spastic
cerebral palsy remains weak.
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CONTENTS
Title Page
Acknowledgment 1
Abstract 3
List of tables 5
List of figures 6
List of abbreviations 7
Chapter (I): INTODUCTION 8
Chapter (II): REVIEW OF LITERATURE 13
Chapter (III): Methodology 29
Chapter (IV): RESULTS 32
Chapter (V): DISCUSSION 43
Chapter (VI): 47
SUMMARY 47
CONCLUSION 48
RECOMMENDATIONS 49
References 50
Arabic summary 54
Appendix 57
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LIST OF TABLES:
Table No. Title page
Table (1): PEDRO scale 30
Table (2): The five selected studies for this systematic review 32
Table (3): Methodology assessment of studies according to
the Physiotherapy Evidence Database (PEDro) scale
33
Table (4): Summary of study characteristics 34
Table (5): Summary of study results 35
Table (6): Summaries means of study groups and control groups and
difference between this means.
37-38
Table (7): Summary of studies: outcomes, measures, and results 38
Table (8): Reported Adverse Events 39
6
LIST OF FIGURES:
Figure No. Title Page
Fig.(1) Components of Evidence-Based Decision 14
Fig.(2) Levels of Evidence 17
Fig.(3) Comparison between study and control
groups regarding mechanical efficiency.
42
Fig.(4) Comparison between study and control
group regarding gross motor function
42
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LIST OF ABBREVIATIONS:
Abbreviation Subject
AACPDM American Academy for Cerebral Palsy and
Developmental medicine
CI Confidence interval
CP Cerebral Palsy
EBP Evidence Based Practice
GMFCS Gross motor function classification system
ICF International Classification of Functioning
N Number of participants in the study
N-of-1 RCTs Number of one randomized controlled trials
PEDro Physiotherapy Evidence Database
PT Physical therapy
Pubmed A free American database that provide access to
Medline literature
RCTs Randomized controlled trials
ROM Range of motion
SR
Systematic review
NDT Neurodevelopmental therapy
ADL Activities of daily living
GMF Gross motor function
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CHAPTER I
INTRODUCTION
A systematic review is the application of scientific strategies that
limit bias by the systematic assembly, critical appraisal and synthesis of
all relevant studies on a specific topic (Manchikanti, 2008).
A Systematic review is a ''study of studies''. All relevant researches
are analyzed in an effort to determine the overall evidence for an
intervention. A systematic review is a literature review focused on a
single clear question which tries to identify, select and appraise all high
quality research evidence relevant to that question then makes assessment
of the included studies and synthesis of findings and interpretation.
Systematic reviews are generated to answer specific, often narrow,
clinical questions in depth (Garg et al., 2008).
A randomized controlled trial (RCT) is an experimental design in
which subjects are randomly assigned to an experimental or control group
permitting the strongest inferences about cause and effect. The results of
a randomized controlled trial (RCT) provide the strongest evidence of
efficacy, that is, whether an intervention is effective when applied to a
selective sample under controlled conditions or not (Campbell et al.,
2006).
The gold standard for testing theory-based interventions'
effectiveness is the randomized controlled trial (RCT). The systematic
review or meta-analysis of randomized controlled trials (RCTs) is
considered to be the strongest evidence (Cottrell and McKenzie, 2005).
9
Cerebral palsy (CP) is the commonly used name for a group of conditions
characterized by motor dysfunction due to non-progressive brain damage
early in life. There are usually associated disabilities as well as emotional
and social family difficulties. The range of severity may be from total
dependency and immobility to abilities of talking, independent self-care
and walking, running and other skills although with some clumsy actions
(Levitt, 2004).
The prevalence of cerebral palsy is about 2 per 1,000 live births. In
most cases of cerebral palsy, the etiology remains unknown or unproven.
Cerebral palsy can be of prenatal, perinatal or postnatal origin (Wolraich,
2003).
The classification of the subtypes of cerebral palsy is based upon
clinical determinations of movement disorder that may change
presentation as the child grows and develops. This movement disorder is
topographically classified by the number of limbs impaired into,
hemiplegia (limbs on one side affected), diaplegia (four limbs are
involved, with arms much less affected than legs) and quadriplegia (all
limbs are involved), and by symptoms of impairment cerebral palsy is
classified into spastic, dyskinetic and a rare ataxic type (Levitt, 2004).
Cerebral palsy presents with "impairments" in body function and
structure such as muscle tone, strength, reflexes and range of motion.
Significant "activity" limitations can also be present (e.g. dressing,
feeding and functional mobility) as well as restricted "participation" (e.g.
playing and participating in school) in social and community roles for the
child (Law M, 2007).
10
Children with cerebral palsy (CP) are functionally limited to
varying degrees because of their decreased central control and
coordination of their movements. The effects of growth predispose
children with neurological impairments to the secondary problems of
muscle contractures, bony deformities, and unusual gait abnormalities.
Health care programs aim to prevent deformities and encourage the
development of functional and independent skills and abilities (Seymour,
2002).
Neurodevelopmental therapy is a problem-solving approach
focusing on the individual’s current needs while aiming for the long-term
goal of function across the lifespan. Occupational, speech, and physical
therapists as well as educators can use NDT. The benefits of utilizing
NDT include improved ability to perform functional activities appropriate
to the needs of the individual, active participation of the child, improved
strength, flexibility, and alignment, and improved function over a
lifespan. It is not an exclusive treatment for individuals with CP.
(Bly , 1991).
Neurodevelopmental treatment has gone through a long evolution
over the years. Time has forced it to become more eclectic and become
one of the most commonly used intervention strategies for children from
infancy through adulthood with CP Since the conception of NDT by Dr.
Karl and Mrs. Berta Bobath in the 1940s, the scientific community’s
understanding of the brain and the conceptual framework of NDT has
evolved (DeGangi, Royeen,1994).
11
Statement of the problem
Is Neurodevelopmental Therapy effective to modulate muscle
tone and improve functional ability for Children with cerebral palsy?
Purpose of the study
To evaluate the best current evidence on the clinical effect of
neurodevelopmental therapy for children with spastic cerebral palsy.
Significance of the study:
Evidence based medicine is needed to improve quality of health
care. A body of evidence regarding safety, effectiveness, appropriate
indications, cost-effectiveness, and other attributes of medical care are
demanded (Manchikanti, 2008).
We live in the information age; the number of published studies in
the biomedical literature has dramatically increased. Because even highly
cited trials may be challenged over time, clinical decision-making
requires ongoing reconciliation of studies that provide different answers
to the same question. Because it is often impractical for readers to track
down and review all of the primary studies, review articles are an
important source of summarized evidence on a particular topic (Garg et
al., 2008).
