Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial

Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis

BACKGROUND AND OBJECTIVE

Bobath therapy, or neurodevelopmental therapy (NDT) is widely practiced despite evidence other interventions are more effective in cerebral palsy (CP). The objective is to determine the efficacy of NDT in children and infants with CP or high risk of CP.

METHODS

Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, and Medline were searched through March 2021. Randomized controlled trials comparing NDT with any or no intervention were included. Meta-analysis was conducted with standardized mean differences calculated. Quality was assessed by using Cochrane Risk of Bias tool-2 and certainty by using Grading of Recommendations Assessment, Development, and Evaluation.

RESULTS

Of 667 records screened, 34 studies (in 35 publications, 1332 participants) met inclusion. Four meta-analyses were conducted assessing motor function. We found no effect between NDT and control (pooled effect size 0.13 [-0.20 to 0.46]), a moderate effect favoring activity-based approaches (0.76 [0.12 to 1.40]) and body function and structures (0.77 [0.19 to 1.35]) over NDT and no effect between higher- and lower-dose NDT (0.32 [-0.11 to 0.75]). A strong recommendation against the use of NDT at any dose was made. Studies were not all Consolidated Standards of Reporting Trials-compliant. NDT versus activity-based comparator had considerable heterogeneity (I2 = 80%) reflecting varied measures.

CONCLUSIONS

We found that activity-based and body structure and function interventions are more effective than NDT for improving motor function, NDT is no more effective than control, and higher-dose NDT is not more effective than lower-dose. Deimplementation of NDT in CP is required.

Comprehensive review of statistical methods for analysing patient-reported outcomes (PROs) used as primary outcomes in randomised controlled trials (RCTs) published by the UK's Health Technology Assessment (HTA) journal (1997-2020)

OBJECTIVES

To identify how frequently patient-reported outcomes (PROs) are used as primary and/or secondary outcomes in randomised controlled trials (RCTs) and to summarise what statistical methods are used for the analysis of PROs.

DESIGN

Comprehensive review.

SETTING

RCTs funded and published by the United Kingdom's (UK) National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme.

DATA SOURCES AND ELIGIBILITY

HTA reports of RCTs published between January 1997 and December 2020 were reviewed.

DATA EXTRACTION

Information relating to PRO use and analysis methods was extracted.

PRIMARY AND SECONDARY OUTCOME MEASURES

The frequency of using PROs as primary and/or secondary outcomes; statistical methods that were used for the analysis of PROs as primary outcomes.

RESULTS

In this review, 37.6% (114/303) of trials used PROs as primary outcomes, and 82.8% (251/303) of trials used PROs as secondary outcomes from 303 NIHR HTA reports of RCTs. In the 114 RCTs where the PRO was the primary outcome, the most used PRO was the Short-Form 36 (8/114); the most popular methods for multivariable analysis were linear mixed model (45/114), linear regression (29/114) and analysis of covariance (13/114); logistic regression was applied for binary and ordinal outcomes in 14/114 trials; and the repeated measures analysis was used in 39/114 trials.

CONCLUSION

The majority of trials used PROs as primary and/or secondary outcomes. Conventional methods such as linear regression are widely used, despite the potential violation of their assumptions. In recent years, there is an increasing trend of using complex models (eg, with mixed effects). Statistical methods developed to address these violations when analysing PROs, such as beta-binomial regression, are not routinely used in practice. Future research will focus on evaluating available statistical methods for the analysis of PROs.

Effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic cerebral palsy: a randomized controlled trial

BACKGROUND

Children with cerebral palsy show various degrees of dysphagia causing late development of oral motor skills.

AIM

To investigate effect of oral sensorimotor stimulation on oropharyngeal dysphagia in children with spastic quadriplegia.

DESIGN

This was a double-masked, randomized controlled clinical trial.

SETTING

Out-patient Clinics of Faculty of Physical Therapy, Cairo University and Modern University of Technology and information.

POPULATION

A convenient sample of 71 children age ranged from 12 to 48 months diagnosed with spastic quadriplegia, were randomly assigned into two groups.

METHODS

Children in the control group received 90 minutes conventional physical therapy training five times/week for 4 successive months while those in the experimental group received 20 minutes of oral sensorimotor stimulation before the same program as in control group for 60 minutes. Oral motor function, body weight, segmental trunk control and gross motor function were assessed at base-line and after completing treatment.

