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 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 Version: Version 2b

Author: Dr M Webb, Public Health Practitioner Version: 2b

Date: 14/05/08 Page: 1 of 30

Status: Approved Intended Audience: Local Health Boards

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

CONTENTS
Executive summary 1. Background 2. Aims 3. Research questions 4. Methods 4.1 Identifying existing and ongoing research 4.1i Literature searching 5. Results 5.1 NDT/Bobath therapy 5.2 Alternative treatments 5. 2i Exercise programmes 5.2ii Botulinum toxin 5.2iii Acupuncture 5.2iv Drug therapy 5.2v Surgery 5.2vi Speech and language therapy 6 Conclusions 7 References Appendix 1 Main search strategy Appendix 2 High level search strategy Appendix 3 Evidence levels and quality grading Appendix 4 Evidence table Page 3 4 4 4 4 5 5 6 6 8 8 8 9 9 9 9 10 11 13 14 15 16

© 2008 National Public Health Service for Wales Material 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.

Author: Dr M Webb, Public Health Practitioner Version: 2b

Date: 14/05/08 Page: 2 of 30

Status: Approved Intended Audience: Local Health Boards

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

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.

Author: Dr M Webb, Public Health Practitioner Version: 2b

Date: 14/05/08 Page: 3 of 30

Status: Approved Intended Audience: Local Health Boards

The evidence for alternative treatments for CP was also evaluated. Methods The research question in Section 3 was converted to a structured question for searching using the Population. 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. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 4 of 30 Status: Approved Intended Audience: Local Health Boards . Research question What is the evidence that Bobath therapy improves motor and functional outcomes for children and adolescents with cerebral palsy? 4. 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. based on the work of the Bobaths.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. Comparison and Outcome (PICO)5 format.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 1. Background In 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). 2. The paper did not seek to separately quantify or compare Bobath therapy as a wider holistic social intervention. 1. 3.4 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 voluntary sector service to Welsh residents with cerebral palsy is provided by Bobath Cymru. Author: Dr M Webb. based in Cardiff. Intervention. Bobath has recently requested increased funding from the local health boards (LHBs) and there are commissioning concerns about this service. 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.

Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 5 of 30 Intended Audience: Local Health Boards i . 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. 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. Outcome: improved motor function. acupuncture. improved abilities in functional skills. search terms contained in the search strategies were used from published reviews and they were kept broad to maximise retrieval of references. do not adequately index all relevant literature. conventional physiotherapy/exercise training. health technology assessments and clinical guidelines were identified first. 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. High level searching: It is well known that the classical databases for medical literature.g. Author: Dr M Webb. It is clear that there had to be a balance between timeliness and rigour and high quality evidence and systematic reviews. decrease in contractures and/or deformities 4.1i Identifying existing and ongoing research 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. 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. such as Medline. It should be emphasised that the review is not a systematic review of primary studies. The basic search strategy is shown in Appendix 1. botulinum toxin.1 4.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 Patient: children and adolescents aged 0 -20i years with a diagnosis of cerebral palsy Intervention: use of Bobath/NDT as a primary intervention Comparison: alternative treatments – e. (Appendix 4) Due to practical limitations a single reviewer performed the final selection. Inclusion criteria Published papers on ‘children’ with CP contained a mix of age ranges and therefore the age range chosen was broad. Evidence was rejected if graded as poor quality. (Appendix 2) For critical appraisal. The data relevant to the research question was entered into an evidence table. surgery. meta-analyses. critical appraisal and data extraction. The quality of the evidence was graded using the NICE hierarchy of evidence and the quality checklists. For the present overview.