Systematic reviews help overcoming limitations of primary
research by testing its finding for consistency and validity, and whether
they can be generalized across population or not. In this way systematic
reviews can help physician and health care providers and policy marker to
take informed decisions in health care (Mckibbon, 2004).
12
Neurodevelopmental approach focused on sensorimotor
components of muscle tone, reflexes and abnormal movement patterns,
postural control, sensation, perception, and memory (i.e. components
thought most likely to be impaired as a result of CNS damage). Handling
techniques that controlled various sensory stimuli were used to inhibit
spasticity, abnormal reflexes, and abnormal movement patterns, and were
also used to facilitate normal muscle tone, equilibrium responses, and
movement patterns. The child was a relatively passive recipient of NDT
treatment. The normal developmental sequence was advocated as a
framework for treatment. Despite the widespread use of
Neurodevelopmental approach, there is a lack of research evidence
demonstrating its effectiveness in spastic human muscles (Barry, 2001).
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CHAPTER II
LITERATURE REVIEW
based medicine:-Evidence
Evidence-based medicine was initially called “critical appraisal” to
describe the application of basic rules of evidence as they evolve into
application in daily practices. It is defined as an explicit and judicious use
of current best evidence in making decisions about the care of individual
patients. Evidence-based practice is defined based on 4 basic and
important events, which include recognition of the patient’s problem and
construction of a structured clinical question, thorough search of medical
literature to retrieve the best available evidence to answer the question,
critical appraisal of all available evidence, and integration of the evidence
with all aspects and contexts of the clinical circumstances
(Manchikanti, 2008).
Evidence-based physiotherapy
Is important for patients because it implies that, within the
limitations of current knowledge they will be offered the safest and most
effective interventions. The expectation is that this will produce the best
possible clinical outcomes. Patients are increasingly demanding
information about their disease or clinical problem and the options
available for treatment. (Higgs et al. 2001)
14
Many patients have access to a wide range of information sources,
but not all of these sources provide reliable information. The most widely
used source of information is probably the internet, but the internet
provides the full spectrum of information quality, from reliable to
spurious data. If patients are to make informed contributions to decisions
about the management of their conditions they will need assistance to
identify high quality clinical research. (Gray, 1997)
Evidence-based practice - as shown in figure (1)- involves
''integration of best research evidence with clinical expertise and patient
values''. It is a process that involves more than knowledge of current
research (Sackett et al., 2000).
Figure (1)
Components of Evidence-Based Decision (Haynes and Haines, 1998).
� Research evidence : it involves tracking down the best and the latest
evidence from research articles that are critically appraised for its validity
and usefulness before applying their results to patient care .
� Clinical expertise : it refers to the clinician's cumulated experience ,
education and clinical skills . It is important to rapidly identify each
15
patient's unique health state , EBP complements experience and doesn’t
replace it .
� Patient values : it means the unique preferences , concerns and
expectations each patient brings to a clinical encounter and which must be
integrated to clinical decisions if they are to serve the patient.
� The full integration of the three components: research evidence,
experience and patient's values into clinical decision enhances the
opportunity for optimal clinical outcomes and quality of life
Decision making is the process by which evidence is (or is not)
applied to practice. The statement ''evidence alone does not make
decisions, people do'' reflects the integral role of the therapist in
translation of evidence to practice. Therapists make decisions on complex
issues related to examination, prognosis, expected outcomes, the plan of
care, and coordination of care on a daily basis (Guyatt et al.,2000 and
Haynes et al., 2002).
The randomized controlled trial (RCT) is a study in which
participants are ''randomly distributed'' into two (or more groups) one of
them receive the studied intervention (experimental group) and the other
receive the control intervention (control group) then participants are
followed prospectively and the results are finally compared
(Abdelghaffar, 2007).
In daily practice the need for valid information about diagnosis ,
prevention, treatment , prognosis and harm are growing .it is estimated that
a clinician would need an answer for many questions and the answer for
such questions should be based on solid research evidence rather than an
opinion or past undocumented and untested experiences , however in
16
reality the answer to these questions for the same patient usually differ
from one clinician to another even in the same situations as clinician are
used to base their decisions on subjective rather than objective
standards(Elstein 2004).
It is reported that although the results of a randomized controlled
trial (RCT) provide the strongest evidence of cause and effect relationship
between the intervention and outcomes, trials are often difficult to
implement with children with developmental disabilities (Campbell et al.,
2006).
Hierarchy of Evidence:
Evidence generated from research is not all the same. Some
evidence is better than others. As shown in figure (2), whenever searching
for evidence, one should start looking for the best available one (in
descending order of importance) which is obtained from:
� Systematic reviews and meta-analysis.
� Randomized controlled studies.
� Non-randomized controlled studies and cohort studies.
� Case control studies.
� Case series.
� Case reports.
� Opinions of experts or respected authorities.
� Animal research and in vitro studies.
17
Figure (2): Levels of Evidence (Sackett et al., 2000)
Systematic reviews and meta-analysis lie on top of the evidence
pyramid both in public health and clinical medicine (Abdelghaffar,
2007).
Appraisal of the evidence includes assessment of the relevance and
validity of the evidence (clinical applicability) and finally the evidence is
integrated with clinical experience and patient values before applying it to
the patient (Attia, 1999).
RCTs
SRs &
Meta-analysis
Non – RCTs
Cohort studies
Case control studies
Case series
Case reports
Opinions of experts
Animal research and in virtro studies
18
Evidence Based Practice requires the adoption of some new skills
including asking clinical questions , basic computer and internet
knowledge for electronic searching of the literature and the application of
critical appraisal rules in evaluating the clinical literature (Scohish
intercollegiate Guidelines Network,2008).
Working with EBP includes the following steps :
� Assessment of the patient : by taking history , examination and
investigation.
� Asking clinical question : it is to convert the patient's problem into
clinical question in a specific format (PICO) where :
' P ' is the patient problem .
' I ' is the intervention or exposure .
' C ' is the comparison intervention or exposure .
' O ' is the outcome that patients look for (patient oriented outcome).
� Acquiring the best available evidence : it requires an efficient
computerized search in EBP resources in a systematic way for finding the
best answer (evidence) for the clinical question generated , key words are
extracted from the generated PICO question and used in search engines of
EBP web sites .
� Appraisal of the evidence : includes assessment of the relevance and
validity of the evidence , however , evidence can be pre-appraised already
which found in pre-appraised EBP resources .
� Finally the evidence is integrated with clinical experience and patient
values before applying it to the patient .
19
Evidence Based Practice resources vary in both the volume and the
methodology and therefore the reliability of evidence. There are two types
of resources pre-appraised resources and non-appraised resources (med
line search) (Rosenberg and Donald, 1995).
o Pre-appraised EBP resources
Provides "ready made" answers for questions which have been
previously considered. Users of such resources can then access this
information and obtain evidence based responses for their questions. Using
this approach , the user doesn't need to appraise the evidence as it has been
already appraised , thus save effort and time .