RESULTS

In total, 64 (experimental n=32, control n=32) children completed treatment and data collection. The baseline assessment showed non-significant difference regarding all measured variables while with-in group comparison showed significant improvement in the two groups. The post-treatment comparisons revealed significant difference the oral motor function and physical growth in favor of the experimental group (p < 0.05). Finally, there was non-significant difference regarding segmental trunk control and gross motor function (p > 0.05).

CONCLUSIONS

Oral sensorimotor stimulation has the capability to improve feeding in children with spastic cerebral palsy diagnosed with oropharyngeal dysphagia.

CLINICAL REHABILITAYION IMPACT

OSMS has effect on some of the essential oral motor skills that contribute toward the improvement of feeding performance in children with spastic CP. The results of our study offer remarkable clinical importance for the children and their families.

The effect of delegation of therapy to allied health assistants on patient and organisational outcomes: a systematic review and meta-analysis

Background

Allied health assistants (AHAs) are support staff who complete clinical and non-clinical tasks under the supervision and delegation of an allied health professional. The effect of allied health professional delegation of clinical tasks to AHAs on patient and healthcare organisational outcomes is unknown. The purpose of this systematic review was to investigate the effect of allied health professional delegation of therapy to AHAs on patient and organisational outcomes.

Methods

A systematic review and meta-analysis was conducted. Databases MEDLINE (Ovid), Embase (Ovid), Informit (all databases), Emcare (Ovid), PsycINFO (Ovid), Cumulative Index to Nursing and Allied Health Literature [CINAHL] (EbscoHost) and the Cochrane Database of Systematic Reviews were searched from earliest date available. Additional studies were identified by searching reference lists and citation tracking. Two reviewers independently applied inclusion and exclusion criteria. The quality of the study was rated using internal validity items from the Downs and Black checklist. Risk ratios (RR) and mean differences (MD) were calculated for patient and organisational outcomes. Meta-analyses were conducted using the inverse variance method and random-effects model.

Results

Twenty-two studies met the inclusion criteria. Results of meta-analysis provided low quality evidence that AHA supervised exercise in addition to usual care improved the likelihood of patients discharging home (RR 1.28, 95%CI 1.03 to 1.59, I² = 60%) and reduced length of stay (MD 0.28 days, 95%CI 0.03 to 0.54, I² = 0%) in an acute hospital setting. There was preliminary evidence from one high quality randomised controlled trial that AHA provision of nutritional supplements and assistance with feeding reduced the risk of patient mortality after hip fracture (RR 0.41, 95%CI 0.16 to 1.00). In a small number of studies (n = 6) there was no significant difference in patient and organisational outcomes when AHA therapy was substituted for therapy delivered by an allied health professional.

Conclusion

We found preliminary evidence to suggest that the use of AHAs to provide additional therapy may be effective for improving some patient and organisational outcomes.

Review registration

CRD42019127449.

Intervention development and treatment success in UK health technology assessment funded trials of physical rehabilitation: a mixed methods analysis

OBJECTIVES

Physical rehabilitation is a complex process, and trials of rehabilitation interventions are increasing in number but often report null results. This study aimed to establish treatment success rates in physical rehabilitation trials funded by the National Institute of Health Research Health Technology Assessment (NIHR HTA) programme and examine any relationship between treatment success and the quality of intervention development work undertaken.

DESIGN

This is a mixed methods study.

SETTING

This study was conducted in the UK.

METHODS

The NIHR HTA portfolio was searched for all completed definitive randomised controlled trials of physical rehabilitation interventions from inception to July 2016. Treatment success was categorised according to criteria developed by Djulbegovic and colleagues. Detailed textual data regarding any intervention development work were extracted from trial reports and supporting publications and informed the development of quality ratings. Mixed methods integrative analysis was undertaken to explore the relationship between quantitative and qualitative data using joint displays.

RESULTS

Fifteen trials were included in the review. Five reported a definitive finding, four of which were in favour of the 'new' intervention. Eight trials reported a true negative (no difference) outcome. Integrative analysis indicated those with lower quality intervention development work were less likely to report treatment success.

CONCLUSIONS

Despite much effort and funding, most physical rehabilitation trials report equivocal findings. Greater focus on high quality intervention development may reduce the likelihood of a null result in the definitive trial, alongside high quality trial methods and conduct.

