Authors:
Heidi Anttila, MSc (Health Sci), PT
Jutta Suoranta, MSc (Health Sci), PT
Cerebral Palsy
Antti Malmivaara, PhD, MD
Marjukka Mäkelä, PhD, MD, MSc
(Clin Epi)
Ilona Autti-Rämö, PhD, MD
LITERATURE REVIEW
Affiliations:
From the Finnish Office for Health
Technology Assessment, National
Research and Development Centre for
Effectiveness of Physiotherapy and
Welfare and Health, Helsinki, Finland
(HA, JS, AM, MM, IAR); Tampere
School of Public Health, University of Conductive Education Interventions
Tampere, Tampere, Finland (JS);
Department of General Practice,
in Children with Cerebral Palsy
University of Copenhagen, Denmark
(MM); The Social Insurance Institute, A Focused Review
Helsinki, Finland (IAR); and
Department of Child Neurology,
Hospital for Children and
ABSTRACT
Adolescents, University of Helsinki,
Finland (IAR).
Anttila H, Suoranta J, Malmivaara A, Mäkelä M, Autti-Rämö I: Effectiveness of
physiotherapy and conductive education interventions in children with cerebral
Correspondence:
palsy: a focused review. Am J Phys Med Rehabil 2008;87:478 501.
All correspondence and requests for
reprints should be addressed to Heidi We conducted a criteria-based appraisal of systematic reviews on the effective-
Anttila, Finnish Office for Health
ness of physiotherapy and conductive education interventions in children with
Technology Assessment, PO Box 220,
cerebral palsy (CP). Computerized bibliographic databases were searched with-
FIN-00531 Helsinki, Finland.
out language restriction up to August 2007. Reviews on trials and descriptive
studies were included. Two reviewers independently identified, selected, and
Disclosures:
assessed the quality of the reviews using the criteria from the Overview Quality
This study was funded by Finohta, a
Assessment Questionnaire complemented with decision rules. Twenty-one re-
national government-funded
views were included, six of which were of high methodological quality. Altogether,
organization for health technology
assessment, and by a grant from the the reviews included 23 randomized controlled trials and 104 observational
Academy of Finland. The authors
studies on children with CP. The high-quality reviews found some evidence
have no financial or personal
supporting strength training, constraint-induced movement therapy, or hippo-
conflicts of interest.
therapy, and insufficient evidence on comprehensive physiotherapy and occupa-
0894-9115/08/8706-0478/0 tional therapy interventions. Conclusions in the other reviews should be inter-
American Journal of Physical
preted cautiously, although, because of the poor quality of the primary studies,
Medicine & Rehabilitation
most reviews drew no conclusions on the effectiveness of the reviewed interven-
Copyright © 2008 by Lippincott
tions. Reviews on complex interventions in heterogeneous populations should use
Williams & Wilkins
rigorous methods and report them adequately, closely following the Quality of
Reporting of Meta-Analyses recommendations.
DOI: 10.1097/PHM.0b013e318174ebed
Key Words: Physiotherapy, Systematic Review, Cerebral Palsy, Quality Assessment,
Clinical Applicability
478 Am. J. Phys. Med. Rehabil. Vol. 87, No. 6
cal quality, and this has been infrequently reported
The principles of evidence-based practice are and incorporated into the analyses.10,23,24
widely accepted among professionals.1,2 The stron- In this study, we wanted to evaluate the meth-
odological validity of SRs and their clinical useful-
gest support for evidence-based decision making
comes from updated, high-quality systematic re- ness when targeting a heterogeneous population
views (SR). Such reviews identify the relevant stud- and looking at variably applied interventions such
as PT and CE in children with CP. The primary
ies, appraise their quality, and summarize the re-
objective was to appraise the methodological qual-
sults, using sound scientific methodology.3,4 They
ity of the reviews on the effectiveness of PT or CE
can also help clinicians to find relevant answers to
interventions in children with CP, and to explore
clinical questions in a time-efficient and reliable
what needs to be done to enhance the quality of
way.3 Professionals treating children with CP often
reviews. The secondary aims were to make conclu-
have limited time, skills, and resources to search
for evidence and to interpret effectiveness studies.5 sions about the effectiveness of the reviewed inter-
ventions, and to consider the included study designs,
Cerebral palsy (CP) is an umbrella term for
populations, interventions, outcome measures, and
 nonprogressive but often-changing motor impair-
results of various PT interventions on children with
ment syndromes secondary to lesions or abnormal-
CP to allow interpretation of possible evidence into
ities of the brain arising in the early stages of
clinical practice. Finally, our aim was to use all this
development. 6 Basic management of the motor
information to make suggestions for future studies in
disability in CP includes physiotherapy (PT) and a
wide spectrum of other therapeutic interventions.7 this field.
Motor learning goals may also be incorporated into
educational programs such as conductive educa- METHODS
tion (CE) instead of separate rehabilitation inter-
Locating and Selecting the Reviews
ventions provided by different professionals.8
Only published SR articles were considered.
An appreciation of the quality of an SR is
To be included, these publications were required
essential before deciding whether its conclusions
to have descriptions of the searched databases,
should be followed. Such quality may mean the
search time period, and selection criteria for
rigor of the review methods, or quality of report-
population and interventions. This review in-
ing. Previous evaluations of SRs in many fields
cluded interventions usually provided by physio-
imply that readers should not accept them uncriti-
therapists and requiring therapeutic manage-
cally, and there is a need for improvement of the
ment7 for instance, neurodevelopmental therapy
methodological quality and guidelines for report-
(NDT), strength training, saddle riding, physical
ing.9 Cochrane reviews are usually more rigorously
activity, swimming programs, functional therapy,
conducted and reported than non-Cochrane re-
and targeted training. In addition, interventions
views.9  12
that in some countries or organizations may be
There are at least 24 instruments to assess the
provided either by physiotherapists or occupational
quality of SRs.13 A rigorously developed and vali-
therapists (upper-limb interventions) or special
dated tool, the Overview Quality Assessment Ques-
teachers (CE) were included. The main focus was to
tionnaire (OQAQ), has been constituted by Oxman
include reviews on therapeutic management with-
and Guyatt.14,15 Hoving et al.16 have slightly mod-
out specialized equipment; thus, interventions of
ified this tool and applied it in rehabilitation re-
solely devices (electrical stimulation, biofeedback,
search. The Quality of Reporting of Meta-Analyses
orthotic, or other assistive devices) were excluded.
statement describes the preferred way to present
The patients were children or adolescents (aged 3
the abstract, introduction, methods, results, and
mos to 20 yrs) with diagnosed CP.
discussion sections of a report of meta-analysis,
If the review had included other interventions
including a flow diagram of the article identifica-
or populations, it was included only if at least 80%
tion and selection process.17 Balanced interpreta-
of the included populations or interventions were
tion of the applicability and clinical relevance re-
similar to our criteria, or if the results of only the
quires accurate information of the reviewed
CP population and PT interventions were presented
populations, interventions, comparison interven-
separately. Further, the review should report the
tions, and outcomes.18  20
results of the included studies. Reviews in Danish,
An essential feature of SRs is critical appraisal
English, Finnish, German, Norwegian, or Swedish
of the methodological quality of the included pri- were accepted.
