Effectiveness_of_Physiotherapy_in_Children_with_Cerebral Palsy.pdf

Authors:

Heidi Anttila, MSc (Health Sci), PT

Jutta Suoranta, MSc (Health Sci), PT

Antti Malmivaara, PhD, MD

Marjukka M¨kel¨, PhD, MD, MSc

(Clin Epi)

Ilona Autti-R¨m¨ , PhD, MD

Cerebral Palsy

Afﬁliations:

From the Finnish Ofﬁce for Health

Technology Assessment, National

Research and Development Centre for

Welfare and Health, Helsinki, Finland

(HA, JS, AM, MM, IAR); Tampere

School of Public Health, University of

Tampere, Tampere, Finland (JS);

Department of General Practice,

University of Copenhagen, Denmark

(MM); The Social Insurance Institute,

Helsinki, Finland (IAR); and

Department of Child Neurology,

Hospital for Children and

Adolescents, University of Helsinki,

Finland (IAR).

LITERATURE REVIEW

Effectiveness of Physiotherapy and

Conductive Education Interventions

in Children with Cerebral Palsy

A Focused Review

ABSTRACT

Anttila H, Suoranta J, Malmivaara A, M¨ kel¨ M, Autti-R¨m¨ I: Effectiveness of

physiotherapy and conductive education interventions in children with cerebral

palsy: a focused review. Am J Phys Med Rehabil 2008;87:478–501.

Correspondence:

All correspondence and requests for

reprints should be addressed to Heidi

Anttila, Finnish Ofﬁce for Health

Technology Assessment, PO Box 220,

FIN-00531 Helsinki, Finland.

We conducted a criteria-based appraisal of systematic reviews on the effective-

ness of physiotherapy and conductive education interventions in children with

cerebral palsy (CP). Computerized bibliographic databases were searched with-

out language restriction up to August 2007. Reviews on trials and descriptive

studies were included. Two reviewers independently identified, selected, and

assessed the quality of the reviews using the criteria from the Overview Quality

Assessment Questionnaire complemented with decision rules. Twenty-one re-

views were included, six of which were of high methodological quality. Altogether,

the reviews included 23 randomized controlled trials and 104 observational

studies on children with CP. The high-quality reviews found some evidence

supporting strength training, constraint-induced movement therapy, or hippo-

therapy, and insufficient evidence on comprehensive physiotherapy and occupa-

tional therapy interventions. Conclusions in the other reviews should be inter-

preted cautiously, although, because of the poor quality of the primary studies,

most reviews drew no conclusions on the effectiveness of the reviewed interven-

tions. Reviews on complex interventions in heterogeneous populations should use

rigorous methods and report them adequately, closely following the Quality of

Reporting of Meta-Analyses recommendations.

Disclosures:

This study was funded by Finohta, a

national government-funded

organization for health technology

assessment, and by a grant from the

Academy of Finland. The authors

have no ﬁnancial or personal

conﬂicts of interest.