Although the topics available in pre-appraised resources are rapidly
expanding, only a relatively small fraction of medicine is currently
available as pre-appraised evidence.
Emerging research results can alter the evidence; accordingly, pre-
appraised topics are continuously updated to incorporate new research
results. The usual frequency of such update varies from site to site.
Pre-appraised resources include the Cochrane library which is a
collection of evidence-based databases that are produced by the Cochrane
collaboration ( www.thecochranelibrary.com ) , Clinical
evidence which is a highly trusted evidence-based medical database it is
based on answering important clinical conditions using a systematic
literature search and appraisal (www.clinicalevidence.com ) , Up to date
provides evidence-based topic reviews that include useful data which are
20
well supported ( www.uptodate.com) ,Turning search into practice (The
TRIP Database ) .
o Non-appraised resources ( med line search)
The med line database represents the largest source for non-appraised
evidence allover the world, it contains over sixteen million abstract of
scientific publications from about 480 medical journals.
The med line database is maintained and continuously updated by the
national library of medicine in USA; it provides health care professionals
as well as the public a free access to the database through the pub med
interface (www.pubmed.com or www.pubmed.gov ).
Developing a Systematic review requires the following steps
according to Sackett DL, (1997).
1. Defining an appropriate healthcare question
This requires a clear statement of the objectives of the review,
intervention or phenomena of interest, relevant patient groups and
subpopulations (and sometimes the settings where the intervention is
administered), the types of evidence or studies that will help answer the
question, as well as appropriate outcomes. These details are rigorously
used to select studies for inclusion in the review.
2. Searching the literature
The published and unpublished literature is carefully searched for the
required studies relating to an intervention or activity (on the right patients,
reporting the right outcomes and so on). For an unbiased assessment, this
search must seek to cover all the literature (not just MEDLINE where, for
21
example, typically less than half of all trials will be found), including non-
English sources. In reality, a designated number of databases are searched
using a standardized or customized search filter.
Furthermore, the grey literature (material that is not formally
published, such as institutional or technical reports, working papers,
conference proceedings, or other documents not normally subject to
editorial control or peer review) is searched using specialized search
engines, databases or websites. Expert opinion on where appropriate data
may be located is sought and key authors are contacted for clarification.
Selected journals are hand-searched when necessary and the
references of full-text papers are also searched. Potential biases within this
search are publication bias, selection bias and language bias.
3. Assessing the studies
Once all possible studies have been identified, they should be
assessed in the following ways , Each study needs to be assessed for
eligibility against inclusion criteria and full text papers are retrieved for
those that meet the inclusion criteria.
Following a full-text selection stage, the remaining studies are
assessed for methodological quality using a critical appraisal framework.
Poor quality studies are excluded but are usually discussed in the review
report. Of the remaining studies, reported findings are extracted onto a data
extraction form. Some studies will be excluded even at this late stage. A
list of included studies is then created. Assessment should ideally be
conducted by two independent reviewers.
22
4. Combining the results
If appropriate, the findings from the individual included studies can
then be aggregated to produce a summary estimate of the overall effect of
the intervention. Sometimes this aggregation is qualitative (i.e., individual
descriptions of the included studies), but more usually it is a quantitative
assessment using meta-analysis. Meta-analysis should only be performed
when the studies are similar with respect to population, outcome and
intervention.
4. Placing the findings in context
The findings from this aggregation of an unbiased selection of
studies then need to be discussed to put them into context. This will
address issues such as the quality and heterogeneity of the included
studies, the likely impact of bias, as well as the chance and the
applicability of the findings.
The four main biases affecting method of quality include selection,
performance, detection, and attrition bias. Selection bias refers to problems
in the randomization process. Improper patient selection and allocation to
treatment groups distort treatment comparisons. Performance bias refers to
systematic differences in the care provided to the participants in the
comparison groups other than the intervention under investigation.
Attrition bias refers to the exclusion of patients or losses to follow-up that
occur after treatment allocation. Detection bias occurs if the investigators
are influenced by the allocation sequence in assessing outcomes.
23
Method of heterogeneity in study design and quality affect the
ability to perform a meta-analysis. When study heterogeneity precludes
meta-analysis, the authors of SR need to summarize findings based on the
strength of the individual studies and reach conclusions if indicated.
Heterogeneity
Studies brought together in a SR will differ; any kind of variability
among studies in a SR may be termed heterogeneity. It can be helpful to
distinguish between different types of heterogeneity. Variability in the
participants, interventions and outcomes studied may be described as
clinical heterogeneity, and variability in trial design and quality may be
described as methodological heterogeneity. Variability in the treatment
effects being evaluated in the different trials is known as statistical
heterogeneity, and is a consequence of clinical and/or methodological
diversity among the studies. Meta-analysis should only be considered
when a group of trials is sufficiently homogeneous in terms of participants,
interventions and outcomes to provide a meaningful summary.
Meta-analysis
Meta-analysis, the use of statistical methods to summarize the results
of independent studies, can provide more precise estimates of the effects of
healthcare than those derived from the individual studies included in a
review and allows decisions that are based on the available evidence ,
Reasons for considering including a meta-analysis in a review are:
24
� To increase power. Power is the chance of detecting a real effect as
statistically significant if it exists. Many individual studies are too small to
detect small effects, but when several are combined there is a higher
chance of detecting an effect.
� To improve precision. The estimation of a treatment effect can be
improved when it is based on more information.
� To answer questions not posed by the individual studies. Primary studies
often involve a specific type of patient and explicitly defined interventions.
A selection of studies in which these characteristics differ can allow
investigation of the consistency of effect and, if relevant, allow reasons for
differences in effect estimates to be investigated.
� To settle controversies arising from apparently conflicting studies or to
generate new hypotheses. Statistical analysis of findings allows the degree
of conflict to be formally assessed, and reasons for different results to be
explored and quantified.
25
Cerebral Palsy:
Definition:
Cerebral palsy is a term used to describe a group of disorders of
movement, muscle tone, or other features that reflect abnormal control
over motor function by the central nervous system. It encompasses only
those non-progressive or static lesions that affect the control of
developing brain over motor abilities (Wolraich, 2003).
Etiology:
Cerebral palsy can be of prenatal origin, secondary to such
conditions as the following: (1) congenital brain malformations, (2)
neuronal migration disorders, (3) vascular disturbances, (4) genetic
syndromes, (5) maternal infections, and (6) other maternal factors.
Common peri-and post natal causes include (1) trauma, (2) asphyxia, (3)
infections, and (4) cerebral hemorrhage (Wolraich, 2003).
Incidence:
Cerebral palsy is a chronic disabling condition of childhood. It
occurs in 1.5/1,000 to 3/1,000 live births with spasticity as a prevalent
disabling clinical symptom. The incidence is higher in males than in
females (Volpe, 2008).