mary studies.3,21 Lack of adherence to defined qual- We searched Medline, CINAHL, the Cochrane
ity criteria may explain the different results of Database of Systematic Reviews, Database of Ab-
studies on the same topic.22 Published SRs have stracts of Reviews of Effects, American College of
heterogeneous approaches to assess methodologi- Physicians Journal Club, Health Technology As-
June 2008 Effectiveness of Interventions in CP 479
sessment database, and the Physiotherapy Evi- score of 18 (Appendix A). Reviews fulfilling all
dence Database (http://www.pedro.fhs.usyd.edu.au/ points, except the item of selection bias (as using
index.html) without language restrictions back to two or more assessors for independently judging
the earliest time available and up until August and selecting studies with predetermined criteria,
2007. An experienced information scientist planned
and/or blinding reviewers to identifying features of
the search strategies. High sensitivity search strat- study, or to treatment outcome), were regarded as
egies for Medline and CINAHL databases developed
being of high quality. Two evaluators (H.A., J.S.)
by the University of York25 were employed and
separately assessed the quality of the included re-
complemented with Medical Subject Headings or
views. The discrepancies in evaluations were solved
text words for populations and interventions. The
by discussion, and remaining disagreements were
search strategy for Medline is shown Table 1. From
decided by a third reviewer (A.M.).
January 2003 to August 2007 the search results
from Medline and CINAHL were limited to  sys-
Analysis of the Reviewers Conclusions
tematic reviews or  review articles using the im-
The included reviews were classified according
proved filters provided by these databases. The ref-
to the intervention types: (1) comprehensive PT
erences of the identified review articles were
approaches (e.g., neurodevelopmental or neuro-
checked by two reviewers (H.A., J.S.) to identify
physiological PT, home programs or Vojta), (2)
possible reviews. We also searched our personal
strength training, (3) constraint-induced move-
files of studies and reviews on children with CP.
ment therapy (CIMT), (3) postural control, (4) soft
Two reviewers (H.A. and R.K. or I.A.R.) inde-
tissue treatment, (6) hydrotherapy, (7) hippo-
pendently screened the titles or abstracts identified
therapy, 8) CE and (9) various (several of the above
in the initial search strategy for inclusion and
interventions in one review). For each group of
exclusion criteria. When the title and abstract did
interventions we considered and weighed up the
not clearly indicate whether an article should be
conclusions according to the methodological qual-
included, two reviewers (H.A., I.A.R.) evaluated the
ity of the SR. We also observed the number and
full article for inclusion criteria. The reviewers
type of included studies and their overlaps between
were not blinded to the names of authors and
the reviews to obtain a comprehensive overview of
institutions, sources of funding or results of the
the research volume in this field.
review.
Data Extraction
RESULTS
One of two reviewers (either H.A. or J.S.) ex-
Article Identification and Selection
tracted the data. The included articles were allo-
cated equally, and data from one review was ex-
Figure 1 shows a flow chart of the literature
tracted by both reviewers to ensure similarity. After
searches and article selection. We found 21 SRs:
data extraction the results were checked by the
four reviews on comprehensive PT,26  29 two on
other reviewer. We tabulated the review focus,
strength training,30,31 one on CIMT,32 one on pos-
search strategies and inclusion criteria, data of the
tural control,33 one on soft tissue treatment,34 one
included populations, interventions, settings, out-
on hydrotherapy,35 two on hippotherapy,36,37 four
come measures; number of studies and the study
on CE,38 41 and five reviews covering a wide range
designs in each review; methods used in quality
of various interventions.42 46
assessment and analyses; and the main results and
conclusions, and reported adverse effects. For
Methodological Quality
quantitative data we extracted the effect sizes of all
The methodological quality scores of the re-
outcome measures used.
views are presented in Table 2. The search meth-
Assessment of the Methodological ods and inclusion criteria were at least partially
Quality described in all reviews, as these were our man-
datory criteria for inclusion. Six reviews fulfilled
The methodological quality of the included
all criteria other than blinding reviewers from au-
SRs was analyzed using a modified version16 of the
thor and outcome information.26,30,32,33,36,42
method described and validated by Oxman et
Twelve reviews26,29,30,32 34,36  39,42,43 had defined
al.14,15 This checklist evaluates nine items covering
quality-assessment criteria, and all but one37 used
search methods, selection of the articles, validity
assessment and methods for synthesis, The modi- these. Many reviews had inadequacies in search
fication, previously applied in the field of rehabili- and synthesis methods. The median quality score
tation, consists of the addition of decision rules to was 11 out of 18 points (range 3 17).
increase transparency of the assessment.16 Each A summary of the reviews focus and methods
item is scored from 0 to 2, with a maximum total is given in Table 3. The methods of qualitative
480 Anttila et al. Am. J. Phys. Med. Rehabil. Vol. 87, No. 6
TABLE 1 High-sensitivity search strategy for identifying review articles in Medline, developed by the
University of York25
1. Cerebral palsy/rh, th [rehabilitation, therapy]
2. Cerebral palsy.mp. or cerebral palsy/
3. Exp physical therapy techniques/
4. (Physical therapy or physical therapies).ab,ti.
5. Physiotherap$.ab,ti.
6. Exp exercise therapy/
7. (Physical activity or physical activities).ab,ti.
8. Exp  physical therapy (specialty) /
9. Exp  physical education and training /
10. Rehabilitation.mp. or REHABILITATION/
11. (Vojta or bobath or neurodevelop$ or NDT or Rood or Kabat or vibroacoust$).ab,ti.
12.  Early intervention (education) /
13. Conductive education.ab,ti.
14. Conservative therap$.ab,ti.
15. (Muscle strength$ or muscle training or motion or therapeutic exercise or excercise training or physical
exercise or fitness or aerobic training or kinetic chain).ab,ti.
16. Movement.mp. or EXERCISE MOVEMENT TECHNIQUES/or MOVEMENT/
17. SWIMMING/or swimming.mp. or hydrotherapy.mp.
18. (Functional therapy or functional therapies).ab,ti.
19. (Self-care training or motor control or motor learning).ab,ti.