Therapy interventions for children with neurodisabilities: a qualitative scoping study

BACKGROUND

Therapy interventions emerged four times in the top 10 research priorities in a James Lind Alliance research prioritisation exercise for children with neurodisabilities (Morris C, Simkiss D, Busk M, Morris M, Allard A, Denness J, et al. Setting research priorities to improve the health of children and young people with neurodisability: a British Academy of Childhood Disability-James Lind Alliance Research Priority Setting Partnership. BMJ Open 2015;5:e006233). The National Institute for Health Research (NIHR) commissioned this study as part of an information-gathering exercise in response to this.

OBJECTIVES

The objectives were to (1) describe the current practice, approaches and schools of thought in relation to physiotherapy, occupational therapy and speech and language therapy for children with neurodisability; (2) explore clinical decision-making; (3) investigate views on outcomes and their measurement, particularly participation as an outcome, that is, the child's ability to have the opportunity to be involved in life situations and activities (e.g. communication, mobility, interpersonal interactions, self-care, learning and applying knowledge); (4) seek views on the aspects of therapy interventions that have an impact on outcomes; and (5) elicit stakeholder views on research needs and priorities.

DESIGN, SETTING AND PARTICIPANTS

More than 70 professionals (therapists, service leads, paediatricians and education staff) and 25 parents participated in a qualitative interview (either individually or as part of a focus group).

RESULTS

Professional thinking and models of service delivery are in a state of flux and development. There is a move towards goals-focused, family-centred approaches. Work tends to be highly individualised, with few protocols. Parents are certain of the value of therapies, although they may experience difficulties with provision and may seek (additional) private provision. Therapy interventions are conceived as three components: the therapist, the procedures/equipment, etc., and the wider therapeutic environment. They are believed to be highly complex and poorly understood. Although participation is widely endorsed as a core intervention objective of therapy interventions, its suitability, or appropriateness, as an outcome measure was questioned. Other child and/or parent outcomes were identified as more or equally important. Notions of intermediate outcomes - in terms of body structure/function, and the achievement of activities - were regarded as important and not counter to participation-focused approaches. Among therapists, research on intervention effectiveness was (cautiously) welcomed. A number of methodological challenges were identified. A portfolio of study designs - quantitative and qualitative, experimental and observational - was called for, and which included economic evaluation and clear pathways to impact.

LIMITATIONS

The study was not successful in recruiting children and young people. Further work is required to elucidate the views of this key stakeholder group.

CONCLUSIONS

Therapy interventions are poorly understood. There was strong support, tempered a little by concerns among some about the feasibility of demonstrating impact, for investment in research.

FUTURE WORK

The identification of research priorities was a core study objective, and a wide-ranging research agenda was identified. It included 'foundational' research into neurodisability, the active components of therapy interventions and the concept of participation. Three areas of evaluation were identified: overall approaches to therapy, service organisation and delivery issues, and the evaluation of specific techniques. Parents regarded evaluations of approaches to therapy (e.g. goals-focused; supporting family-self management) as priorities, along with evaluations of models of service provision. Professionals' views were broadly similar, with an additional emphasis on methodological research. In terms of specific techniques, there was no shared agreement regarding priorities, with views informed by personal interests and experiences.

FUNDING

The NIHR Health Technology Assessment programme.

The uses of outcome measures within multidisciplinary early childhood intervention services: a systematic review

Purpose of the article: To review the use of outcome measures, across the domains of activity, participation, and environment, within multidisciplinary early childhood intervention services.

MATERIALS AND METHODS

A systematic literature search was undertaken that included four electronic databases: Medline, CINAHL, EMBASE, and the Cochrane Library and Cochrane Database of Systematic Review. Inclusion criteria were age 0-24 months, having or at risk of a developmental disability, in receipt of multidisciplinary early childhood intervention services, and included outcome measures across all domains of the International Classification of Functioning-Child & Youth (ICF-CY). Only peer-reviewed journal articles were considered. Eligible studies were coded using the Oxford Levels of Evidence. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) Scale for randomised controlled trials and the QualSyst for non-randomised control trials.

RESULTS

Of the total of 5764 records identified, 10 were considered to meet inclusion criteria.

CONCLUSION

Fourteen outcome measures were identified, addressing the domains of activity, participation, and environment. Of these, eight have been recommended in the early intervention literature. While the methodological quality of the 10 studies varied, these papers make a contribution to the body of research that acknowledges the role of routine and enriched environments. Implications for Rehabilitation Core practice elements of multidisciplinary early childhood intervention services indicate it is necessary to select outcome measures framed within the International Classification of Functioning-Child & Youth to inform clinical decision-making for measuring intervention effectiveness across the domains of activity, participation and environment. Of the identified measures, three (Canadian Occupational Performance Measure, Pediatric Evaluation of Disability Inventory, and Goal Attainment Scaling) are well-established and identified in the literature as multidisciplinary outcome measures for children with developmental disability. The selection of an appropriate outcome measure depends on the age of the child, individual goals of the family, and the type of intervention. This requires the combination of measures as no one measure alone will capture all components of the International Classification of Functioning-Child & Youth.

