Appendix S2: Body Structures and Function Interventions

Interventions targeting an improvement in the musculoskeletal system, focused at the body

structures and function level of the (ICF)1, may improve a child’s biomechanical alignment or
strength, may improve healing, may prevent impairments or may reduce pain. Importantly,
these physical alterations do not lead to an upstream improvement in function at the
activities level of the (ICF)1, unless combined with interventions to improve function. It is
therefore critical for therapists to understand the mechanism of action for each therapy,
and to select therapies capable of achieving the child’s goals. If the child wants to improve
their performance of a functional task, practice of the task is recommended, but body
structures and functions interventions will not be efficacious and therefore are not
recommended. Conversely, body structures and functions interventions are necessary and
evidence-based for preventing impairments (i.e. muscle contractures), promoting wound
healing and managing pain and are recommended for these musculoskeletal indications.

BODY STRUCTURES AND RECOMMENDATION STRENGTH OF

FUNCTIONS RECOMMENDATION &
INTERVENTION & QUALITY OF EVIDENCE
PROPOSED
MECHANISM OF
ACTION
FITNESS TRAINING Fitness training is recommended for STRONG +
Exercises involving improving heart health. Clinical RECOMMENDATION
movement of skeletal trials indicate that gains in fitness High quality evidence
muscles that result in does not spontaneously confer for improving fitness
increased aerobic gains in function.
activity to improve or CONDITIONAL +
maintain cardiovascular It may not be possible for children RECOMMENDATION
fitness and or health. GMFCS levels II-V to move fast Very low certainty
enough to achieve a change in evidence for improving
aerobic activity. In these gross motor function2
circumstances, physical activity
could be considered.
MASSAGE Massage is not recommended for CONDITIONAL –
Decreased cortisol improving gross motor skills in RECOMMENDATION
levels & increased vagal children with cerebral palsy, and Very low certainty
nerve activity, which multiple alternative motor learning evidence that massage
correspondingly might approaches exist. In clinical trials, no does not improve gross
reduce pain making it superior gains could be identified motor skills3
easier for a child to from massage for gross motor
move. Massage is a function. Massage may be helpful
passive intervention for pain & stress management.
that does not involve
self-activation of the
motor pathways.
NEURO- NDT/Bobath where the movement STRONG –
DEVELOPMENTAL is passively applied to the child by a RECOMMENDATION
THERAPY (NDT/Bobath) therapist or adult, and where the Low certainty evidence
In its traditional passive child does not have to self-initiate that does NDT/Bobath
format, NDT/Bobath movements are not recommended not improve gross
normalised movement, for improving function. In multiple motor skills4,5
prepared the body for clinical trials, no superior gains over
movement and no therapy at all could be identified
normalised tone
from NDT/Bobath for improving
through therapist
gross motor function.
facilitation and handling
techniques
PHYSICAL ACTIVITY Physical activity is recommended for CONDITIONAL +
Exercise, strength and improving physical activity levels. RECOMMENDATION
endurance training, and Clinical trials indicate that gains in Low certainty evidence
balance training physical activity do not confer any for physical activity6-8
gains in gross motor function.
CONDITIONAL –
RECOMMENDATION
Low certainty evidence
that Vojta does not
improve gross motor
function2
SENSATION TRAINING For children with low sensation CONDITIONAL +
Enriched & targeted accompanying their motor RECOMMENDATION
exposure to a variety of impairment, targeted sensation Very low certainty
tactile stimuli, training could be considered for evidence for sensation
correspondingly might improving their sensation. Clinical training improving
improve sensation & trials indicate that gains in sensation sensation or function9
thus hand function via do not spontaneously confer gains
improved internal in function unless accompanied by
feedback. active interventions to improve
function.
STRENGTH TRAINING Strength training is recommended STRONG +
Use of progressively for improving muscle strength and RECOMMENDATION
more challenging endurance. Gains in muscle strength High quality evidence
resistance to muscular do not spontaneously confer gains for improving muscle
contraction to build in function. strength10-12
muscle strength and
anaerobic endurance CONDITIONAL +
RECOMMENDATION
Very low certainty
evidence for improving
function
STRETCHING For children with contracture CONDITIONAL –
Use of an external and/or risk of contracture, passive RECOMMENDATION
passive force (e.g. stretching of muscles is not Very low to low
parent/therapist) recommended for improving muscle certainty evidence that
exerted upon the limb length or function. In clinical trials, stretching does not
 to move it into a new superior gains could be identified improve muscle length
and lengthened muscle from stretching for muscle length, or gross motor skills.13
position plus the treatment causes
discomfort and may affect the
parent-child relationship. Gains in
muscle length do not spontaneously
confer gains in function.
VOJTA Vojta is not recommended for CONDITIONAL –
Reflexive muscle improving gross motor skills in RECOMMENDATION
responses following children with cerebral palsy, and Low certainty evidence
stimulation of specific multiple alternative task-specific that Vojta does not
activation zones, which approaches exist. In clinical trials, improve gross motor
is theorised to improve superior gains could be identified skills14-16
movement. Vojta is a from Vojta for gross motor function.
passive intervention One trial reported gains however
that does not involve serious confounders existed
self-activation of the affecting interpretation of the
motor pathways. results. If children experience
distress, then Vojta should be
discontinued, given distress will
elevate the child’s cortisol levels
with detrimental effects.
WHOLE BODY Whole body vibration may confer CONDITIONAL +
VIBRATION short-term improvements in RECOMMENDATION
Vibration applied to the spasticity over and above stretching, Very low certainty
whole body through a but highly effective and more lasting evidence for whole
vibrating platform. effects are achievable from body vibration
pharmacological agents. Whole improving spasticity,
body vibration may also improve strength and gross
strength and gross motor function, motor function17
but highly effective substitutes exist.

METHODOLOGY
The search was carried out using a protocol based upon recommendations from the
Cochrane Collaboration. Relevant articles were identified by searching: CINAHL (2012 to
2019); Cochrane Database of Systematic Reviews [www.cochrane.org]; EMBASE (2012 to
2019); ERIC (2012 to 2019); PubMED (2012 to 2019), PsycINFO (2012 to 2019), MEDLINE
(2012 to 2019), OTSeeker [www.otseeker.com]; Physiotherapy Evidence Database (PEDro)
[www.pedro.fhs.usyd.edu.au]; Psychological database for Brain Impairment Treatment
Efficacy (PsycBITE) [www.psycbite.com]; PsycINFO (1935 to 2012); PubMED; and Speech
Pathology Database for Best Interventions and Treatment Efficacy (speechBITE)
[www.speechbite.com]. Searches were supplemented by hand searching. The search was
performed in March-July 2019. Electronic databases were searched with OVID host software
using PICOs search terms. The full search strategy is published elsewhere 18.
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