French or Spanish Interventions relating to Bobath therapy in the treatment of children and adolescents (age range 0-20 years) with cerebral palsy. contractures and deformity. quantity of therapy. motor development. 5. The searches revealed 350 documents for NDT/Bobath therapy and cerebral palsy. and other domains of child development (cognitive. German. mainly on the basis of the principles of NDT. 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. language. A total of 40 citations was downloaded into Reference Manager Software and critically appraised. social. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 6 of 30 Status: Approved Intended Audience: Local Health Boards . Results The scoping search revealed several key evidence documents and these high quality secondary sources were used to inform this paper. 23 articles were selected to inform this review. 9 The outcomes considered were motor responses. Only one study reported a better motor outcome in the experimental group than in the control group. Randomised controlled trials Systematic reviews Meta-analyses Guidelines Observational studies (where higher quality evidence was not available) 5. Eight studies evaluated the effects of NDT or physiotherapy. emotional etc The authors conclude that although there are still concerns regarding how to effectively measure the effectiveness of NDT in academic studies.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 Search period January 1995 – May 2008 Papers in English. 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 Author: Dr M Webb. functional limitation/activity.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. 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 2007 health technology assessment {HTA}. confounding and length of follow up. or the need for orthopaedic interventions. 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. 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.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 NDT. The result emphasises the importance of measuring outcomes other than locomotion and the inputs from local services. 15 Another RCT ( Level 1-) reported that the change scores for children in the intensive NDT group were higher than those of the standard group. particularly with sample size and power. 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. 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. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 7 of 30 Status: Approved Intended Audience: Local Health Boards . The multiAuthor: Dr M Webb.) 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. One RCT (Level 1. There were no significant differences between the groups in the incidence of contractures. The HTA again found that the published studies had methodological problems. One well designed (Level 1+). 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. c) investigation of the nature and intensity of NDT ) In spite of the lack of evidence for the effectiveness of NDT/Bobath. motor outcome in the NDT group was similar to that of the control group. motor development was worse in children treated in accordance with the principles of NDT than in children who received an infant stimulation programme. In the seventh study. 16 The statistical methods however. The other seven studies compared NDT with infant stimulation or with a form of standard care that was not defined further. used to analyse the results of this latter trial were not appropriate. not in the primary analysis and the effect was short lived. In six of the seven studies. sample heterogeneity. (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:comparison of NDT with other therapeutic approaches. lack of controls.

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. since they suggest that there is a sufficiency of therapy that will be helpful and above that there is no effect. and quality of life in children with cerebral palsy when added to standard care. 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. participation level.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. 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.) of an exercise training program demonstrated an improvement in physical fitness. 17 5. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 8 of 30 Status: Approved Intended Audience: Local Health Boards .2i Exercise programmes The results of a small RCT (Level 1 . 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. The trial is due for completion in August 2008.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 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. 5.2 Alternative treatments 5. It may be more important to be able to perform the functional task rather than to attain normal patterns of movement. 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. 20 21 Further Author: Dr M Webb. The authors stress that research is required into what is the optimum level of provision. 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.

selection bias.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 research incorporating larger sample sizes. 22 5. improvement in the use of arms or legs. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 9 of 30 Status: Approved Intended Audience: Local Health Boards . However. and comparative. Benefits claimed for acupuncture have included warmer extremities.2v Surgery A surgical method to reduce spasticity by selective posterior nerve root division was first described in 1913 and reintroduced in the 1970s. dantrolene and baclofen have been commonly used to alleviate spasticity in cerebral palsy.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. 27 The authors conclude that research is needed to investigate the effectiveness of new and established interventions and their acceptability to families. and application of subjective outcome measures have reported good results leading to the widespread use of this technique.2iii Acupuncture Acupuncture has been used to treat children and adolescents with CP for more than 20 years. efficacy of baclofen. and debate remains about their usefulness and there is a Cochrane protocol to assess the absolute.23 Intrathecal baclofen. 26 There is a Cochrane protocol designed to determine the effectiveness of selective dorsal rhizotomy in the management of children with spastic cerebral palsy. more restful sleep. a decrease in painful spasms. Numerous studies with confounding. positive trends in communication change were shown. rigorous methodology. measurement of upper limb function and functional outcomes is essential. Author: Dr M Webb. surgeon and therapist.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.2iv Drug therapy Three drugs diazepam. A Cochrane protocol aims to review all RCTs of acupuncture for children with CP. needs to be justified. family. which is expensive and very demanding of the child. dantrolene and diazepam for spasticity in cerebral palsy. improvement in mood and better bowel function. a much more invasive treatment has been recently introduced and a separate Cochrane protocol will review the evidence for the effectiveness of intrathecal baclofen. 25 5. 5. lack of controls and use of variable surgical techniques. 24 5.