Exercise interventions for cerebral palsy

BACKGROUND

Cerebral palsy (CP) is a neurodevelopmental disorder resulting from an injury to the developing brain. It is the most common form of childhood disability with prevalence rates of between 1.5 and 3.8 per 1000 births reported worldwide. The primary impairments associated with CP include reduced muscle strength and reduced cardiorespiratory fitness, resulting in difficulties performing activities such as dressing, walking and negotiating stairs.Exercise is defined as a planned, structured and repetitive activity that aims to improve fitness, and it is a commonly used intervention for people with CP. Aerobic and resistance training may improve activity (i.e. the ability to execute a task) and participation (i.e. involvement in a life situation) through their impact on the primary impairments of CP. However, to date, there has been no comprehensive review of exercise interventions for people with CP.

OBJECTIVES

To assess the effects of exercise interventions in people with CP, primarily in terms of activity, participation and quality of life. Secondary outcomes assessed body functions and body structures. Comparators of interest were no treatment, usual care or an alternative type of exercise intervention.

SEARCH METHODS

In June 2016 we searched CENTRAL, MEDLINE, Embase, nine other databases and four trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs of children, adolescents and adults with CP. We included studies of aerobic exercise, resistance training, and 'mixed training' (a combination of at least two of aerobic exercise, resistance training and anaerobic training).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and potentially relevant full-text reports for eligibility; extracted all relevant data and conducted 'Risk of bias' and GRADE assessments.

MAIN RESULTS

We included 29 trials (926 participants); 27 included children and adolescents up to the age of 19 years, three included adolescents and young adults (10 to 22 years), and one included adults over 20 years. Males constituted 53% of the sample. Five trials were conducted in the USA; four in Australia; two in Egypt, Korea, Saudi Arabia, Taiwan, the Netherlands, and the UK; three in Greece; and one apiece in India, Italy, Norway, and South Africa.Twenty-six trials included people with spastic CP only; three trials included children and adolescents with spastic and other types of CP. Twenty-one trials included people who were able to walk with or without assistive devices, four trials also included people who used wheeled mobility devices in most settings, and one trial included people who used wheeled mobility devices only. Three trials did not report the functional ability of participants. Only two trials reported participants' manual ability. Eight studies compared aerobic exercise to usual care, while 15 compared resistance training and 4 compared mixed training to usual care or no treatment. Two trials compared aerobic exercise to resistance training. We judged all trials to be at high risk of bias overall.We found low-quality evidence that aerobic exercise improves gross motor function in the short term (standardised mean difference (SMD) 0.53, 95% confidence interval (CI) 0.02 to 1.04, N = 65, 3 studies) and intermediate term (mean difference (MD) 12.96%, 95% CI 0.52% to 25.40%, N = 12, 1 study). Aerobic exercise does not improve gait speed in the short term (MD 0.09 m/s, 95% CI -0.11 m/s to 0.28 m/s, N = 82, 4 studies, very low-quality evidence) or intermediate term (MD -0.17 m/s, 95% CI -0.59 m/s to 0.24 m/s, N = 12, 1 study, low-quality evidence). No trial assessed participation or quality of life following aerobic exercise.We found low-quality evidence that resistance training does not improve gross motor function (SMD 0.12, 95% CI -0.19 to 0.43, N = 164, 7 studies), gait speed (MD 0.03 m/s, 95% CI -0.02 m/s to 0.07 m/s, N = 185, 8 studies), participation (SMD 0.34, 95% CI -0.01 to 0.70, N = 127, 2 studies) or parent-reported quality of life (MD 12.70, 95% CI -5.63 to 31.03, n = 12, 1 study) in the short term. There is also low-quality evidence that resistance training does not improve gait speed (MD -0.03 m/s, 95% CI -0.17 m/s to 0.11 m/s, N = 84, 3 studies), gross motor function (SMD 0.13, 95% CI -0.30 to 0.55, N = 85, 3 studies) or participation (MD 0.37, 95% CI -6.61 to 7.35, N = 36, 1 study) in the intermediate term.We found low-quality evidence that mixed training does not improve gross motor function (SMD 0.02, 95% CI -0.29 to 0.33, N = 163, 4 studies) or gait speed (MD 0.10 m/s, -0.07 m/s to 0.27 m/s, N = 58, 1 study) but does improve participation (MD 0.40, 95% CI 0.13 to 0.67, N = 65, 1 study) in the short-term.There is no difference between resistance training and aerobic exercise in terms of the effect on gross motor function in the short term (SMD 0.02, 95% CI -0.50 to 0.55, N = 56, 2 studies, low-quality evidence).Thirteen trials did not report adverse events, seven reported no adverse events, and nine reported non-serious adverse events.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions is low to very low. As included trials have small sample sizes, heterogeneity may be underestimated, resulting in considerable uncertainty relating to effect estimates. For children with CP, there is evidence that aerobic exercise may result in a small improvement in gross motor function, though it does not improve gait speed. There is evidence that resistance training does not improve gait speed, gross motor function, participation or quality of life among children with CP.Based on the evidence available, exercise appears to be safe for people with CP; only 55% of trials, however, reported adverse events or stated that they monitored adverse events. There is a need for large, high-quality, well-reported RCTs that assess the effectiveness of exercise in terms of activity and participation, before drawing any firm conclusions on the effectiveness of exercise for people with CP. Research is also required to determine if current exercise guidelines for the general population are effective and feasible for people with CP.