20. Occupational therapy.mp. or Occupational Therapy/
21. (Constraint adj induced).mp. [mp ti, ab, tx, kw, ct, ot, sh, hw]
22. Restraint, physical/
23. (Forced adj2 treatment).mp. [mp ti, ab, tx, kw, ct, ot, sh, hw]
24. (Psychomotor performance or sensation).mp. [mp ti, ab, tx, kw, ct, ot, sh, hw]
25. Sensory integration.ab,ti.
26. (Sensory adj perceptual).mp. [mp ti, ab, tx, kw, ct, ot, sh, hw]
27. Parent child relations/or parents/or parent education.mp.
28. Physical stimulation.mp. or physical stimulation/
29. (Posture or positioning).mp. [mp ti, ab, tx, kw, ct, ot, sh, hw]
30. Facilitat$.ti,ab.
31. 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or
22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30
32. 2 and 31
33. 1 or 32
34. Controlled.ab.
35. Design.ab.
36. Evidence.ab.
37. Extraction.ab.
38. Randomized controlled trials/
39. Meta-analysis.pt.
40. Review.pt.
41. Sources.ab.
42. Studies.ab.
43. Or/34 42
44. Letter.pt.
45. Comment.pt.
46. Editorial.pt.
47. Or/44 46
48. 43 not 47
49. 33 and 48
Limitations (from January 2003 to August 2007):
50. Limit 49 to systematic reviews
51. Limit 49 to  review articles
52. 51 and 50
June 2008 Effectiveness of Interventions in CP 481
FIGURE 1 Flow chart of the article selection process.
categorization and synthesis varied considerably. A full description of the characteristics of re-
Eight reviews classified the study results into out- viewed populations, interventions, outcome mea-
come-related categories by dimensions of disability,27 sures, and results of studies on children with CP is
ICIDH-2 (International Classification of Impair- in Appendix B. The population in terms of age, type
ments, Disabilities and Handicaps),34,38,43 ICF (In- and severity of CP, the interventions, and the out-
ternational Classification of Functioning, Disability come measures are heterogeneous in all reviews
and Health),30,35,36 or own classification.41 One re- and intervention groups. The included studies were
view applied meta-analysis on randomized con- conducted in various settings (clinic, home,
trolled trials (RCT).43 Effect sizes and confidence school, or community). The settings are suffi-
intervals were available from three reviews.30,32,34 ciently reported in only four reviews.30,38,39,42 Ex-
Nine reviews applied levels of evidence analysis. cept for one review,32 the content of each interven-
Four reviews26,31,35,43 used a method described by tion is described only with a short title. The
Sackett47,48 and one review36 modified this method2 number of different outcome measures reported
to include Physiotherapy Evidence Database rat- varies from 6 to 30 per review. Two reviews do not
ings. Three reviews27,33,34 applied American Acad- report any outcomes.40,45
emy for Cerebral Palsy and Developmental Medi-
Conclusions on Effectiveness of the
cine (AACPDM) methodology,49 and one review33
Interventions Included in the Reviews
used the methodology of AACPDM and Sackett.47
Comprehensive PT
One review42 applied the evidence synthesis
method described by van Tulder.50 One high-quality26 and three low-quality
SRs27 29 on comprehensive PT approaches have
Characteristics of the Review Contents
evaluated 15 RCTs and 28 observational studies, of
The reviews were based altogether on 31 RCTs which 9 RCTs61 69 and 19 observational studies
and 199 observational studies. Ten reviews in- were on children with CP. Seven of the 9 RCTs
cluded non-CP children,26,28,29,34,35,37,40,41,45,46 and (total number of children, n 309) and 5 of the 19
four reviews also included interventions that were observational studies (n 493) are included in
outside the scope of this review,33,42,43,45 which more than one review. The high-quality review
were excluded from the analyses. Twenty-three concludes that  the current research. . . does not
RCTs and 104 observational studies were on chil- clearly demonstrate the efficacy or inefficacy of
dren with CP; of these, 13 RCTs and 29 observa- NDT as a treatment approach. 26(p242) Conclusions
tional studies were included in more than one in the low-quality reviews are similar:  The prepon-
review (Table 4). derance of the results . . . did not confer any advan-
482 Anttila et al. Am. J. Phys. Med. Rehabil. Vol. 87, No. 6
TABLE 2 Methodological assessment scores of the included 21 systematic reviews
Search Methods Selection Methods Validity Assessment Synthesis
Avoidance of Definition of the Use of the Acceptability of Conclusions Total
Search Inclusion Selection Validity Assessment Quality-Assessment Synthesis the Synthesis Supported by Points
First Author (Year) Search Methods Comprehensiveness Criteria Bias Criteria Criteria Methods Methods Data Analysis (Max 18)
Comprehensive physiotherapy
Brown26 (2001) 2 2 2 1 2 2 2 2 2 17
Butler27 (2001) 2 2 2 0 0 0 2 1 2 11
Parette28 (1991) 1 1 1 0 0 0 0 0 0 3
Tirosh29 (1989) 1 1 1 0 2 2 0 1 2 10
Strength training
Dodd30 (2002) 2 2 2 1 2 2 2 2 2 17
Darrah31 (1997) 2 1 1 1 0 0 2 2 2 11
Constraint-induced movement
therapy
Hoare32 (2007) 2 2 2 1 2 2 2 2 2 17
Postural control
Harris33 (2005) 2 2 2 1 2 2 2 2 2 17
Soft-tissue treatment
Pin34 (2006) 2 1 2 0 2 2 2 0 0 11
Hydrotherapy
Getz35 (2006) 2 2 2 1 0 0 2 2 2 13
Hippotherapy
Snider36 (2007) 2 2 2 0 2 2 2 2 2 16
Sterba37 (2007) 2 1 2 0 2 0 0 0 0 7
Conductive education
Darrah38 (2003) 2 1 2 0 2 2 2 1 2 14
Ludwig39 (2000) 2 2 2 1 2 2 0 1 0 12
Pedersen40 (2000) 1 1 1 0 0 0 0 0 0 3
French41 (1992) 1 2 2 0 0 0 1 1 2 9
Various interventions
Steultjens42 (2004) 2 2 2 1 2 2 2 2 2 17
Boyd43 (2001) 2 2 2 0 2 1 1 1 0 11
Woolfson44 (1999) 1 2 2 0 0 0 0 0 1 6
Hur45 (1995) 1 1 1 0 0 0 0 1 2 6
Horn46 (1991) 2 2 2 0 0 0 0 1 2 9
Yes 15 13 16 0 12 10 11 8 14
Partially 6 8 5 8 0 1 2 8 1
No 0 0 0 13 9 10 8 5 6
Scoring: 2, the criterion is fulfilled; 1, partially fulfilled or cannot tell; 0, not fulfilled or not reported; the decision rules are in Appendix A.
June 2008
Effectiveness of Interventions in CP
483
TABLE 3 Characteristics of methods and conclusions of systematic reviews on physiotherapy and conductive education (n 21)
Methods of Analyses (Search Period,
Methodological Quality Assessment
(QA), Categorization of the Results,
Review (Year) Objectives of the Review Designs Included* Synthesis Method) Quality Score Conclusions of Review*
Comprehensive physiotherapy
Brown and Burns26 Efficacy on NDT in pediatric CCT (11) Search until 1998 17 NDT: ?