26
Different Classification systems according to (Levitt, 2004
and Macnair and Hicks, 2008):
*Topographical classifications are as follows:
� Tetraplegia (quadriplegia): Involvement of all limbs. Arms
are equally or more affected than the legs. Many are
asymmetrical (one side more affected) and called double
hemiplegia.
� Diplegia: Involvement of limbs, with arms much less
affected than legs.
� Hemiplegia: Limbs on one side affected.
*Classification according to types of cerebral palsy:
There are several different types of cerebral palsy. While some
people are severely affected, others have only minor disruption,
depending on which parts of the brain have been damaged. The main
types of cerebral palsy are:
� Spastic cerebral palsy - some of the muscles in the body are tight,
stiff and weak, making control of movement difficult.
� Athetoid (dyskinetic) cerebral palsy - control of muscles is
disrupted by spontaneous and unwanted movements. Control of
posture is also disrupted.
� Ataxic cerebral palsy - problems include difficulty with balance,
shaky movements of hands or feet, and difficulty with speech.
� Mixed cerebral palsy - a combination of two or more of the above.
Although cerebral palsy causes a variety of upper motor neuron
dysfunctions, spasticity is the most common and typically results in
asymptomatic foot dysfunction (Volpe, 2008).
27
Neurodevelopmental Therapy:
This is the most commonly used therapy method in CP worldwide.
It aims to normalize muscle tone, inhibit abnormal primitive reflexes and
Stimulate normal movement. It uses the idea of reflex inhibitory positions
to decrease spasticity and stimulation of key points of control to promote
the development of advanced postural reactions .It is believed that
through positioning and stimulation, a sense of normal movement will
develop. An important part of therapy of the infant is teaching the mother
how to position the child at home during feeding and other activities.The
baby is held in the anti spastic position to prevent contracture
formation.(Berker and Yalcin, 2005)
NDT, also known as the Bobath approach, emphasizes the role of
neurological dysfunction in impeding typical postural control and motor
development. Furthermore, normal motor skills are the aim of therapy.
NDT focuses on inhibiting primitive reflexes, spasticity, and abnormal
movement patterns, and emphasis is placed on the quality of movement
and functional activities.( Alexander et al. 2000)
According to the Bobath the motor problems of CP arise
fundamentally from CNS dysfunction, which interferes with the
development of normal postural control against gravity and impedes
normal motor development.(Bobath. 1984)
Their goal was the establishment of normal motor development and
function and/or the prevention of contractures and deformities. Their
neurodevelopmental approach focused on sensorimotor components of
muscle tone, reflexes and abnormal movement patterns, postural control,
sensation, perception, and memory (i.e. components thought most likely
to be impaired as a result of CNS damage).( DeGangi G, Royeen C.
1994)
28
Handling techniques that controlled various sensory stimuli were
used to inhibit spasticity, abnormal reflexes, and abnormal movement
patterns, and were also used to facilitate normal muscle tone, equilibrium
responses, and movement patterns. The child was a relatively passive
recipient of NDT treatment. The normal developmental sequence was
advocated as a framework for treatment. ( Bly L.1991)
NDT-trained therapists are able to use a variety of handling
techniques. These specialized techniques encourage active use of
appropriate muscles and diminish involvement of muscles not necessary
for the completion of a task. Child-directed and –initiated movement
tasks are critical to the success of neurodevelopmental treatment.
Therapists practicing NDT set functional individual session goals, which
build upon each other to facilitate new motor skills or improve the
efficiency of learned motor tasks. Improvements in efficiency can include
decreased energy used during a task, decreased work required of the
muscles during a task, and habituation of new patterns of movement.
These tasks are specific to and driven by the functional needs of the child.
In NDT the child takes an active role in treatment design. The therapist
must be constantly evaluating their input into the child’s movement with
the goal of active, habituated, independent movement.
( Damiano et al.1995)
Principle:
The strength of NDT has always been the clinical management
of the sensorimotor problems resulting from ongoing analysis of system
and motor impairment from CNS pathology.The primary difference that
separate NDT from all other approaches that include facilitation and
inhibition as a key points of control.( Janet, 2001).
29
CHAPTER III
METHODOLOGY
Search Strategy for Identification of Studies:
Search was done in: PubMed(Medline),the Cochrane Library and
Physiotherapy Evidence Database (PEDro) to systematically review
studies published in English language which study the effects of
neurodevelopmental therapy in children (0-18 years) with cerebral palsy.
The following key words were used in the search:"Cerebral palsy",
"Neurodevelopmental therapy", "Functional abilities", "Gait",
"Spasticity" and "Bobath technique". Reference lists in the relevant
studies and review articles were examined.
Methods:
Study Selection Criteria:
Types of Studies:
Published English studies with all research designs except expert opinions.
Types of Participants:
The review included children (0-18 years) with spastic cerebral palsy.
Types of Interventions:
This review included studies which demonstrate the effects of
Neurodevelopmental therapy with reported findings for analysis of its
effectiveness.
30
Exclusion criteria:
� Unpublished studies.
� Studies that compared NDT with the effects of medications,
surgery, or serial casting were excluded.
� Studies that combined NDT with other types of modalities; such
as casting and splinting.
� Non-randomized control trials studies.
Quality assessment of methodology:
All the included studies were scored on their methodological
rigour with the Physiotherapy Evidence Database (PEDro) scale
(PEDro, 2010). The PEDro scale examines 11aspects of the quality
of methodology.
Table (1) PEDRO scale:
Criteria N o Y e s
1. Eligibility criteria were specified
2. Subjects were randomly allocated to groups (in a crossover
study, subjects were randomly allocated in the order in which
treatments were received)
3. Allocation was concealed
4. The groups were similar at baseline regarding the most important
prognostic indicators
5. There was blinding of all subjects
6. There was blinding of all therapists who administered the therapy
7. There was blinding of all assessors who measured at least one key
outcome
8. Measures of at least one key outcome were obtained from more
than 85% of the subjects initially allocated to groups
9. All subjects for whom outcome measures were available received
the treatment or control condition as allocated or, where this was
not the case, data for at least one key outcome was analyzed by
“intention to treat”
10. The results of between-group statistical comparisons are reported
for at least one key outcome
11. The study provides both point measures and measures of
variability for at least one key outcome
31
Data Extraction:
Data from all the included studies were summarized in the format
as suggested by the American Academy for Cerebral Palsy and
Developmental Medicine (AACPDM). The format included: participants'
characteristics (number in each group, target population, diagnosis,
numbers in each diagnostic subgroup, and ages), intervention used,
control used, research design and level of evidence for the study, and
outcomes of interest.