Little information was found on service input and costs for children and adolescents with CP who receive NDT/Bobath therapy. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 10 of 30 Status: Approved Intended Audience: Local Health Boards . 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. one high quality RCT that used additional methodologies to study the effectiveness of intense levels of therapy failed to demonstrate an effect on outcomes. However. There was limited evidence for the effectiveness of alternative treatments (exercise programmes. Conclusions • Despite the widespread use of NDT/Bobath in children and adolescents with CP the existing published evidence.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 6. 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. some of which is good quality Level 1. does not provide support for the effectiveness of the NDT/Bobath treatment approach. medication. botulinum toxin. The present review has methodological limitations in that. whilst every effort was made to maximise retrieval of relevant references. surgery. 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. • • • • • • Author: Dr M Webb. speech and language therapy) used to treat children and adolescents with CP. acupuncture.

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 7. References Author: Dr M Webb. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 11 of 30 Status: Approved Intended Audience: Local Health Boards .

review. randomized. exercise ( in combination with strength. metanalyses and systematic reviews from Medline.ab. Author: Dr M Webb. motor intervention. NDT.ab. neurodevelopmental training. alternative therapy.ab.ab. medline. working capacity.pt. synthesis. sources. published. review. Bobath therapy.hw. occupational therapy. controlled.ab. aerobic power. cardiorespiratory physical training or programme).hw. reviewed.ab. surgery.ab.ab were used to retrieve RCTs.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 Appendix 1 Main search strategy Search terms included subject headings and text words based on: cerebral palsy.ab. selection.hw. literature. anaerobic power. The search terms meta. fitness.ab. articles. complementary therapy. meta-analysis pt.ab. trials. endurance. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 12 of 30 Status: Approved Intended Audience: Local Health Boards . early intervention. trials.

Population and Health Sciences University of Newcastle Centre for Reviews & Dissemination Clinical Evidence Department of Health Effective Practice & Organisation of Care Group Guidelines International Network Google Google scholar Health Evidence Bulletin Wales Health Management Information Consortium Health Technology Assessment Programme Kings Fund National Assembly for Wales National Library for Health ( NLH) – Children’s Health Specialist Library National Guideline Clearinghouse National Institute for Health and Clinical Excellence National Public Health Service for Wales NHS Centre for Reviews and Dissemination NHS Modernisation Agency PEDro Scottish Intercollegiate Guidelines Network (SIGN) Social Science I Centre SUMSearch Turning Research Into Practice (TRIP) Database UpToDate Author: Dr M Webb.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 Appendix 2 High level search strategy Agency for Healthcare Research and Quality Chronic Care (AHRQ) Audit Commission Agency for Quality in Medicine (AZQ) Canadian Coordinating Office for Health Technology Assessment (CCOHTA) Centre for Health Services Research . Public Health Practitioner Version: 2b Date: 14/05/08 Page: 13 of 30 Status: Approved Intended Audience: Local Health Boards .

case series) Expert opinion. systematic reviews of RCTs.= poor Author: Dr M Webb. Highquality case–control or cohort studies with a very low risk of confounding. or RCTs with a very low risk of bias Well-conducted meta-analyses.= fair to poor . or RCTs with a high risk of bias High-quality systematic reviews of case–control or cohort studies. systematic reviews of RCTs. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 14 of 30 Status: Approved Intended Audience: Local Health Boards . bias. bias. or chance and a significant risk that the relationship is not causal Non-analytic studies (for example. or chance and a moderate probability that the relationship is causal Case–control or cohort studies with a high risk of confounding bias. formal consensus 2+ 2- 3 4 Quality grading ++ = good quality + = fair +/.or RCTs with a low risk of bias Meta-analyses. case reports. systematic reviews of RCTs.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 Appendix 3 Evidence levels and quality grading modified from NICE Guideline Methodology Manual) ref 7 Level of Evidence 1++ 1+ 12++ Type of evidence High-quality meta-analyses. or chance and a high probability that the relationship is causal Well-conducted case–control or cohort studies with a low risk of confounding.

Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy. No. parental opinion and cost effectiveness.: CD001408.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 Appendix 4 Evidence table Study Population/ setting Children between the ages of 0 and 19 years old with CP who had been treated for lower limb spasticity. Three eligible studies were found each with small numbers of subjects. Outcomes Results Comments italics= reviewers comments Poor quality trials with potential for confounding and heterogeneity Design Evidence level/ quality 1- Ade-Hall RA. Intervention/ aim Systematic review of RCTs to determine effectiveness of BtA. Motor function measures including disability rating & gait analysis. quality of life. DOI: 10. Art. One study of twelve ambulant children. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 15 of 30 Intended Audience: Local Health Boards .C D001408. compared BtA with injection of a placebo and found non-significant improvements in gait in the BtA group compared to the placebo group. Issue 1. range of movement. Two studies compared BtA with the use of casts and there were no significant differences between the groups in either trial Status: Approved Systematic review + Author: Dr M Webb. Submeasures included spasticity.1002/14651858. Cochrane Database of Systematic Reviews 2000. Moore AP.

Adding covariates of age and severity levels produced a trend towards intensive therapy. The efficacy of Children with neurological Systematic review of trial Motor function and general Not restricted to children Systematic review 2++ Author: Dr M Webb. 43: 4–15. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 16 of 30 . Dev Med Child Neurol 2001. There were a similar number of Status: Approved Intended Audience: Local Health Boards Systematic review + Questionable statistical methods. Burns SA. Motor development assessment tools 34 studies fulfilled the selection criteria. Dev Med Child Neurol 2005. The results showed that NDT does not have a beneficial effect on motor development 56 children with CP. Intervention/ aim Systematic review of all types of study to determine the effects of physiotherapy A 2 x 2 RCT to compare the effects of routine amounts of physiotherapy with intensive amounts. A systematic review of the effects of early intervention on motor development. Bower E.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 Study Population/ setting Children from 0 to 18 months with Downs syndrome or CP Children with CP aged 3 – 12 years. Hadders-Algra M. Mitchell D. Burnett M et al. 1 child died. Randomized controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 months. RCT 1- Motor function and performance + Brown GA. There was no statistically significant difference in scores between intensive and routine amounts of physiotherapy. Outcomes Results Comments italics= reviewers comments Design Evidence level/ quality 2++ Blauw-Hospers CH. 47:421-32.

65:235-44. an AACPDM evidence report. development. Varied outcomes such as motor function and physiological parameters. Anti Spastic Medication Children with CP aged 6 months . Howard DC.15 years Systematic review of data on the effectiveness of NDT. Public Health Practitioner Version: 2b Intended Audience: Local Health Boards . British Journal of Occupational Therapy 2001. Comments italics= reviewers comments with CP. social activities. Dev Med Child Neurol 2001. Butler C. why Systematic review 2++ ++ Children and adults with Systematic review to Date: 14/05/08 Page: 17 of 30 Status: Approved Author: Dr M Webb. Darrah J. Effects of neurodevelopmental treatment (NDT) for cerebral palsy. Good methodology to minimise bias etc. published research studies supporting the benefit of NDT intervention (n=6) compared with no benefit (n=9). Design Evidence level/ quality + No inclusion of grey literature.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 Study Population/ setting dysfunction Intervention/ aim data on the effectiveness of NDT Outcomes Results neurodevelopmental treatments in children: a systematic review. NDT was not effective in any of the outcomes measured. Protocol listed in 2000. The studies that included the use of NDT with paediatric subjects diagnosed with CP had inconsistent results regarding the efficacy of NDT 21 articles were included.43: 778-90.