Effects of Neuromuscular Electrical Stimulation on Swallowing Functions in Children with Cerebral Palsy: A Pilot Randomised Controlled Trial

Objective/Background

Oral-motor and sensory dysfunctions are primary reasons for difficulties with swallowing in children with cerebral palsy (CP). Neuromuscular electrical stimulation (NMES) has been shown to provide positive effects on the swallowing function in adult populations with various neurological disorders. However, there is a lack of studies regarding the effects of NMES in children with dysphagia. The aim of the present study was to investigate the effects of NMES and oral sensorimotor treatment (OST) by occupational therapists in children with CP and dysphagia.

Methods

The present study was a two-group experimental design. Participants were randomly assigned to either the experimental group (n = 10) or the control group (n = 10). The NMES group received both NMES and OST, with NMES on the pharyngeal level for 20 minutes after OST, while the control group received OST and sham–-NMES only. The treatment sessions occurred twice a week for 8 weeks.

Results

The experimental group demonstrated a significant improvement in: lip closure while swallowing, ability to swallow food without excess loss, ability to sip liquid, ability to swallow liquid without excess loss, and ability to swallow without cough (p < .05).

Conclusion

This study demonstrated that OST and NMES facilitated swallowing functions than OST and sham–-NMES in children with CP and dysphagia. Future studies need to utilise video fluoroscopy swallowing study for outcome measurements in a large participant group.

Knowledge Translation of the Gross Motor Function Classification System Among Pediatric Physical Therapists

PURPOSE

To learn where pediatric physical therapists in the United States are in the process of knowledge translation of the Gross Motor Function Classification System (GMFCS).

METHODS

Links to an online survey were distributed electronically.

RESULTS

All 283 respondents reported hearing about the GMFCS, 95% agreed it was useful, 81% reported they were confident in their ability to use it, 77% reported they use it, and 42% reported they use it consistently. Therapists primarily used the GMFCS to predict gross motor function, set realistic goals, and anticipate need for assistive technology. The American Physical Therapy Association Section on Pediatrics members were more likely than nonmembers to agree the GMFCS is useful, they are able to use it, that they use it, and that they use it consistently.

CONCLUSIONS

The majority of therapists responding use the GMFCS, but not consistently.

VIDEO ABSTRACT

For more insights from the authors, see Supplemental Digital Content 1, available at http://links.lww.com/PPT/A91.

Intensive training of motor function and functional skills among young children with cerebral palsy: a systematic review and meta-analysis

BACKGROUND

Young children with cerebral palsy (CP) receive a variety of interventions to prevent and/or reduce activity limitations and participation restrictions. Some of these interventions are intensive, and it is a challenge to identify the optimal intensity. Therefore, the objective of this systematic review was to describe and categorise intensive motor function and functional skills training among young children with CP, to summarise the effects of these interventions, and to examine characteristics that may contribute to explain the variations in these effects.