Data Analysis
Meta-analysis is a quantitative method employing statistical
techniques, to combine and summarize the results of studies that address
the same question without major differences in its inclusion or exclusion
criteria of the participants, mode of administration, doses, and duration of
the intervention as well as the comparison intervention, and the outcomes
assessed and the methods of their assessment. Studies were clinically,
methodologically and statistically homogenous before combining its
results .So, Meta-analysis was done to three studies as they are
homogenous and descriptive analysis was done to two studies as they are
heterogonous.
32
CHAPTER IV
RESULTS
Literature search results:
Only five studies met the inclusion criteria. Randomized controlled
trials were made on the topic (Miedaner and Renander, 1987).
Table (2): The five selected studies for this systematic review
Study Title
Hamid et al.(2009)
Effect of the Bobath technique, Conductive
education and Education to parents in
activities of daily living in children with
cerebral palsy in Iran.
Nikos et al.(2004) Effect of intensive neurodevelopmental
treatment in gross motor function of
children with cerebral palsy.
Haim et al.(2006) Comparison of efficacy of Adeli suit and
neurodevelopmental treatment in children
with cerebral palsy.
Munhee et al.(2011) Effect of Task-oriented Training and Neuro-
developmental Treatments on the Sitting
Posture in Children with Cerebral Palsy.
Haim et al.(2010) Effectiveness of motor learning coaching in
children with cerebral palsy: a randomized
controlled trial.
The main reasons for exclusion of the other studies were:
� The other study doesn’t meet the inclusion criteria.
� The other studies not randomized control trials.
� Combined NDT with other intervention.
33
Methodological Quality Results:
The scoring of each study with the Physiotherapy Evidence
Database (PEDro) scale is listed in Table 2. The scores of the all studies
included in the study ranges from six to seven, the more the number of
scores of the aspects evaluating the quality of the study, the more quality
of the study.
Table (3): Methodology assessment of studies according to the
Physiotherapy Evidence Database (PEDro) scale
Criteria Hamid
et al 2009
Nikos et al 2004
Haim et al 2006
Munhee et al 2011
Haim et al 2010
1-Specified eligibility criteriaa Yes Yes Yes Yes yes
2-Random allocation of participants
Yes Yes Yes Yes yes
3-Concealed allocation
Yes No No No No
4-Similar prognosis at baseline
Yes Yes Yes Yes Yes
5-Blinded participant
No No No No Yes
6-Blinded therapists No Yes No No No
7-Blinded assessors No Yes No Yes No 8-More than 85% follow-up for at least one key outcome
Yes Yes Yes Yes Yes
9-‘Intention to treat' analysis Yes No Yes Yes Yes
10-Between group statistical analysis for at least one key outcome
Yes Yes Yes Yes Yes
11-Point estimates of variability for at least one key out come
Yes Yes Yes Yes Yes
PEDro score 7/10 7/10 6/10 7/10 7/10
34
Table (4) summarizes the characteristics of the research
participants in these five studies. The participants were aged from
four to fourteen years of age.
Table (4): Summary of study characteristics
Hamid et al
2009
Nikos et al
2004
Haim et al
2006
Munhee
et al 2011Haim et al
2010
Research design
Randomized
Control
Trial
Randomized
Control
trial
Randomized
Control
trial
Randomized
Control
Trial
Randomized
Control
trial
Level of evidence II II II II II
Participant
characteristics
Children
with CP
matched
together by
sex ,age and
IQ
Children
with spastic
hemiplegic,
diaplegic
and
tetraplegic
CP
Children
with spastic
CP level II,III
and IV
according to
GMFM
Children
with spastic
diaplegic CP
Children
with spastic
diaplegic and
quadriplegic
CP level II
according to
GMFM
Nr of
participants
Treatment
Group
Bobath
approach=1517 12 5 39
Control
group
1-CE=15
2-Education to
parents=15
17 12 5 39
Age range 4–8 3-14 6-12 2-9 6-12
CE=Conductive Education ,CP=cerebral palsy ,GMFM=Gross Motor Function Measure
35
Table (5) summarizes the outcomes of interest of these five
studies and codes the outcomes of interest.
Table (5): Summary of study results
Hamid et al.
(2009)
Nikos et al.
(2004)
Haim et al.
(2006)
Munhee et
al.(2011)
Haim et al.
(2010)
Intervention
Bobath
approach For;
3 months
4sessions/week
3 hours daily
Intensive
neurodevelopm
ental treatment
for:
16 weeks
5 times/week
Adeli suit
therapy
Task-oriented
training
Motor
learning
coaching
Control
Intervention
- Conductive
education
-Education to
parents
Non- Intensive
neurodevelopm
ental treatment
for:
16 weeks
2 times/week
Neuro
developmen
tal treatment
Neuro
developmenta
l treatment
Neuro
developmen
tal treatment
Outcome of
interest
Activities of
daily living
Gross motor
function
-Gross
motor
function
-Mechanical
efficiency
Sitting
posture
control
-Gross
motor
function
-Mechanical
efficiency
Measures
The Client
Developmental
Evaluation
Report (CDER)
-GMFM 66
-GMFM 88
-GMFM
-Metabolic
cost during
stair
climbing
EMG -GMFM
-Metabolic
cost during
stair
climbing
Component
of health
Activity and
participation
Activity and
participation
Activity and
participation
Activity and
participation
Activity and
participation
36
There are five studies investigating the effect of neurodevelopmental
treatment on children with cerebral palsy. (Hamid et al.2009, Nikos et
al.2004, Simona et al.2006, Munhee et al.2011and Simona et
al.2010)
The study by Hamid et al.2009 suggest that conductive
education has great effect on activities of daily living than education
to parents and Bobath technique.
The study by Nikos et al.2004 demonstrate that intensive
neurodevelopmental treatment (5times per week for 16 weeks) has
greater effect on gross motor function than neurodevelopmental
treatment (2times per week for 16 weeks).
The study by Haim et al.2006 show that both groups of the
study increase the value of GMFM-66 after 1month of treatment, but
after 10 months of treatment show increasing of value of GMFM-66
for the control group by1.2 and decreasing this value for study
group by 0.3.
The study by Munhee et al.2011 demonstrate that both task
oriented training and neurodevelopmental treatment muscle
vitalization and improve sitting posture of children with cerebral
palsy.
The study by Haim et al.2010 demonstrate that In higher
functioning children with cerebral palsy, the motor learning coaching
treatment resulted in significantly greater retention of gross motor
Function and transfer of mobility performance to unstructured
environments than neurodevelopmental treatment.
37
Table (6): summaries means of study groups and control groups
and difference between this means.
Hamid et al.
(2009)
Nikos et al.
(2004)
Haim et al.
(2006)
Munhee et
al. (2011)
Haim et al.