(2001) subjects ( 18 yrs) diagnosed OD (6) QA: 5 criteria, Quality
with a neurological Assessment of Randomised
dysfunction Clinical Trials by Jadad et al.51;
1 criterion, Concealment of
Treatment Allocation scale by
Schulz et al.52
Categorization by findings/results
(benefits, statistical significance)
Levels-of-evidence
analyses by Sackett48
Butler and Darrah27 Current state of evidence about RCT (7) Search (1956 spring 2001) 11 NDT: dynamic ROM , abnormal motor
(2001) NDT in children with CP OD (14) QA: No responses ?, slowing or prevention of
Categorization by contractures ?, facilitation of normal
outcomes (dimensions of motor development ?, functional motor
disability) Levels-of-evidence activities ?, social emotional
analyses by Butler49 development ?, language ?, cognitive
development ?, home environments ?,
parent child interaction ?, parent
satisfaction ? More intensive NDT:
benefit
Parette et al.28 Efficacy and intensity of CCT (3) Search period (1960 1989) 3 Therapeutic intervention: efficacy
(1991) therapeutic interventions (OT OD (10) QA: No Intensive therapeutic intervention:
and PT) for infants and young Categorization by the study efficacy ?
children ( 5 yrs) with CP designs Descriptive analyses
Tirosh and Rabino29 Efficacy and effectiveness of PT RCT (7) Search (1973 1987) 10 Physiotherapy: efficacy
(1989) interventions in the rehabilitation CCT (2) QA: 12 criteria, modified from
of children Sackett53
with CP Categorization by study results
(benefits/no benefits) and methodology scores
Descriptive analyses. Effect sizes and
95% CIs provided
Strength training
Dodd et al.30 (2002) Effects of strength training or RCT (1) Search (1966 1997) 17 Strength training program: muscle
progressive resistance exercise OD (9) QA: 10 of 11 criteria on PEDro strength , increased spasticity ,
program for adults or children with CP Reviews (4) scale based on the Delphi list by mobility ?, function ?, participation ?,
Verhagen et al.54 contextual factors ?
Categorization by ICF
Descriptive analyses
Darrah et al.31 (1997) Effects of progressive resistance RCT (1) Search (1966 1997) 11 Progressive muscle strengthening:
muscle strengthening in OD (6) QA: No efficacy , muscle performance ,
children with a diagnosis of CP Levels-of-evidence analyses by Sackett47 functional abilities ?
Constraint-induced movement
therapy
Hoare et al.32 (2007) Effectiveness of CIMT, modified RCT (2) Search until August 2006 17 Modified CIMT:
CIMT, or forced use in the CCT (1) QA: 4 criteria by Schulz et al.52 CIMT: , Forced use:
treatment of affected upper Studies analyzed separately
limb in children ( 19 yrs) Descriptive analyses: data entered into
with hemiplegic CP review manager 4.2. Effect sizes
and 95% CIs were provided
484
Anttila et al.
Am. J. Phys. Med. Rehabil.

Vol. 87, No. 6
TABLE 3 Continued
Methods of Analyses (Search Period,
Methodological Quality Assessment
(QA), Categorization of the Results,
Review (Year) Objectives of the Review Designs Included* Synthesis Method) Quality Score Conclusions of Review*
Postural control
Harris and Roxborough33 Efficacy and effectiveness of OD (12) Search (1990 2004) 17 Externally generated movements:
(2005) postural control intervention QA: AACPDM Quality Postural perturbations: reactive
strategies for children with CP Assessment Scale by Butler49 balance
Categorization by study designs Group NDT or practice:
(group/single subject)
Levels-of-evidence analyses by
Sackett47 for group designs;
Butler49 for single-subject
designs
Soft-tissue treatment
Pin et al.34 (2006) Effectiveness of passive RCT (4) Search until April 2006 11 Passive stretching: ROM , spasticity
stretching by using ICIDH-2 OD (3) QA: PEDro scale54 Sustained stretching vs. manual
in children with CP Categorization by outcomes stretching: ROM , spasticity
(ICIDH-2)
Levels-of-evidence analyses by
Butler49
Mean effect sizes and confidence
intervals calculated
Hydrotherapy
Getz et al.35 (2006) Effectiveness of aquatic RCT (1) Search (1966 January 2005) 13 Hydrotherapy: respiratory function ,
interventions with regard to OD (10) QA: No activity ?, participation ?
the ICF dimensions in Categorization by
children with neuromotor outcomes (ICF)
impairments Levels-of-evidence synthesis by
Sackett48
Hippotherapy
Snider et al.36 (2007) Effectiveness of hippotherapy RCT (3) Search (1806 2005) 17 Hippotherapy: muscle symmetry
and therapeutic horseback OD (6) QA: RCTs by PEDro scale54; other designs by Therapeutic horseback riding or
riding on impairments, Newcastle Ottawa scale55 hippotherapy: activities , participation ?
activities, and participation Categorization by interventions and
in children with CP outcomes (ICF)Levels-of-evidence
synthesis by Sackett,2 modified to include
PEDro scale54
Sterba37 (2007) Effectiveness of horseback RCT (0) Search (1981 December 2005) 7 All intervention categories: gross motor
riding used as therapy to CCT (3) QA: 16 criteria, Critical Review Form for function
improve gross motor OD (7) Quantitative Studies by Law et al.56
function in children with CP Categorization by interventions
Descriptive analyses
Conductive education
Darrah et al.38 (2003) Current state of evidence of RCT (1) Search (1966 Fall 2001) 14 CE: ?
CE programs in children OD (14) QA: 7 criteria (inclusion/exclusion criteria,
with CP intervention, measures used, blinding,
statistical evaluation, dropouts, controlling
the variables and limiting bias)
Categorization by outcomes (dimension
of disability, ICIDH-2)
Descriptive analyses
June 2008
Effectiveness of Interventions in CP
485
TABLE 3 Continued
Methods of Analyses (Search Period,
Methodological Quality Assessment
(QA), Categorization of the Results,
Review (Year) Objectives of the Review Designs Included* Synthesis Method) Quality Score Conclusions of Review*
Ludwig et al.39 (2000) Effectiveness of CE and RCT (1)CCT (4) Search (1966 2000) 12 CE: ?
intensive therapy on the OD (4Å›) QA: 6 criteria (sampling strategy,
overall learning and health population, setting, intervention,
status of children with CP or statistical methods, and outcome
other motor disorders (or measures) by University of Alberta,57
the perceptions of parents Jadad,58 and Lonigan et al.59
whose children had received CE) Categorization by participants (children
and parents)
Descriptive analyses
Pedersen40 (2000) Examination of CE programs RCT (1) Search period not available 3 CE:
based on CE principles in OD (8) QA: No
studies using control groups Categorization by effects (yes/no)
Descriptive analyses
French and Nommensen41 Empirical legitimacy of CE RCT (1) Search period not available 9 CE: ?
(1992) programs outside Hungary OD (5) QA: No
Categorization by outcomes
Descriptive analyses
Various interventions
Steultjens et al.42 (2004) Efficacy of six OT intervention RCT (7) Search until June 2003 17 Comprehensive OT: ?
categories for children ( 19 CCT (1) QA: 11 criteria by van Tulder et al.60 and Training of sensorimotor function: ?
yrs) with CP OD (9) 1 criterion by Wells et al.55. Training of skills: ?