self care and social function. Art. Preliminary study but no follow up publication was identified. Case series 3 + Author: Dr M Webb. self care skills ( p=0. Participants demonstrated a significant improvement in scores for motor function (p=0. 20 children were recruited but only 15 children were enrolled for a 6 week course of therapy.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 Study Population/ setting CP Intervention/ aim assess the absolute. Parents and therapists perceptions of change. Issue 2. Dev Med Child Neurol 2002. dantrolene and diazepam for spasticity in cerebral palsy. Outcomes Results for Spasticity in Cerebral Palsy. Motor function. No. Evaluation of the CP aged 2functional effects of a 12 years course of Bobath therapy in children with cerebral palsy: a preliminary study. 44: 44760. (Protocol) Cochrane Database of Systematic Reviews 2000. .C D002260. efficacy of baclofen.: CD002260. and comparative. Lloyd Evans Children with A. Preliminary study to evaluate of the functional effects of Bobath therapy. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 18 of 30 Intended Audience: Local Health Boards .086) and caregiver Status: Approved Small numbers with high risk for bias.001). mobility. DOI: 10.1002/14651858. Comments italics= reviewers comments no publication? Design Evidence level/ quality Knox V.

Darrah J. Dev Med Child Neurol 1997. perception of improvement RCT 1- + Children with CP aged 1 – 5 years. Russell D. Pollock N et al.012) Hand function. 50 children secondary completed the outcomes study. A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy program for children with cerebral palsy. QOL Planned to recruit 220 children.39: 664– 70. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 19 of 30 Status: Approved Intended Audience: Local Health Boards . Trial finished 2007.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 Study Population/ setting Intervention/ aim Outcomes Results Comments italics= reviewers comments Insufficient details of randomisation process Design Evidence level/ quality Law M. There were were upper no significant limb differences in movement outcomes between and parents’ the groups. BMC Children with CP aged 18 months – 4 years RCT to compare the effectiveness of intensive NDT and casting with regular OT programme assistance ( p=0. Law M. Publication ? RCT ? Author: Dr M Webb. RCT to compare a task /content focussed treatment approach with a child focussed treatment. Motor function. disability measures. Pollock N et al. Focus on function – a randomized controlled trial comparing two rehabilitation interventions for young children with cerebral palsy.

Children with CP aged 0 – 18 months RCT to determine the effectiveness of intensive versus regular physiotherapy. The effect of physical therapy for children with motor delay and cerebral palsy: a randomized clinical trial. 7:31. which with 24 df was associated with P = 0. Am J Phys Med Rehabil 1991. RCT 1- +/- Author: Dr M Webb.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 Study Population/ setting Intervention/ aim Outcomes Results Comments italics= reviewers comments Insufficient details of randomisation . A statistical test led to an equivalent of a Student's t = 3.0019 (two-sided). Problems with methodology. Design Evidence level/ quality Pediatrics 2007. after adjusting for the child's age. Mayo NE. 70: 258-67.49. 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. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 20 of 30 Status: Approved Intended Audience: Local Health Boards .

and mental quotient 48 children were Well studied. 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) Outcomes Results Narayanan U. Motor quotient. (Protocol) Cochrane Database of Systematic Reviews 2001.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 Study Population/ setting Children with CP Intervention/ aim Systematic review to determine the effectiveness of selective dorsal rhizotomy in the management of children with spastic cerebral palsy.02) and were less likely to walk (12 vs. 318: 803-8.1. Comments italics= reviewers comments Protocol listed 2001.: CD003360. Wachtel RC et al.C D003360. No. 58. Art.1 vs. DOI: 10. Design Evidence level/ quality Children with CP aged 12 – 19 months. 35 percent. P = 0. After six designed trial months. These differences Status: Approved Intended Audience: Local Health Boards RCT 1+ + Author: Dr M Webb. The effects of physical therapy on cerebral palsy: a controlled trial in infants with spastic diplegia. Selective dorsal rhizotomy in the management of children with spastic cerebral palsy. Issue 3. Palmer FB. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 21 of 30 . Shapiro BK. Howard A. motor ability.07). NEJM 1988. P = 0. the infants but with small in Gp A had a lower numbers mean motor quotient than those in Gp B (49.1002/14651858.