(2010)
OutcomesActivities of
daily living
Gross motor
function
*Gross motor
function
1-right
rectus
abdominis
*Gross motor
function
*mechanical
efficiency
2-left rectus
abdominis
*mechanical
efficiency
3-right
erector
spinae
4-left erector
spinae
Mean for
control
group
-conductive
education:
*Pre=26.47
*Post=42.8
GMFM88
*Pre=80.31
*Post=82
(Gross motor
function)
*pre=52.2
*1month=52.9
*10month=54.1
1-pre=7.61
post=10.64(Gross motor
function)
*Pre=59.5
*Post=62.52-pre=4.41
post=7.1
-education to
parents:
*Pre=30.33
*Post=36.8
GMFM66
*Pre=65.85
*Post=67.04
(mechanical
efficiency)
*Pre=4.2
*Post=4.44
3-pre=6.69
post=10.58(mechanical
efficiency)
*pre=11.1
*1month=12.5
*10month=13.1
4-pre=6.66
post=9.45
Mean for
study
group
-Bobath
approach:
*Pre=29.4
*Post=34.6
GMFM88
*Pre=77.36
*Post=79.99(Gross motor
function)
*pre=54.2
*1month=55
*10month=54.7
1-pre=6.37
post=18.20(Gross motor
function)
pre=60.4
post=62.22-pre=8.47
post=18.23
GMFM66
*Pre=62.17
*Post=64.54
(mechanical
efficiency)
pre=4.2
post=4.1
3-pre=7
post=8.22(mechanical
efficiency)
*pre=12.7
*1month=15.1
*10month=19.6
4-pre=4.66
post=6.35
Difference
between
means
-Bobath
approach=5.2
GMFM88
*Control
group=1.69
(control group)
-(Gross motor
function)
*1month=0.7
1-
control=3.03
study=11.83
-(Gross motor
function)
control
group=2.5
38
-conductive
education=16.33
*Study
group=2.63
*10month=1.2
-(mechanical
efficiency)
*1month=1.4
*10month=0.6
2-
control=2.69
study=9.76
study
group=2.3
-(mechanical
efficiency)
control
group=0.2
study group=
-0.1
GMFM66
*Control
group=1.19
*Study
group=2.37
3-
control=3.89
study=1.22
-education to
parents=6.47
(study group)
-(Gross motor
function)
*1month=1
*10month=-0.3
-(mechanical
efficiency)
*1month=2.4
*10month=4.5
4-
control=2.79
study=1.69
Table (7): Summary of studies: outcomes, measures, and
results
Group
studies
Outcomes of
interestMeasures
Component of healthBody
Structure/sBody
Functions
ActivitiesAnd
Participation
Contextual Factors
1-Hamid et
al.
(2009)
1-Activities of daily
living
-The Client Developmental
Evaluation Report (CDER) Yes
2-Nikos et
al.(2004)1-Gross motor
function
-GMFM 66
-GMFM 88Yes
3-Haim et
al. (2006)
1-Gross motor
function
2-Mechanical
efficiency
-GMFM
-Metabolic cost during
stair climbingYes
4- Munhee et
al. (2011)
-Sitting posture
control-EMG Yes
5- Haim et
al.
(2010)
1-Gross motor
function
2-Mechanical
efficiency
- GMFM
-Metabolic cost during
stair climbingYes
39
Table (8): contains information regarding the adverse events
reported in each study and the method the authors used to ascertain the
adverse events.
ns=not stated
At Hamid et al.(2009):
This study was a quasi-experimental clinical trial with pre/post
design. Forty-five children with cerebral palsy were selected by
convenience sampling in a rehabilitation centre and allocated to three
groups by matching closely their sex, age, and IQ; 15 children were in the
Bobath group, 15 were in the CE group, and 15 were in the education-to-
parents group. Outcome measures were the good enough test and the
Client Development Evaluation Report.
There were significant differences in ADLs after treatment within
each group (p = .001). Significant differences were also found in the
average total ADLs scores between the three groups after treatment (p <
.0001). We found that the most effective approach was CE, followed by
education to parents and the Bobath technique. There were significant
differences between 12 sub-skills out of 16 in ADLs in the three groups,
and children in the CE group achieved higher scores in comparison with
other groups.
Study Level of
evidence Total n
Method of
Ascertaining
Adverse Event
Description of
Adverse
Events
1-Hamid et al. (2009)
II 45 Ns -
2- Nikos et al.(2004) II 34 Ns -
3- Haim et al.(2006) II 24 Ns -
4-Munhee et al. (2011) II 10 Ns -
5- Haim et al. (2010) II 78 Ns -
Table (8): Reported Adverse Events
40
At Nikos et al.(2004):
This study examined the effect of neurodevelopmental treatment
(NDT) and differences in its intensity on gross motor function of children
with cerebral palsy (CP). Participants were 34 children with mild to
moderate spasticity and hemiplegia (n=10), diplegia (n=12), and
tetraplegia (n=12). Gross Motor Function Classification System levels
were: I (n=10), II (n=10), and III (n=14). The paired sample, which was
obtained by ratio stratification and matching by sex, age, and distribution
of impairment from a total of 114 children with CP, was assigned
randomly to two groups: group A underwent NDT twice a week and
group B five times a week for 16 weeks. The outcome measure used was
the Gross Motor Function Measure, which assessed the performance of
the children before and after intervention.
At haim et al.(2006)
This study compared the efficacy of Adeli suit treatment (AST)
with neurodevelopmental treatment (NDT) in children with cerebral palsy
(CP). Twenty-four children with CP, Levels II to IV according to the
Gross Motor Function Classification System (GMFCS), were matched by
age and functional status and randomly assigned to the AST or NDT
treatment groups. Both groups were treated for 4 weeks (2 hours daily, 5
days per week, 20 sessions). To compare treatments, the Gross Motor
Function Measure (GMFM-66) and the mechanical efficiency index
during stair-climbing.
41
At Munhee et al. (2011)
At This study the control group (n=5) received NDT and the
experimental group (n=5) received the task oriented Training approach to
improve sitting balance control, 5 times per week for 6 weeks. Sitting
posture was assessed the gross motor functional measure (GMFM), and
electromyography (EMG) pre and post intervention.
GMFM and right rectus abdominis activities showed no significant
differences in either treatment. The activity strength of the left rectus
abdominis, right and left erector muscles significantly increased in both
groups. With regard to the difference in the GMFM and EMG between
the experiment and control groups, there was no difference.
At haim et al (2010)
This study to evaluate effectiveness of motor learning coaching and
neurodevelopmental treatment on retention and transfer of gross motor
function in children with cerebral palsy.
Block randomized trial, matched for age and gross motor function,
78 children with spastic cerebral palsy, gross motor functional levels II
and III, aged 66 to 146 months, 1 hr/day, 3 days/week for 3 months
treatment with motor learning coaching or neurodevelopmental treatment,
Measured by Gross motor function Measure (GMFM-66), stair-climbing
mechanical efficiency (ME) and parent questionnaire rating their child’s
mobility.