METHODS

Ten databases were searched for controlled studies that included young children (mean age less than seven years old) with CP and assessments of the effects of intensive motor function and functional skills training. The studies were critically assessed by the Risk of bias tool (RoB) and categorised for intensity and contexts of interventions. Standardised mean difference were computed for outcomes, and summarised descriptively or in meta-analyses.

RESULTS

Thirty-eight studies were included. Studies that targeted gross motor function were fewer, older and with lower frequency of training sessions over longer training periods than studies that targeted hand function. Home training was most common in studies on hand function and functional skills, and often increased the amount of training. The effects of constraint induced movement therapy (CIMT) on hand function and functional skills were summarised in six meta-analyses, which supported the existing evidence of CIMT. In a majority of the included studies, equal improvements were identified between intensive intervention and conventional therapy or between two different intensive interventions.

CONCLUSIONS

Different types of training, different intensities and different contexts between studies that targeted gross and fine motor function might explain some of the observed effect variations. Home training may increase the amount of training, but are less controllable. These factors may have contributed to the observed variations in the effectiveness of CIMT. Rigorous research on intensive gross motor training is needed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42013004023.

The effect of long-term conventional physical therapy and independent predictive factors analysis in children with cerebral palsy

OBJECTIVES

This study evaluated the effect of long-term conventional physical therapy (PT) on cerebral palsy (CP) children and to identify the predictors of therapy's response.

METHODS

We performed a retrospective review of CP children treated with PT, and their motor function was assessed every 3 months between 2008 and 2011.

RESULTS

Fifty-six children with a mean age of 4.2 ± 2.8 years, gross motor function classification system (GMFCS) levels were level I (n = 14), level II (n = 20), level III (n = 5), level IV (n = 8), and level V (n = 9). In the generalized estimating equations model, there was a significant improvement in the Gross Motor Function Measure (GMFM-66) score (p < 0.001); the improvement was different in five GMFCS levels (p < 0.001) and GMFCS level II had faster progression. The younger CP children had better PT efficacy, and the GMFM-66 score continued improving until 8.4 years old in the older group.

CONCLUSION

The long-term conventional PT is effective even in older CP children, and PT was most efficient in younger children and GMFCS level II.

Surface EMG analysis and changes in gait following electrical stimulation of quadriceps femoris and tibialis anterior in children with spastic cerebral palsy

PURPOSE

To evaluate the clinical feasibility and effect of neuromuscular electrical stimulation (NMES) therapy of quadriceps femoris (QF) and tibialis anterior (TA) muscles on improving gait and functional outcomes in children with spastic cerebral palsy (CP).

METHOD

Ten children with spastic diplegic/hemiplegic CP who were in the age group of 7 to 14 years recruited from a rehabilitation institute were randomly assigned either to a control group or a NMES group. Both groups obtained conventional physiotherapy and muscle strengthening exercises. The NMES group in addition received surface electrical stimulation to QF and TA muscles for four weeks duration.

RESULTS

The NMES group showed significant improvements as compared to the control group in walking speed (mean difference: 7.83 meters per min, 95% confidence interval: 3.13 to 12.53, p&#60;0.01) and cadence (mean difference: 23.33 steps per min, 95% confidence interval: 5.90 to 40.77, p&#60;0.01). The NMES group also showed significant reduction in physiological cost index of walking or PCI (mean difference: -1.32 beats per meter, 95% confidence interval: -1.83 to -0.80, p&#60;0.001) indicating greater energy-efficiency of walking. No significant changes were seen in EMG parameters.

CONCLUSIONS

The findings of this study suggests that NMES therapy together with conventional physiotherapy more efficiently improves walking ability and functional outcomes as compared to conventional physiotherapy alone in children with spastic CP.

Amount and focus of physical therapy and occupational therapy for young children with cerebral palsy

The aims of this study were to describe physical therapy (PT) and occupational therapy (OT) services for a cohort of 399 children with cerebral palsy (CP), 2-6 years old, residing in the United States and Canada. Parents completed a services questionnaire by telephone interview. Therapists classified children's Gross Motor Function Classification System (GMFCS) level. Mean minutes per month of PT and OT were greater for children receiving services in both an educational and clinic setting. Mean minutes per month of PT and OT were greater for children in levels IV-V than children in level I and greater for children in the United States than children in Canada. Parents reported that interventions focused a moderate to great extent on primary impairments, secondary impairments, activity, and structured play activities, a moderate extent on environmental modifications and equipment; and a moderate to small extent on self-care routines. The results support the importance of coordination of PT and OT services.