P = 0.01. Issue 3.1002/14651858. Marshall J. as measured by change in interaction patterns. respectively) Eleven studies were included in the review. Speech and language therapy to improve the communication skills of children with cerebral palsy. and 36 vs. Children with CP Systematic review to determine the effectiveness of SLT that focuses on the child or their familiar communication partners. No. No conclusions could be made about the effectiveness of SLT due to methodological problems with the Date: 14/05/08 Page: 22 of 30 Status: Approved Intended Audience: Local Health Boards Pennington L. Public Health Practitioner Version: 2b .3. DOI: 10. Cochrane Database of Systematic Reviews 2003.: CD003466.pub2. P less than 0. 73 percent. Seven studies evaluated treatment given directly to children. four investigated the effects of training for communication partners. Art. 63.9 vs.01. • To determine if individual types of SLT Poor quality studies Systematic review 1- + Author: Dr M Webb.C D003466. Outcomes Results Comments italics= reviewers comments Design Evidence level/ quality persisted after 12 months of therapy (47. Goldbart J.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 Study Population/ setting Intervention/ aim of infant stimulation [NDT] .

Issue 1. Rice JE.1002/14651858. DOI: 10. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 23 of 30 Status: Approved Intended Audience: Local Health Boards . No. O'Donnell ME. Children with CP Systematic review to determine the effectiveness of intrathecal baclofen in treating spasticity in children with CP.C D004552.: CD004552. Author: Dr M Webb. Art.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 Study Population/ setting Intervention/ aim intervention are more effective than others in changing interaction patterns. Outcomes Results Comments italics= reviewers comments Design Evidence level/ quality studies. Intrathecal Baclofen for treating spasticity in children with cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2004.

Dev Med Child Neurol 2004. Children receiving intensive NDT performed better ( p<0. Verschuren O. Evaggelinou C.001) and anaerobic capacity (P = . Public Health Practitioner Version: 2b Date: 14/05/08 Page: 24 of 30 Intended Audience: Local Health Boards . Grouios G et al. Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsy.004).001). 86 children were randomly assigned to an exercise training programme or no training. 46: 740-45. Motor function improved in both groups. A significant effect was also found for agility (P < . Ketelaar M. ANCOVA not used. Arch Pediatr Adolesc Med 2007. Gorter JW et al.05) that regular NDT group. A significant training effect was found for aerobic (P < . Status: Approved Comments italics= reviewers comments Inappropriate statistical methods. Outcomes Results Tsorlakis N. Design Evidence level/ quality 1- RCT +/- RCT 1- + Author: Dr M Webb. Authors conclusions not supported by results. Exercise training program in children and adolescents with cerebral palsy: a randomized controlled trial. 161: 1075-81.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 Study Population/ setting Children with CP aged 3 – 14 years Intervention/ aim RCT to determine the effect of intensive NDT compared with regular schedules. Motor function Children and adolescents with CP aged 7 – 18 years RCT to determine the effect of an exercise training programme Aerobic and anaerobic capacity 34 children were randomised to intensive NDT (5/week) or regular NDT (2/week).

The results from the 2 trials were inconsistent and no Status: Approved Some trials had methodologic al problems. Hoare B.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 Study Population/ setting Intervention/ aim Outcomes Results Comments italics= reviewers comments Design Evidence level/ quality muscle strength (P < . Public Health Practitioner Version: 2b Date: 14/05/08 Page: 25 of 30 Intended Audience: Local Health Boards . Children with CP aged 6 – 20 years Systematic review of the literature on the effectiveness of exercise programmes Wasiak J. Am J Phys Med Rehabil 2008.001). 87:404-417. Exercise programs for children with cerebral palsy: a systematic review of the literature. 2 trials were included. Verschuren O. 005). Takken T et al. Botulinum toxin A as an adjunct to treatment in the management of the Children with CP Systematic review to assess the effectiveness of Motor outcomes 5 trials on children with CP met the inclusion criteria. and athletic competence (P = . The results suggest that exercise programmes that focus on lower extremity muscle strength and /or cardiovascular fitness may be of benefit. Wallen M. Systematic review 1+ + Systematic review 1+ Author: Dr M Webb. Ketelaar M.