42
META analysis:
We found that Haim et al( 2006) and Haim et al( 2010) are
homogenous in mechanical efficiency.
Figure (3): Comparison between study and control groups regarding
mechanical efficiency.
Also, we found that Haim et al( 2006), Haim et al( 2010)and Nikos et
al(2004) are homogenous in gross motor function.
Figure (4): Comparison between study and control groups
regarding gross motor function
43
CHAPTER V
DISCUSSION
The purpose of the current review is to evaluate the
effectiveness of NDT on (mechanical efficiency, gross motor function,
activities of daily living and sitting posture control) , this review includes
studies published from 2001 up to 2011 and searched on Medline data
base through Pub Med and Ovid that most likely include huge amount of
papers published each year and also PEDro , Physiotherapy Evidence
Database , PEDro is a free database of over 18000 RCTs , SRs and
clinical practice guidelines in physiotherapy,Cochrane library also was
searched and Google web site.
This SR analyzed five RCTs , by applying strict selection
criteria for inclusion, only full text articles of RCTs were included . All
trials met at least six criteria on the PEDro scale.
After collecting data according to items of AACPDM sheet it was found
that:
From all studies included all studies fulfill the criteria of high
methodological quality which judged as strong ("yes" on 6-7 questions)
according to AACPDM method of quality assessment of the studies.
There was no report about any adverse effects of the NDT
intervention in the included studies and all the outcomes of the studies
represent the ICF component of activity and participation
44
At the study of Hamid et al. (2009) compare the effect of
neurodevelopmental treatment with conductive education and education
to parents on activities of daily living in children with cerebral palsy and
found that all this techniques improve ADL skills and there was a
significant difference in the average total of ADL scores among the three
groups before and after the intervention and the conductive education
group performed the score better than the other groups.
There were no significant differences in mean age and IQ at
baseline among the three groups. There were significant differences in
ADLs after treatment within each group. Significant differences were also
found in the average total ADLs scores between the three groups after
treatment. We found that the most effective approach was CE, followed
by education to parents and the Bobath technique. There were significant
differences between 12 sub-skills out of 16 in ADLs in the three groups,
and children in the CE group achieved higher scores in comparison with
other groups.
At the study of Munhee et al(2011) compare the effect of task
oriented training with NDT on sitting posture control in children with
cerebral palsy. In this study we found that there is a significant increase in
muscle vitalization especially in erector spinae but there is no significant
difference between both groups.
45
GMFM and right rectus abdominis activities showed no significant
differences in either treatment. The activity strength of the left rectus
abdominis, right and left erector muscles significantly increased in both
groups. With regard to the difference in the GMFM and EMG between
the experiment and control groups, there was no difference. The results of
this study suggest that the method of task-oriented training and
neurodevelopmental treatment for muscle vitalization both improved the
sitting posture of children with cerebral palsy.
According to META-analysis for haim et al.2006 and haim et
al.2010 regarding mechanical efficiency it was found that there is no
Significant difference between study groups(Adeli suit therapy and Motor
learning coaching) and control groups(Neurodevelopmental treatment).
According to META-analysis for Nikos et al 2004,haim et al.2006
and haim et al.2010 regarding gross motor function it was found that
there is a Significant difference between study groups(Intensive NDT,
Adeli suit therapy and Motor learning coaching) and control
groups(Neurodevelopmental treatment).
From clinical point of view NDT has an effect on modulation
muscle tone in children with spastic cerebral palsy; also it is beneficial for
improving hand function (reaching, transfer and hand weight bearing)
46
From the previous studies it can be concluded that NDT (intensive
form) should be considered as a treatment supplement in the physical
therapy program for children with cerebral palsy. It can be applied as an
intervention to facilitate sitting posture control combined with motor
learning, and NDT has no any significant difference with other techniques
on improving mechanical efficiency in children with cerebral palsy.
As the treatment strategies are rapidly increasing and changeable
so in order to cope with the new information about the traditional treatment
strategies and the recent one, so physical therapists have to use the evidence
in practice to improve the quality of patient care and best update of
treatment is delivered. However, incorporating research into practice is time
consuming, and so we need methods of facilitating easy access to evidence
for busy clinicians, systematic reviews aim to inform and facilitate this
process through research synthesis of multiple studies, enabling increased
and efficient access to evidence.
47
CHAPTER VI
SUMMARY, CONCLUSIONS AND
RECOMMENDATIONS
Summary
This systematic review aimed to study the effect of
neurodevelopmental treatment children with spastic cerebral palsy.
In order to answer this question we searched in PubMed, The
Cochrane Library, PEDro and Google scholar using the words :"Cerebral
palsy", "Neurodevelopmental therapy", "Functional abilities", "Gait",
"Spasticity" and "Bobath technique". We expanded our search to all
research designs except expert opinions dealing with spastic cerebral
palsy from birth to eighteen years of age and used the
neurodevelopmental treatment as a method of intervention. The outcomes
measured are gross motor function, activities of daily living, sitting
control and mechanical efficiency.
According to the criteria mentioned we selected five studies for
detailed descriptive analysis in order to critically appraise their results.
48
Conclusions
The current level of evidence to support the effectiveness of
neurodevelopmental treatment in children with spastic CP is not
sufficient. As according to this review there is no support enough to use
NDT for children with cerebral palsy except only in intensive form of
treatment.
There are few conclusions that can be drawn from the existing
evidence as follows: (1) there appears to be some evidence favoring
intensive neurodevelopmental treatment in improving gross motor
function in children with CP, although the effect size remained small
and (2) there is some evidence to indicate that NDT is preferable to
improve sitting posture control and increase muscle vitalization in
children with cerebral palsy.
49
Recommendations
1- It is recommended that physical therapists should have a
positive attitude about evidence based practice and to be
interested in learning and improving the skills necessary to
implement evidence based practice.
2- It is recommended to do further research using systematic
reviews to study the effect of NDT on different cases in
pediatric physical therapy.
3- More search is needed for Combination of NDT and other
treatment modalities, such as; electrical stimulation, orthoses
and casting.