Categorization by interventions Training of sensorimotor function
Levels-of-evidence analysis by van Tulder vs. training of skills: ? Parental
et al.50 counseling: ? Advice/instruction on
assistive devices: ?
Provision of splints: ?
Boyd et al.43 (2001) Efficacy of different treatments RCT (5, of which 2 were Search (1966 December 2000)54 11 All interventions: ?
for the management of botulinum studies) QA: Only RCTs by PEDro scale
upper-limb dysfunction in children OD (51) Categorization by interventions, ICIDH-2
with CP Meta-analysis of 3 studies with same
outcome measure
Levels-of-evidence analyses by Sackett48
Woolfson44 (1999) Efficacy on educational RCT (2) Search period not available 6 All interventions: ?
programs for infants and OD (8) QA: No
preschool ( 5 yrs) children Categorization by intervention groups
with CP Descriptive analyses
Hur45 (1995) Effect of PT interventions for RCT (7) Search (1966 1994). 6 Therapeutic interventions: ?
children with CP CCT (2) QA: No
OD (28) Categorization by study designs
Descriptive analyses
Horn46 (1991) Effectiveness of basic motor RCT (2) Search (1983 1989) 9 NDT: ?
skills interventions (training OD (26) QA: No Behavioral programming (how to
of motor skills or components Categorization by interventions train):
of skills) for children ( 10 yrs) Descriptive analyses
with significant motor deficits
attributable to neurological disorders
*
As stated by the author; Improved outcome; indications for improvement; evidence for ineffectiveness; ? insufficient evidence.
CP, cerebral palsy; PT, physiotherapy; OT, occupational therapy; NDT, neurodevelopmental therapy; CIMT, constraint-induced movement therapy; ROM, range of motion; CE, conductive education; RCT,
randomized controlled trial; CCT, clinical controlled trial; OD, other design; ICIDH-2, International Classification of Impairments, Disabilities and Handicaps; PEDro scale, Physiotherapy Evidence Database
scale; QA, quality-assessment methods.
486
Anttila et al.
Am. J. Phys. Med. Rehabil.

Vol. 87, No. 6
TABLE 4 Included RCTs on children with CP and their overlaps in the 21 systematic reviews
Systematic Reviews (First Author)
Randomized Controlled Trials
No. of Reviews
First Author Sample Including
(Year) Size the Study
Sung71 (2005) 31 1 1
Cherng78 (2004) 14 1 1b 2
Benda79 (2003) 15 1 1
Deluca72 (2002), 18 1 1
Taub73 (2004)
McConachie82 58 11
(2000)
Reddihough81 34a 1 1 1 1b 4
(1998)
Law61 (1997) 50 1b 1 1 1 4
Steinbok62 (1997) 28 1b 1
Dorval77 (1996) 20 1 1
MacKinnon80 (1995) 19 1 1b 2
O Dwyer74 (1994) 15 1 1
Law63 (1991) 73 1b 1 1 1 4
Richards75 (1991) 19 1 1
Palmer64 (1990), 48 1b,c 1 1b,c 1b 1b,c 11b 7
Palmer65 (1988)
Tremblay76 (1990) 21 1 1
Hanzlik83 (1989) 20 1b 1b 13
McGubbin70 (1985) 30 1 1 1 3
Sommerfeld66 29 1 1b 1 1 1 5
(1981)
Talbot84 (1981) 59 11
Sellick85 (1980) 20 1 1 2
Scherzer67 (1976) 22 1b 1 1b 1 1 1 6
Carlsen68 (1975) 12 1b 1 1b 11 1 6
Wrigth69 (1973) 47 1 1b 1 1 1 5
Sum 702 7 8 5 4 1 1 2 0 3 1 3 2 1 1 1 0 6 5 1 5 6
a b c
The trial included additional 32 nonrandomized children; Not classified as an RCT by the authors; only the Palmer et al.65 publication was included in the review.
June 2008
Effectiveness of Interventions in CP
487
42
44
40
39
28
41
31
38
26
29
36
27
37
33
32
30
46
43
35
45
34
Brown
Butler
Parette
Tirosh
Dodd
Darrah
Hoare
Harris
Pin
Getz
Snider
Sterba
Darrah
Ludwig
Pedersen
French
Steultjens
Boyd
Woolfson
Hur
Horn
tage to NDT over the alternatives . . . 27(p22);
Hippotherapy
 . . . only four studies used a rigorous design, and
One high-quality36 and one lower-quality37 re-
three of these concluded that no evidence exists for
view compare therapist-directed hippotherapy vs.
the efficacy of the intervention. . . 29(p555); or  the
recreational horseback riding therapy. These re-
available literature offers some support for the ef-
views include three RCTs78 80 and seven observa-
ficacy of therapeutic interventions for infants and
tional studies (n 100). Of these, two RCTs78,80
young children with cerebral palsy. 28(p5)
and six observational studies are included in both
reviews. The results of Snider et al.36 indicate that
Strength Training
hippotherapy has short-term positive effects on
We found one high-quality30 and one lower-
muscle symmetry in the trunk and hip and that
quality31 SR on strength training in children with
therapeutic horseback riding is no more effective
CP, evaluating altogether 1 RCT and 11 observa-
than other therapies for improving muscle tone.
tional studies (n 102). Four studies are included
Observational studies have shown positive effects of
in both reviews, including the RCT.70 The conclu-
both hippotherapy and therapeutic horseback
sions are similar: strength training programs im-
riding on activities. The low-quality review37 states
prove muscle strength in children and young
that clinicians and therapists can recommend hip-
adults with CP, with no adverse effects on spastic-
potherapy as an efficacious, medically indicated
ity.30,31
therapy for gross motor rehabilitation of children
with CP.
CIMT
One high-quality Cochrane review32 analyzed
CE
two RCTs71 73 and one controlled clinical trial (CCT)
The effectiveness of CE has been evaluated in
(n 94). This SR found  a significant treatment
four reviews.38 41 These include 1 RCT81 and 21
effect [on bimanual performance] using modified
observational studies (n 1264), with 7 of the
CIMT in a single trial. A positive trend favoring CIMT
observational studies being included in more than
and forced use was also demonstrated. 32(p10)
one review. The overall conclusions of these re-
views are concordant: the number of studies was
Postural Control
too small, and the quality was too low, to make
From one high-quality review33 on interven-
conclusions about the effectiveness or ineffective-
tions aiming to improve postural control, we in-
ness of CE.
cluded four observational studies on NDT, rocker
platform, and massed practice (n 22). The review
Various Interventions
concludes with suggestive evidence for the effec-
One high-quality42 and four low-quality re-
tiveness of interventions comprising externally
views43 46 include different types of interventions
generated movement on the development of pos-
from 13 RCTs61,63-70,81-85 and 47 observational
tural control, promising evidence for postural per-
studies. The reviewers conclusions unanimously
turbations improving reactive balance when a high
pinpoint the paucity of evidence. According to
number of repetitions is provided, and moderately
Steultjens et al.,42 evidence for the efficacy of oc-
strong evidence for the lack of group-level effects of
cupational therapy is insufficient in all interven-
1 wk of NDT or practice.
tion categories. Horn et al.46 have found  no evi-
dence of the effectiveness or ineffectiveness of
Soft-Tissue Treatment
NDT, sensory integration or naturalistic program-
One low-quality review34 evaluated three
ming. No conclusions are made on treatment ap-
RCTs74  76 and two observational studies on passive
proaches for upper-limb dysfunction,43 on training
stretching in children with CP (n 89). The con-
and behavior-modification techniques in conjunc-
clusion is that the effectiveness of passive stretch-
tion with PT,45 or on multidomain developmental
ing remains weak, although some evidence indi-
and CE programs,44 because of the paucity of evi-
cates that sustained stretching is preferable to
dence and methodological limitations.
manual stretching in improving range of motion
and reducing spasticity.