Outcomes Results Comments italics= reviewers comments Design Evidence level/ quality + upper limb in children with spastic cerebral palsy. conclusions can be made Children aged < 3 years.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 Study Population/ setting Intervention/ aim intramuscular BtA injections as an adjunct to managing the upper limb in children with spastic CP.1002/14651858. Cochrane Database of Systematic Reviews 2004. Cunningham CC. Qualitative studies were also performed. No. DOI: 10. parent satisfaction. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 26 of 30 Intended Audience: Local Health Boards . PAG = one extra session physiotherapy 3. Health Technol Assess 2007. Participants were randomised to 3 interventions :1. Multicentred RCT to determine whether additional support for children with CP and their falilies improves outcomes Motor function.pub3. 79 families started the intervention and 76 completed the 6 month intervention. 11(16). developmenta l status. RCT 1++ + Author: Dr M Webb.C D003469. Weindling AM. Issue 4. Art. FSWG = weekly home visits from a family social Status: Approved Well designed trial with adequate details of methodology. Glenn SM et al. Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial. CG= routine physiotherapy and support 2.: CD003469. adaptive functioning.

Ai CL. Zhang MM. Public Health Practitioner Version: 2b .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 Study Population/ setting Intervention/ aim Outcomes Results Comments italics= reviewers comments Design Evidence level/ quality worker. The detailed analyses of found no significant effect of extra intervention in the form of physiotherapy or extra social worker input. He J. (Protocol) Cochrane Database of Systematic Reviews 2008. Art. Follow up was at 12 and 18 months. Acupuncture for children with cerebral palsy. athetoid cerebral palsy and ataxic Date: 14/05/08 Page: 27 of 30 Status: Approved Intended Audience: Local Health Boards Author: Dr M Webb. No.C D007127 Children with CP Systematic review to determine the efficacy and safety of acupuncture therapy for children with CP including spastic cerebral palsy.: CD007127.1002/14651858. . Li J. DOI: 10. Issue 2.

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 Study Population/ setting Intervention/ aim cerebral palsy Outcomes Results Comments italics= reviewers comments Design Evidence level/ quality Author: Dr M Webb. Public Health Practitioner Version: 2b Date: 14/05/08 Page: 28 of 30 Status: Approved Intended Audience: Local Health Boards .