0894-9115/08/8706-0478/0

American Journal of Physical

Medicine & Rehabilitation

Williams & Wilkins

DOI: 10.1097/PHM.0b013e318174ebed

Key Words: Physiotherapy, Systematic Review, Cerebral Palsy, Quality Assessment,

Clinical Applicability

478

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Vol. 87, No. 6

T he principles of evidence-based practice are

widely accepted among professionals. 1,2 The stron-

gest support for evidence-based decision making

comes from updated, high-quality systematic re-

views (SR). Such reviews identify the relevant stud-

ies, appraise their quality, and summarize the re-

sults, using sound scientiﬁc methodology. 3,4 They

can also help clinicians to ﬁnd relevant answers to

clinical questions in a time-efﬁcient and reliable

way. 3 Professionals treating children with CP often

have limited time, skills, and resources to search

for evidence and to interpret effectiveness studies. 5

Cerebral palsy (CP) is an umbrella term for

“nonprogressive but often-changing motor impair-

ment syndromes secondary to lesions or abnormal-

ities of the brain arising in the early stages of

development.” 6 Basic management of the motor

disability in CP includes physiotherapy (PT) and a

wide spectrum of other therapeutic interventions. 7

Motor learning goals may also be incorporated into

educational programs such as conductive educa-

tion (CE) instead of separate rehabilitation inter-

ventions provided by different professionals. 8

An appreciation of the quality of an SR is

essential before deciding whether its conclusions

should be followed. Such quality may mean the

rigor of the review methods, or quality of report-

ing. Previous evaluations of SRs in many ﬁelds

imply that readers should not accept them uncriti-

cally, and there is a need for improvement of the

methodological quality and guidelines for report-

ing. 9 Cochrane reviews are usually more rigorously

conducted and reported than non-Cochrane re-

views. 9 –12

There are at least 24 instruments to assess the

quality of SRs. 13 A rigorously developed and vali-

dated tool, the Overview Quality Assessment Ques-

tionnaire (OQAQ), has been constituted by Oxman

and Guyatt. 14,15 Hoving et al. 16 have slightly mod-

iﬁed this tool and applied it in rehabilitation re-

search. The Quality of Reporting of Meta-Analyses

statement describes the preferred way to present

the abstract, introduction, methods, results, and

discussion sections of a report of meta-analysis,

including a ﬂow diagram of the article identiﬁca-

tion and selection process. 17 Balanced interpreta-

tion of the applicability and clinical relevance re-

quires accurate information of the reviewed

populations, interventions, comparison interven-

tions, and outcomes. 18 –20

An essential feature of SRs is critical appraisal

of the methodological quality of the included pri-

mary studies. 3,21 Lack of adherence to deﬁned qual-

ity criteria may explain the different results of

studies on the same topic. 22 Published SRs have

heterogeneous approaches to assess methodologi-

cal quality, and this has been infrequently reported

and incorporated into the analyses. 10,23,24

In this study, we wanted to evaluate the meth-

odological validity of SRs and their clinical useful-

ness when targeting a heterogeneous population

and looking at variably applied interventions such

as PT and CE in children with CP. The primary

objective was to appraise the methodological qual-

ity of the reviews on the effectiveness of PT or CE

interventions in children with CP, and to explore

what needs to be done to enhance the quality of

reviews. The secondary aims were to make conclu-

sions about the effectiveness of the reviewed inter-

ventions, and to consider the included study designs,

populations, interventions, outcome measures, and

results of various PT interventions on children with

CP to allow interpretation of possible evidence into

clinical practice. Finally, our aim was to use all this

information to make suggestions for future studies in

this ﬁeld.

METHODS

Locating and Selecting the Reviews

Only published SR articles were considered.

To be included, these publications were required

to have descriptions of the searched databases,

search time period, and selection criteria for

population and interventions. This review in-

cluded interventions usually provided by physio-

therapists and requiring therapeutic manage-

ment 7 —for instance, neurodevelopmental therapy

(NDT), strength training, saddle riding, physical

activity, swimming programs, functional therapy,

and targeted training. In addition, interventions

that in some countries or organizations may be

provided either by physiotherapists or occupational

therapists (upper-limb interventions) or special

teachers (CE) were included. The main focus was to

include reviews on therapeutic management with-

out specialized equipment; thus, interventions of

solely devices (electrical stimulation, biofeedback,

orthotic, or other assistive devices) were excluded.

The patients were children or adolescents (aged 3

mos to 20 yrs) with diagnosed CP.

If the review had included other interventions

or populations, it was included only if at least 80%

of the included populations or interventions were

similar to our criteria, or if the results of only the

CP population and PT interventions were presented

separately. Further, the review should report the

results of the included studies. Reviews in Danish,

English, Finnish, German, Norwegian, or Swedish

were accepted.

We searched Medline, CINAHL, the Cochrane

Database of Systematic Reviews, Database of Ab-

stracts of Reviews of Effects, American College of

Physicians Journal Club, Health Technology As-

June 2008

Effectiveness of Interventions in CP

479

sessment database, and the Physiotherapy Evi-

dence Database (http://www.pedro.fhs.usyd.edu.au/

index.html) without language restrictions back to

the earliest time available and up until August

2007. An experienced information scientist planned

the search strategies. High sensitivity search strat-

egies for Medline and CINAHL databases developed

by the University of York 25 were employed and

complemented with Medical Subject Headings or

text words for populations and interventions. The

search strategy for Medline is shown Table 1. From

January 2003 to August 2007 the search results

from Medline and CINAHL were limited to “sys-

tematic reviews” or “review articles” using the im-

proved ﬁlters provided by these databases. The ref-

erences of the identiﬁed review articles were

checked by two reviewers (H.A., J.S.) to identify

possible reviews. We also searched our personal

ﬁles of studies and reviews on children with CP.

Two reviewers (H.A. and R.K. or I.A.R.) inde-

pendently screened the titles or abstracts identiﬁed

in the initial search strategy for inclusion and

exclusion criteria. When the title and abstract did

not clearly indicate whether an article should be

included, two reviewers (H.A., I.A.R.) evaluated the

full article for inclusion criteria. The reviewers

were not blinded to the names of authors and

institutions, sources of funding or results of the

review.

score of 18 (Appendix A). Reviews fulﬁlling all

points, except the item of selection bias (as using

two or more assessors for independently judging

and selecting studies with predetermined criteria,

and/or blinding reviewers to identifying features of

study, or to treatment outcome), were regarded as

being of high quality. Two evaluators (H.A., J.S.)

separately assessed the quality of the included re-

views. The discrepancies in evaluations were solved

by discussion, and remaining disagreements were

decided by a third reviewer (A.M.).