DISCUSSION
Hydrotherapy
We identified and critically analyzed 21 SRs on
In one low-quality review on aquatic interven- PT and CE interventions in children and adoles-
tions,35 one RCT77 and four observational studies cents with CP. Our analysis of the quality of evi-
address children with CP (n 68). Getz et al.35 dence summaries and of the volume, characteris-
conclude that hydrotherapy might improve respi- tics, and effectiveness of primary studies in this
ratory function in children with CP. field provides insights into the current scientific
488 Anttila et al. Am. J. Phys. Med. Rehabil. Vol. 87, No. 6
basis for clinical decision making and future re- Clinical Heterogeneity of the Reviewed
search agendas.
Interventions
CP is a heterogeneous condition where the
developmental potential and goals for rehabilita-
Recommendations for SRs
tion vary with age.93 Many reviews include non-CP
SRs are based on critically appraised, high-
children, which may bias conclusions when results
quality effectiveness research, usually RCTs. Six of
are not analyzed separately. Thus, it is difficult to
the identified SRs were of high quality.26,30,32,33,36,42 All
determine which patient groups may benefit from
reviews included observational studies, possibly be-
the studied interventions. An SR in this field can be
cause of the limited number of RCTs available. The
improved by focusing on clearly defined target
terminology in various observational study designs
groups.
was very mixed. Some reviews did not even recog-
Many older reviews include a variety of incom-
nize RCTs among their included studies.26,28,37 As-
parable interventions. Complex interventions with
sessment of the included studies revealed that re-
several, often vaguely defined, interacting compo-
views on the same topics included somewhat
nents can complicate analyses, decreasing clinical
different studies. No review had excluded studies
applicability. Interventions may be insufficiently
on the basis of quality. The differences may be
described in the original studies,94 and interven-
attributable to different search periods, search
tions in different countries may actually not be
terms and databases, or somewhat different foci on
comparable at all, despite similar names.39 Nar-
inclusion criteria. We recommend that future re-
rower inclusion criteria for interventions may al-
views clearly define what study designs are to be
low better comparison across studies, as seen in the
included.
recent reviews.30  37 First steps toward interna-
Twelve reviews had defined quality-assess-
tional intervention categories in PT with adults
ment criteria, and all but one used these. How- have been taken,95 which may help future evidence
ever, most quality criteria only suit RCTs, not
syntheses.
observational studies. In three reviews,27,33,34 It is important to know whether all clinically
quality was assessed by a tool49 that raises single- relevant outcomes have been reported. Numerous
case studies to the level of RCTs in the evidence noncomparable outcome measures were used in
the studies, and the clinical relevance of many of
hierarchy. Today, the AACPDM methodology has
been updated86 to meet the criteria of evidence- them remains unclear. Without a consensus on
measures to apply in CP94 or in rehabilitation in
based evaluation.87 The variety of quality-assess-
general,96 the combination of results across studies
ment tools reflects the lack of consensus as to
is problematic.
which components and what tools would best
All these factors may complicate reviews of
assess trial quality.10,88,89 Previous research on
complex interventions in this heterogeneous
the role of nonrandomized studies and case se-
population, as recognized earlier.92 Clinicians
ries in SRs in other fields has been hampered by
and researchers would benefit from a more pre-
both the paucity and the poor quality of these
cise description of the studies in terms of popu-
studies.90,91 More research is needed on how the
lation, interventions, comparison interventions,
methodological features of observational studies
and outcomes to increase the clinical applicabil-
affect outcomes in this field.
ity of reviews. Many problems were caused by
The qualitative synthesis methods were built
insufficient reporting of the details of the re-
on different combinations of different aspects
viewed studies, possibly because of poor report-
across the reviews. The categorization of the re-
ing in original studies.97 We recommend using
sults was made either by outcomes, interventions,
guidelines such as the Quality of Reporting of
study designs, study quality, or populations. These
Meta-Analyses statement to increase the quality
categories are then summarized, either descrip-
of the review report.17
tively by levels of evidence analyses, or by counting
for the numbers of studies in different categories.
Effectiveness and Clinical Applicability
Most of these hide important factors, such as the
of the Reviewed Interventions
number of patients included and the real effect
The six high-quality reviews allow conclusions
sizes. Only three reviews provide effect sizes to-
on some of the interventions reviewed. Evidence of
gether with the confidence intervals. A common
comprehensive PT approaches26 and occupational
understanding on how to summarize findings on
therapy interventions42 is insufficient. The four
individual studies in a qualitative synthesis is ob- high-quality reviews on more focused interven-
viously needed, as found earlier on Cochrane re- tions provided positive evidence on some out-
views in PT and occupational therapy interven- comes: strength training on muscle strength,30
tions.92 intensive upper-extremity training on bimanual
June 2008 Effectiveness of Interventions in CP 489
performance,32 hippotherapy on muscle symmetry
CONCLUSIONS
and activities,36 and effectiveness of externally gen-
SRs of PT or CE interventions in children with
erated movements and postural perturbations to
CP require cautious interpretation of the findings.
reactive balance.33
On the basis of six high-quality reviews, conclu-
The four reviews posing targeted questions
sions on the effectiveness of some interventions on
may be clinically easier to apply because they in- specific outcomes could be made. Otherwise, the
clude a limited number and type of interventions
effects remain unclear or unsupported by data. The
and outcomes. For example, in the strength train- low number of RCTs resulted in the inclusion of a
ing review, the interventions, outcome measures, large variety of observational studies in reviews.
and patient inclusion criteria are fairly unambigu- Well-conducted studies on current treatment op-
tions as well as new treatment approaches using
ous.30 The positive evidence on effectiveness is
valid outcomes are obviously needed. Because re-
based on only one RCT70 and several concordant
views on rehabilitation within such a heteroge-
observational studies. The evidence-grading system
neous population as CP are demanding to conduct,
by the GRADE Working Group98 suggests upgrad-
compliance with methodological guidelines on re-
ing for cohort studies, when two or more observa-
porting, such as the Quality of Reporting of Meta-
tional studies show a consistent association, with
Analyses statement, is recommended.
no plausible confounders. This was the case for the
studies on strength training.