50
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54
العربى الملخص
:ثالبح عنوان
ين بالشلل الدماغى بطريقة العالج :عالج االطفال المصاب منهجي فحص
العصبى التطورى
:البحث من الهدف
العالج العصبى التطورى فعالية تقييم المنهجية المراجعة هذه من الهدف
.التقلصى الدماغى بالشلل المصابين األطفال على وتأثيرها
:البحث أسلوب طورىللعالج العصبى الت عملية تجارب تضمنت التى الدراسات استخدام
و PEDro العلمى الباحثفى الدماغى التقلصى الشلل حاالت في
Cochrane ومكتبة Pubmed : :النتائج
:الدراسة هذه تضمنت
لفعالية للدليل الحالى المستوى أن النتائج أظهرت عملية، تجارب خمس
التقلصى الدماغى بالشلل المصابين األطفال فى العالج العصبى التطورى . فىمازال غير كا
:التوصيات المبنية العملية الممارسة بأهمية الطبيعي العالج ألخصائي الوعي نشر -١
.لألطفال الطبيعي العالج مجال في الدليل على المستقبل في التصميم جيدة المحكومة العشوائية التجارب عمل يجب -٢
بالشلل المصابين ألطفالل طريقة العالج العصبى التطورى تأثير لبحث
. اغيالدم المستخلص
طريقة العالج فعالية لتقييم منهجى فحص إلي الدراسة هذه تهدف :الهدف
العصبى التطورى
التقلصى، الدماغى بالشلل المصابين األطفال على وتأثيرها
55
:البحث طرق
العلمى البحث تصميمات بجميع المنشورة التجارب لجميع منهجي فحص
الخبراء أراء ماعدا التقلصى الدماغي الشلل من يعانون الذين األطفال على ساتالدرا واشتملت
عشر ثمانية حتي الوالدة منذ أعمارهم وتتراوح فى الباحث البحث وتم عاما
عام يناير شهر حتى : Pubmed ومكتبة Cochrane و PEDro العلمى
٢٠12. :الدراسات نتائج
هذه بينس التجان وبسبب السابقة المعايير وافقت فقط دراساتخمسة
هناك .بالشرحالتوضيح وتم مشترك إحصائى تحليل عمل تمالدراسات،تحليل احصائى أثبت أن العالج العصبى التطورى اليختلف فى تأثيره على الكفاءة الميكانيكية بالنسبة للتدخالت االخرى لألطفال المصابين بالشلل
لعالج العصبى الدماغى التقلصى بينما أثبت تحليل احصائى أخر ان طريقة االتطورى لها تأثيرضعيف على(القدرات الوظيفية للحركة)ماعدا فى
صورته المكثفة :االستنتاج األطفال فى طريقة العالج العصبى التطورى لفعالية للدليل الحالى لمستوىا
مازال غير كافى. التقلصى الدماغى بالشلل المصابينالعالج العصبى التطورى , ي،الدماغ الشلل منهجي، فحص :الدالة الكلمات
الوظيفية.القدرات
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عالج االطفال المصابين بالشلل الدماغى بطريقة العالج ى :منهج فحص العصبى التطورى
الطبيعى العالج فى الماجستير درجة على للحصول توطئة
من مقدمة
محمود سمير محمد
الطبيعى العالج بكالوريوس األطفال عند وجراحتها والتطور النمو مراحل الضطرابات الطبيعى العالج قسم
إشراف تحت
الهام السيد سالم .د.أ الضطرابات الطبيعى العالج بقسم أستاذ
األطفال عند وجراحتها والتطور النمو مراحل القاهرة جامعة - الطبيعي العالج ليةك
ايمان عبد الرؤف .دأ.
االطفالأستاذ طب القصر العينى جامعة القاهرة
الطبيعى العالج ليةك 2012ةرالقاه جامعة
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APPENDIX
Study Data Extraction Summary Form for Group Design
Studies
Reviewer’s Name: Mahmoud samir
Citation information: Hamid et al.(2009)
1-Level of Evidence:
Research Design: randomized control trial
Level of Evidence: level II
2. Conduct Rating of the Study: 7/10
3. Descriptive Information about the Study
Participant description: Children with CP matched together
by sex ,age and IQ
Number: In treatment group: 15
In control group1:15
In control group2:15
Specific intervention used: Bobath approach
Description of control state: conductive education and
Education to parents
4. Outcomes: Activities of daily living
Measures: The Client Developmental Evaluation Report (CDER)
SS: there is statistically significant difference between groups as
conductive education is more significant increase more than the
other groups
5. Adverse Events: not stated
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Study Data Extraction Summary Form for Group Design Studies
Reviewer’s Name: Mahmoud samir
Citation information: Nikos et al. (2004)
1-Level of Evidence:
Research Design: randomized control trial
Level of Evidence: level II
2. Conduct Rating of the Study: 7/10
3. Descriptive Information about the Study
Participant description: Children with spastic hemiplegic
,diaplegic and tetraplegic CP.
Number: In treatment group:17
In control group :17
Specific intervention used: Intensive neurodevelopmental
treatment for 16 weeks 5 times/week
Description of control state: Non- Intensive
neurodevelopmental treatment for: 16 weeks 2 times/week
4. Outcomes: Gross motor function
Measures: -GMFM 66 -GMFM 88
SS: there is statistically significant difference between groups as
intensive NDT is more significant increase more than non-
intensive.
5. Adverse Events: not stated
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Study Data Extraction Summary Form for Group Design Studies
Reviewer’s Name: Mahmoud samir
Citation information: Haim et al.(2006)
1-Level of Evidence:
Research Design: randomized control trial
Level of Evidence: level II
2. Conduct Rating of the Study: 6/10
3. Descriptive Information about the Study
Participant description: Children with CP level II,III and IV
according to GMFM
Number: In treatment group: 12
In control group:12
Specific intervention used: Adeli suit therapy
Description of control state: Neuro developmental treatment
4. Outcomes:
1-Gross motor function
2-Mechanical efficiency
Measures: GMFM -Metabolic cost during stair climbing
SS: there is statistically significant difference between both
groups.
5. Adverse Events: not stated
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Study Data Extraction Summary Form for Group Design Studies
Reviewer’s Name: Mahmoud samir
Citation information: Munhee et al.(2011)
1-Level of Evidence:
Research Design: randomized control trial
Level of Evidence: level II
2. Conduct Rating of the Study: 7/10
3. Descriptive Information about the Study
Participant description: Children with spastic diaplegic CP
Number: In treatment group: 5
In control group: 5
Specific intervention used: Task-oriented training
Description of control state: Neuro developmental treatment
4. Outcomes: Sitting posture control
Measures: EMG
NS: there is no statistically difference between both groups.
5. Adverse Events: not stated
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Study Data Extraction Summary Form for Group Design
Studies
Reviewer’s Name: Mahmoud samir
Citation information: Haim et al.(2010)
1-Level of Evidence:
Research Design: randomized control trial
Level of Evidence: level II
2. Conduct Rating of the Study: 7/10
3. Descriptive Information about the Study
Participant description: Children with spastic diaplegic and
quadriplegic CP level II according to GMFM
Number In treatment group: 39
In control group:39
Specific intervention used: Motor learning coaching
Description of control state: Neuro developmental treatment
4. Outcomes: 1-Gross motor function 2-Mechanical efficiency
Measures: GMFM -Metabolic cost during stair climbing
SS: there is statistically significant difference between both
groups.
5. Adverse Events: not stated