Analysis of the Reviewers’ Conclusions

The included reviews were classiﬁed according

to the intervention types: (1) comprehensive PT

approaches (e.g., neurodevelopmental or neuro-

physiological PT, home programs or Vojta), (2)

strength training, (3) constraint-induced move-

ment therapy (CIMT), (3) postural control, (4) soft

tissue treatment, (6) hydrotherapy, (7) hippo-

therapy, 8) CE and (9) various (several of the above

interventions in one review). For each group of

interventions we considered and weighed up the

conclusions according to the methodological qual-

ity of the SR. We also observed the number and

type of included studies and their overlaps between

the reviews to obtain a comprehensive overview of

the research volume in this ﬁeld.

Data Extraction

One of two reviewers (either H.A. or J.S.) ex-

tracted the data. The included articles were allo-

cated equally, and data from one review was ex-

tracted by both reviewers to ensure similarity. After

data extraction the results were checked by the

other reviewer. We tabulated the review focus,

search strategies and inclusion criteria, data of the

included populations, interventions, settings, out-

come measures; number of studies and the study

designs in each review; methods used in quality

assessment and analyses; and the main results and

conclusions, and reported adverse effects. For

quantitative data we extracted the effect sizes of all

outcome measures used.

RESULTS

Article Identification and Selection

Figure 1 shows a ﬂow chart of the literature

searches and article selection. We found 21 SRs:

four reviews on comprehensive PT, 26 –29 two on

strength training, 30,31 one on CIMT, 32 one on pos-

tural control, 33 one on soft tissue treatment, 34 one

on hydrotherapy, 35 two on hippotherapy, 36,37 four

on CE, 38–41 and ﬁve reviews covering a wide range

of various interventions. 42– 46

Methodological Quality

The methodological quality scores of the re-

views are presented in Table 2. The search meth-

ods and inclusion criteria were at least partially

described in all reviews, as these were our man-

datory criteria for inclusion. Six reviews fulﬁlled

all criteria other than blinding reviewers from au-

thor and outcome information. 26,30,32,33,36,42

Twelve reviews 26,29,30,32–34,36 –39,42,43 had deﬁned

quality-assessment criteria, and all but one 37 used

these. Many reviews had inadequacies in search

and synthesis methods. The median quality score

was 11 out of 18 points (range 3–17).

A summary of the reviews’ focus and methods

is given in Table 3. The methods of qualitative

Assessment of the Methodological

Quality

The methodological quality of the included

SRs was analyzed using a modiﬁed version 16 of the

method described and validated by Oxman et

al. 14,15 This checklist evaluates nine items covering

search methods, selection of the articles, validity

assessment and methods for synthesis, The modi-

ﬁcation, previously applied in the ﬁeld of rehabili-

tation, consists of the addition of decision rules to

increase transparency of the assessment. 16 Each

item is scored from 0 to 2, with a maximum total

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TABLE 1 High-sensitivity search strategy for identifying review articles in Medline, developed by the

University of York 25

1. Cerebral palsy/rh, th [rehabilitation, therapy]

2. Cerebral palsy.mp. or cerebral palsy/

3. Exp physical therapy techniques/

4. (Physical therapy or physical therapies).ab,ti.

5. Physiotherap$.ab,ti.

6. Exp exercise therapy/

7. (Physical activity or physical activities).ab,ti.

8. Exp “physical therapy (specialty)”/

9. Exp “physical education and training”/

10. Rehabilitation.mp. or REHABILITATION/

11. (Vojta or bobath or neurodevelop$ or NDT or Rood or Kabat or vibroacoust$).ab,ti.

12. “Early intervention (education)”/

13. Conductive education.ab,ti.

14. Conservative therap$.ab,ti.

15. (Muscle strength$ or muscle training or motion or therapeutic exercise or excercise training or physical

exercise or ﬁtness or aerobic training or kinetic chain).ab,ti.

16. Movement.mp. or EXERCISE MOVEMENT TECHNIQUES/or MOVEMENT/

17. SWIMMING/or swimming.mp. or hydrotherapy.mp.

18. (Functional therapy or functional therapies).ab,ti.

19. (Self-care training or motor control or motor learning).ab,ti.

20. Occupational therapy.mp. or Occupational Therapy/

21. (Constraint adj induced).mp. [mp