ACKNOWLEDGMENTS
Some low-quality reviews have made conclu-
The authors thank professor Regina Kunz, PhD,
sions on indicative evidence of passive and sus-
MD, MSc (Epi), for reviewing the abstracts until June
tained stretching on range of motion and spastic-
2003; information scientists Riitta Grahn, MSc, and
ity,34 hydrotherapy on respiratory function,35 and
Jaana Isojärvi, MSocS, for their support in the liter-
hippotherapy and horseback riding therapy for
ature search; and Mark Phillips, BA, for his help in
gross motor performance.37 This evidence should
reviewing the language of the article.
be interpreted cautiously because of the method-
ological limitations. In the other reviews, the au-
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82. McConachie H, Huq S, Munir S, Ferdous S, Zaman S,
selective posterior rhizotomy plus physiotherapy with
Khan N: A randomized controlled trial of alternative
physiotherapy alone in children with spastic diplegic ce- modes of service provision to young children with cerebral
rebral palsy. Dev Med Child Neurol 1997;39:178 84
palsy in Bangladesh. J Pediatr 2000;137:769 76
63. Law M, Cadman D, Rosenbaum P, Walter S, Russell D,
83. Hanzlik J: The effect of intervention on the free-play ex-
DeMatteo C: Neurodevelopmental therapy and upper-ex- perience for mothers and their infants with developmental
tremity inhibitive casting for children with cerebral palsy.
dealy and cerebral palsy. Phys Occup Ther Pediatr 1989;
Dev Med Child Neurol 1991;33:379 87
9:33 51
64. Palmer FB, Shapiro BK, Allen MC, et al: Infant stimulation
84. Talbot M, Junkala J: The effect of auditorally augmented
curriculum for infants with cerebral palsy: effects on in- feedback on the eye-hand coordination of students with
fant temperament, parent-infant interaction, and home
cerebral palsy. Am J Occup Ther 1981;35:525 8
environment. Pediatrics 1990;85:411 5
85. Sellick KJ, Over R: Effects of vestibular stimulation on
65. Palmer FB, Shapiro BK, Wachtel RC, et al: The effects of
motor development of cerebral-palsied children. Dev Med
physical therapy on cerebral palsy. A controlled trial in
Child Neurol 1980;22:476 83
infants with spastic diplegia. N Engl J Med 1988;318:803 8
86. O Donnell M, Darrah J, Adams R, Butler C, Roxborough L,
66. Sommerfeld D, Fraser BA, Hensinger BN, Beresford CV:
Damiano D: AACPDM Methodology to Develop Systematic
Evaluation of physical therapy service for severely men- Reviews of Treatment Interventions (Revision 1.1): 2004
tally impaired students with cerebral palsy. Phys Ther
Version. Available at: http://www.aacpdm.org/resources/
1981;61:338 44
systematicReviewsMethodology.pdf. Accessed November
28, 2006
67. Scherzer AL, Mike V, Ilson J: Physical therapy as a deter-
minant of change in the cerebral palsied infant. Pediatrics 87. Centre for Evidence-Based Medicine: Levels of evidence.
1976;58:47 52 Available at: http://www.cebm.net/levels_of_evidence.asp.
Accessed November 28, 2006
68. Carlsen PN: Comparison of two occupational therapy ap-
proaches for treating the young cerebral-palsied child. 88. Sutton AJ, Abrams KR, Jones DR, Sheldon TA, Song F:
Am J Occup Ther 1975;29:267 72 Systematic reviews of trials and other studies. Health
Technol Assess. 1998;2
69. Wright T, Nicholson J: Physiotherapy for the spastic child:
an evaluation. Dev Med Child Neurol 1973;15:146 63 89. Jüni P, Witcshi A, Bloch R, Egger M: The hazards of
492 Anttila et al. Am. J. Phys. Med. Rehabil. Vol. 87, No. 6
scoring the quality of clinical trials in meta-analysis. JAMA
a search of unpublished or nonindexed
1999;282:1054 60
literature (e.g., manual searches or let-
90. MacLehose RR, Reeves BC, Harvey IM, Sheldon TA, Russell
ters to primary authors)
IT, Black AMS: A systematic review of comparisons of
1 point: Cannot tell; search strategy par-
effect sizes derived from randomised and non-randomised
studies. Health Technol Assess 2000;4:1 145
tially comprehensive (e.g., at least one of
91. Dalziel K, Round A, Stein K, Garside R, Castelnuovo E, the strategies in the foregoing section
Payne L: Do the findings of case series studies vary signif-
were performed)
icantly according to methodological characteristics?
0 points: No; search not comprehensive or
Health Technol Assess 2005;9:1 146
not described well enough to make a
92. van den Ende CHM, Steultjens EMJ, Bouter LM, Dekker J:
Clinical heterogeneity was a common problem in Co- judgment
chrane reviews of physiotherapy and occupational therapy.
J Clin Epidemiol 2006;59:914 9
Selection Methods
93. Rosenbaum PL, Walter SD, Hanna SE, et al: Prognosis for
gross motor function in cerebral palsy: creation of motor
3. Were the criteria used for deciding which
development curves. JAMA 2002;288:1357 63
studies to include in the review reported?
94. Kunz R, Autti-Rämö I, Anttila H, Malmivaara A, Mäkelä M:
2 points: Yes; inclusion and exclusion cri-
A systematic review finds that methodological quality is
teria clearly defined
better than its reputation but can be improved in physio-
therapy trials in childhood cerebral palsy. J Clin Epidemiol
1 point: Partially; reference to inclusion
2006;59:1239 48
and exclusion criteria can be found in the
95. Finger M, Cieza A, Stoll J, Stucki G, Huber E: Identifica-
paper but are not defined clearly enough
tion of intervention categories for physical therapy, based
to duplicate
on the International Classification of Functioning, Disabil-
ity and Health: a Delphi exercise. Phys Ther 2006;86:
0 points: No; no criteria defined
1203 20
4. Was bias in the selection of articles avoided?
96. Haigh R, Tennant A, Biering-Sorensen F, et al: The use of
2 points: Yes; key issues influencing selec-
outcome measures in physical medicine and rehabilitation
tion bias were covered. Two of three of
within Europe. J Rehabil Med 2001;33:273 8
the following bias avoidance strategies
97. Anttila H, Malmivaara A, Kunz R, Autti-Rämö I, Mäkelä M:
Quality of reporting randomized, controlled trials in cere-
were used: two or more assessors inde-
bral palsy. Pediatrics 2006;117:2222 30
pendently judged study relevance and se-
98. Atkins D, Best D, Briss PA, et al: Grading quality of evi-
lection using predetermined criteria, re-
dence and strength of recommendations. BMJ 2004;328:
viewers were blinded to identifying
1490 4
features of study (i.e., journal title, au-
99. The definition and classification of cerebral palsy. Dev Med
Child Neurol 2007;49:1 44 thor(s), funding source), and assessors
100. Campbell M, Fitzpatrik R, Haines A, et al: Framework for were blinded to treatment outcome.
design and evaluation of complex interventions to improve
1 point: Cannot tell; if only one of the three
health. BMJ 2000;321:694 6
strategies above were used
0 points: No; selection bias was not avoided
APPENDIX A
or was not discussed
Quality-assessment criteria for review articles.