Still too little qualitative research to shed light on results from reviews of effectiveness trials: a case study of a Cochrane review on the use of lay health workers

BACKGROUND

Qualitative research is used increasingly alongside trials of complex interventions to explore processes, contextual factors, or intervention characteristics that may have influenced trial outcomes. Qualitative research conducted alongside trials can also be used to shed light on the results of systematic reviews of effectiveness by looking for factors that can help explain heterogeneous results across trials. In a Cochrane review on the effects of using lay health workers on maternal and child health and infectious disease control, we identified 82 trials. These trials showed promising benefits but results were heterogeneous.

OBJECTIVE

To use qualitative studies conducted alongside these trials to explore factors and processes that might have influenced intervention outcomes.

METHODS

We attempted to identify qualitative research carried out alongside the trials by contacting trial authors, checking papers for references to qualitative research, searching Pubmed for related studies, and carrying out citation searches. For those qualitative studies that we included, we extracted information regarding study objective, data collection and analysis methods, and key themes and categories.

RESULTS

For 52 (63%) of the trials, we found no qualitative research that had been conducted alongside the trials. For 16 (20%) trials, some form of qualitative data collection had been done but was unavailable or had been done before the trial. For 14 (17%) trials, qualitative research had been done during or shortly after the trial, although descriptions of qualitative methods and results were often sparse. Most of these 14 studies aimed to elicit trial participants' perspectives and experiences of the intervention. A common theme was participants' appreciation of the lay health workers' shared circumstances, for instance with regard to social background or experience of the health condition. In six studies, researchers explored the experiences of the lay health workers themselves. Issues included the importance of regular supervision and health professionals' support or lack of support.

CONCLUSIONS

Qualitative studies carried out alongside trials of complex interventions could offer opportunities to authors of systematic reviews of effectiveness wishing to understand the heterogeneity of trial results. For interventions of lay health worker programmes at least, too few such studies exist at present for these opportunities to be realised.

Consulting parents about the design of a randomized controlled trial of osteopathy for children with cerebral palsy

BACKGROUND

Although the UK Department of Health has advocated the involvement of service users and carers in health research for several years, there is little evidence about their contribution to the design of randomized controlled trials (RCTs).

OBJECTIVE

To demonstrate how consulting parents about the design of a study, including which outcomes to use, led to the design and successful delivery of a RCT of osteopathy for children with cerebral palsy (CP).

DESIGN

Semi-structured interviews were carried out with 20 parents of children with CP and other neurological conditions, asking them to choose between four different trial designs, to talk about noticeable changes in their child's condition and their views about payment for trial treatment.

SETTING AND PARTICIPANTS

The parents interviewed were all members of Cerebra, a charity for 'brain-injured' children and young people. All interviews were carried out at the parents' homes.

RESULTS

Parents had mixed views about possible trial designs; however, a waitlist design which allowed all children eventually to receive the treatment emerged as a clear favourite. Parents did not focus on isolated outcomes, but suggested a range of factors relevant to their child's quality of life. They expressed a clear preference for the costs of treatment to be funded by the trial.

CONCLUSIONS

Involvement of parents helped design a trial which was acceptable to families and addressed outcomes that mattered to them. By consulting parents about the design of the research, the subsequent trial achieved excellent recruitment and retention rates.

Efficacy of intensive versus nonintensive physiotherapy in children with cerebral palsy: a meta-analysis

A commonly used treatment for cerebral palsy in children is so-called 'conventional therapy', which includes physiotherapy or the neurodevelopmental approach. Although more intensive rehabilitative treatment is thought to be more effective than less intensive interventions, this assumption has not been proven. In this study we compared the efficacy of intensive versus nonintensive rehabilitative treatment in children with cerebral palsy. A meta-analysis of the studies published between January 1996 and July 2007 was performed.

INCLUSION CRITERIA

infants/children/adolescents (1-18 years old); randomized controlled trials using, as outcome measure, the Gross Motor Function Measure score.

EXCLUSION CRITERIA

studies that included therapies not generally used in 'so-called' conventional treatment (i.e. constraint, taping). Treatment effects were combined using the weighted mean difference method. Fixed and random effect meta-analyses were carried out and results were compared. Heterogeneity was also assessed. Funnel plots were examined and the presence of small-study effects was tested. Intensive therapy tended to have a greater effect than nonintensive therapy (1.32; 95% confidence interval: 0.55-2.10). The effect of intensive treatment tended to be apparently stronger for children 2 years of age. Our meta-analysis shows that, in children with cerebral palsy, intensive conventional therapy may improve the functional motor outcome, but the effect size seems to be modest.

Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases

BACKGROUND

Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions.

OBJECTIVES

To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases.

SEARCH STRATEGY

For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers.

SELECTION CRITERIA

Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained.

MAIN RESULTS

Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective.

AUTHORS' CONCLUSIONS

LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.

Parent and therapist perceptions of an intense model of physical therapy

PURPOSE

The purpose of this study was to determine parent and therapist perceptions regarding the effect of an intense model of physical therapy for children with cerebral palsy.

METHODS

Informants included 5 parents, 5 therapists, and 5 children with cerebral palsy who previously participated in an intense program (ie, strengthening and functional activities 4 hours/day, 5 days/week for 3 weeks). Parents and therapists were interviewed, and children were observed. Data were collected and analyzed using qualitative methodology.

RESULTS

Five common themes emerged, based on perceptions: (1) improvement in motor function, (2) improvement in confidence and independence, (3) stress during the program but a time of no therapy between sessions, (4) increased participation in the community, and (5) fatigue during the program but perceived rapid attainment of goals.

CONCLUSIONS

The constructs identified should be considered by clinicians in program development and by researchers for further study.

Psychosocial experiences of parents of a child with imperforate anus

PURPOSE

This study aims to examine the psychosocial experiences of parents of children with imperforate anus (IA) and to describe their potential positive experiences.

DESIGN AND METHODS

Parents of IA children and a comparison group answered a questionnaire, which was analyzed quantitatively and with manifest content analysis.

RESULTS

Social relationships and respect for the child's will were more affected among IA mothers. Positive experiences were revealed in relation to the child, the parent, and the family.

PRACTICE IMPLICATIONS

Support to parents in caring for a child with IA should be individualized and occasionally undertaken through collaboration with experts from child and adolescent psychiatry.

Assessment of the quality of cost analysis literature in physical therapy

BACKGROUND

Policy makers, payers, and other stakeholders increasingly call for greater evidence of the cost-effectiveness of health care interventions.

OBJECTIVE

The purposes of this study were to identify and rate the quality of cost analysis literature in physical therapy and to report summary information on the findings from the reviewed studies.

DESIGN

This study was a targeted literature review and rating of relevant studies published in the last decade using a quality evaluation tool for economic studies.

MEASUREMENTS

The Quality of Health Economic Studies (QHES) instrument was used to obtain quality scores.

RESULTS

Ninety-five in-scope studies were identified and rated using the QHES instrument. The average quality score was 82.2 (SD=15.8), and 81 of the studies received a score of 70 or higher, placing them in the "good" to "excellent" quality range. Investigators in nearly two thirds of the studies found the physical therapy intervention under investigation to be cost-effective.

LIMITATIONS

The small number of studies meeting the inclusion criteria was a limitation of the study.

CONCLUSIONS

The quality of the literature regarding the cost-effectiveness of physical therapy is very good, although the magnitude of this body of literature is small. Greater awareness of the strengths and limitations of cost analyses in physical therapy should provide guidance for conducting high-quality cost-effectiveness studies as demand increases for demonstrations of the value of physical therapy.

Maternal parenting stress and its correlates in families with a young child with cerebral palsy

OBJECTIVE

To investigate factors predicting parenting stress in mothers of pre-school children with cerebral palsy.

METHOD

Eighty mothers and children participated. Mothers completed the Parenting Stress Index (PSI) and the following measures of family functioning: family support, family cohesion and adaptability, coping strategies, family needs and locus of control. Children were assessed using the Griffiths Scales and the Gross Motor Function measure. The child's home environment was assessed using Home Observation for Measuring the Environment.

RESULTS

Mothers had higher mean total PSI scores than the means for the typical sample; 43% had total PSI scores above the threshold for clinical assessment. Cluster analysis demonstrated five distinct clusters of families, more than half of whom were coping well. High stress items were role restriction, isolation and poor spouse support, and having a child who was perceived as less adaptable and more demanding. Lower stress items indicated that this sample of mothers found their children emotionally reinforcing and had close emotional bonds. Regression analysis showed that the factors most strongly related to parenting stress levels were high family needs, low family adaptability and cognitive impairment in the child.

CONCLUSIONS

The results confirmed the individuality of families, and that individual characteristics of coping and feeling in control, together with family support and cohesion, are associated with variation in amount of stress experienced in parenting a child with cerebral palsy.