BMC Pediatrics 2007.org/fullmono/mon1116. Guideline development methods. 70: 258-67.uk. Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy. Glenn SM et al. [Accessed 10th May 2008] 7 National Institute for Health and Clinical Excellence. 11 Blauw-Hospers CH. Available at: http://www.nphs. NPHS 2008. 20 Ade-Hall RA. 19 Verschuren O. Rosenberg W et al.ncchta. NEJM 1988. Issue 1. Am J Phys Med Rehabil 1991. Available at: http://www. 13 Palmer FB. 161: 1075-81. Dev Med Child Neurol 2005. Cochrane Database of 1 .com/1471-2431/7/31. Pollock N et al. [Accessed 1st May 2008] 2 Bobath K. Ketelaar M. Scoping brief: Bobath therapy. [Accessed 10th May 2008] 8 National Public Health Service. Pollock N et al. Russell D. Burns SA. Lloyd Evans A. Evidence checklist. Mitchell D. 12 Mayo NE. Wachtel RC et al. 10 Brown GA. Darrah J. Dev Med Child Neurol 2001. The efficacy of neurodevelopmental treatments in children: a systematic review. A systematic review of the effects of early intervention on motor development. 16 Tsorlakis N.wales. 6 National Public Health Service. Hoare B. 2007. 11(16). 21 Wasiak J. 17 Law M. Ketelaar M. Am J Phys Med Rehabil 2008. Evidence based medicine: how to practice and teach EBM. Focus on Function – a randomized controlled trial comparing two rehabilitation interventions for young children with cerebral palsy.nice. Richardson WS. A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy program for children with cerebral palsy. Available at: http://www.Weindling AM. Management of the motor disorders of children with cerebral palsy. 46: 740-45.43: 4–15. [Accessed 12th May 2008] 18 Verschuren O. cited in 3 3 Knox V.60. Randomized controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 months. Oxford: Blackwell Scientific Publications Ltd. Dev Med Child Neurol 2001. Cardif:NPHS. unpublished 5 Sackett DL. The neurodevelopmental treatment In: Scrotton D. 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 2000. 15 Bower E. Effects of neurodevelopmental treatment (NDT) for cerebral palsy. Developmental Medicine Child Neurology 1997. 65:235-44. Takken T et al. Hadders-Algra M. Dev Med Child Neurol 2002. Bobath therapy. Shapiro BK. No. ed. Evaluation of the functional effects of a course of Bobath therapy in children with cerebral palsy: a preliminary study. [unpublished] 9 Butler C. Edinburgh: Churchill Livingstone. Exercise training program in children and adolescents with cerebral palsy: a randomized controlled trial.1002/14651858. Gorter JW et al. Grouios G et al.nhs. Bobath B. Arch Pediatr Adolesc Med 2007. 7:31. 87:404-17. Burnett M et al. Art. 47: 421-32. DOI: 10. 1984. 39: 664–70.43: 778-90. 4 Regional Commissioning Support Unit (SE).org. Available at: http://www/biomedcentral.CD001408. Dev Med Child Neurol 2004. Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsy.: CD001408. The effects of physical therapy on cerebral palsy: a controlled trial in infants with spastic diplegia. Wallen M. Health Technol Assess 2007. Exercise programs for children with cerebral palsy: a systematic review of the literature.pdf. 318: 803-808. 44: 447. 1995. Darrah J. Evaggelinou C. Cunningham CC. British Journal of Occupational Therapy 2001. Moore AP. The effect of physical therapy for children with motor delay and cerebral palsy: a randomized clinical trial. 14 Law M. an AACPDM evidence report.uk. Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial.

Anti Spastic Medication for Spasticity in Cerebral Palsy. No.: CD004552.CD003469. Issue 2. Selective dorsal rhizotomy in the management of children with spastic cerebral palsy.CD007127. Art. O'Donnell ME.CD003466.1002/14651858. 26 Landau WM. DOI: 10.CD003360.pub3.Systematic Reviews 2004. Marshall J. (Protocol) Cochrane Database of Systematic Reviews 2004.1002/14651858. (Protocol) Cochrane Database of Systematic Reviews 2008. Issue 2. Howard A.5:174-8. Art. Et al. a treatment of unproven efficacy [comment] [see comments]. He J. (Protocol) Cochrane Database of Systematic Reviews 2001. Goldbart J. Issue 1.CD004552. Dorsal rhizotomy. Issue 3. DOI: 10.: CD002260. Art. 22 Zhang MM. (Protocol) Cochrane Database of Systematic Reviews 2000. J Child Neurol 1990. 25 Narayanan U. Art. Speech and language therapy to improve the communication skills of children with cerebral palsy. Acupuncture for children with cerebral palsy.1002/14651858.: CD007127. DOI: 10. Hunt CC. 24 Rice JE. 23 Howard DC. Ai CL. DOI: 10. No.: CD003469. Issue 4.: CD003466. No. No. Issue 3. DOI: 10. No.CD002260.: CD003360.1002/14651858. Intrathecal Baclofen for treating spasticity in children with cerebral palsy. No. Art. . Art. Cited in 22 27 Pennington L.1002/14651858. DOI: 10.pub2. Cochrane Database of Systematic Reviews 2003.1002/14651858.

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