A modified version by Hoving at al.16 of an index
Validity Assessment
constituted by Oxman and Guatt14 and Oxman et
al.15 Maximum total score is 18.
5. Were the criteria used for assessing the
validity for the studies that were reviewed
Search Methods
reported?
1. Were the search methods used to find evi- 2 points: Yes; criteria defined explicitly
dence (primary studies) on the primary 1 point: Partially; some discussion or ref-
question(s) stated? erence to criteria but not sufficiently de-
2 points: Yes; includes description of data- scribed to duplicate
bases searched, search strategy, and 0 points: No; validity or methodological
years reviewed. Described well enough to quality criteria not used or not described
duplicate. 6. Was the validity for each study cited as-
1 point: Partially; partial description of sessed using appropriate criteria (either in
methods, but not sufficient to duplicate selecting studies for inclusion or in analyz-
search ing the studies that are cited)?
0 points: No; no description of search 2 points: Yes; the criteria used address the
methods major factors influencing bias (for exam-
2. Was the search for evidence reasonably ple: population, intervention, outcomes,
comprehensive? follow-up)
2 points: Yes; must include at least one 1 point: Partially; some discussion of
computerized database search as well as methodological review strategy, but not
June 2008 Effectiveness of Interventions in CP 493
clearly described with predetermined cri- 0 points: No; no attempt was made to
teria combine findings, and no statement
0 points: No; criteria not used or not de-
was made regarding the inappropriate-
scribed
ness of combining findings; should be
marked if a summary (general) esti-
Synthesis
mate was given anywhere in the ab-
7. Were the methods used to combine the
stract, the discussion, or the summary
findings for the relevant studies (to reach a
section of the paper, and the method of
conclusion) reported?
deriving the estimate was not de-
2 points: Yes; qualitative or quantitative
scribed, even if there is a statement
methods are acceptable
regarding the limitations of combining
1 point: Partially; partial description of
the findings of the studies reviewed
methods to combine and tabulate; not
9. Were the conclusions made by author(s)
sufficient to duplicate
supported by the data or analysis reported
0 points: Methods of combining studies
in the review?
not stated or described
2 points: Yes; data, not merely citations,
8. Were findings of the relevant studies com-
were reported that support the main con-
bined appropriately relative to the primary
clusions regarding the primary ques-
question the review addresses?
tion(s) that the overview addresses
2 points: Yes; combining of studies seems
1 point: Partially
acceptable
1 point: Cannot tell; should be marked if in 0 points: No; conclusions not supported or
doubt unclear
494 Anttila et al. Am. J. Phys. Med. Rehabil. Vol. 87, No. 6
APPENDIX B Study designs, populations, interventions, outcomes, and results on children with cerebral palsy in 21 systematic reviews
Studies on Children with Diagnosed CP
Number of Studies, Excluded
Studies, a and Reasons for
Review (Year) Exclusion (n) Study Designs (n) Population Interventions, Length (L), and Settings (S) Outcome Measures Results
Comprehensive
physiotherapy
Brown and Burns26 17 10 Diagnosed CP NDT, facilitation and functional Ambulatory status, Bayley Scales (motor, mental), Inconsistent results. Six studies reported a
(2001) 7 excluded 5 studies with control Age: 3 mos to 14 yrs interventions: short-leg casting, sensory clinical observation, COPM, DDST, fine motor benefit from using the NDT approach.
Non-CP population (suspected groups, 5 studies integration, Rood and proprioceptive skills, gait measurements, Gesell Three studies reported no benefit, and
CP or high-risk infants) without control neuromuscular facilitation and selective Developmental Schedules, GMFM, goniometry, one study did not specifically examine
(n 519) groups posterior rhizotomy MAS, modified MCMDST and GS, Motor effects of NDT
(n 299) Control groups: Regular OT sessions, infant Development Evaluation Form, neurological
stimulation program signs scale (nonstandardized), PFMS, PCI,
L: 7 days to 12 mos, sessions: from two QUEST, ROM, SBIS, self-care evaluation
visits to daily sessions (nonstandardized), strength, the Hollingshead
S: Home or nr Four-Factor Index for Social Position, the
Maternal Observation Interview, Vanguard
spirometer, Videotape, VSMS
Butler and Darrah27 21 21 Children with CP NDT individual therapy home program, Attainment or observation defined skills, Bayley NDT: Immediate improvement in dynamic
(2001) 7 RCT, 3 cohort (spastic, ataxic, intensive NDT individual therapy, Bobath Scales (mental, motor), Biofeedback ROM, no consistent evidence that NDT
studies, 3 before athetoid, hypotonic, method, facilitation group therapy, instrument, bracing recommended, CITQ, changed abnormal motoric responses,
after case series, 4 di-, hemi-, tri-, or neurophysiologic individual therapy COPM, DDST, DMIB, GM, GMFM, goniometer, slowed or prevented contractures,
multiple crossover quadriplegic; mild, Control groups: Untreated period, functional HOME, kinematic analyses, neurological facilitated more normal motor
trials, 4 case series moderate, or therapy, traditional therapy, play, infant examination, PAS, pedographs, PFMS, Q development or functional motor activities.
(n 471) severe; mobile and stimulation, mother child interaction (parent satisfaction), Q (social activities and No clear evidence that NDT produced other
nonmobile) instruction, NDT with lesser intensity, home management), Q (motor development), benefits such as enhancement of social
Age: 1 15 yrs CE, skill practice, functional skills OT QUEST, rate of movements, rated observation emotional, language, or cognitive domains
L: 25 days to 12 mos (of automatic reflexes, GM activities, position), of development, better home
S: nr Rating Scale, RMCRE, ROM Scale, surgery environments, improved parent-child
recommended, video analysis, VSMS, WDRP interactions, or greater parent satisfaction.
No benefit of more intensive therapy
Parette et al.28 13 9 Children with PT, unspecified individualized treatment, Bayley Scales (mental, motor), Children s Hands Inconsistent results. Seven studies
(1991) 4 excluded 6 studies with control diagnosed CP facilitation, neurophysiologic PT and Skills Survey, DDST, GM evaluation, Hartwell reported positive findings of PT,
Non-CP population groups, 3 Age: 5 yrs parent-provided therapy, direct Motor Age Test, Minear (1956) Classification unspecified individualized treatment,
(n 102) descriptive studies treatment, early PT using Vojta system, Motor Development Evaluation Form, facilitation, individual therapy or
(n 451) Control groups: Functional approach, Physical therapy (based on the work of Holt neurophysiologic PT of early PT using
passive ROM exercises, developmental 1976), Preschool Functional Activity Test, Vojta, while there were no differences
stimulation by parents, no treatment, Standardised Neurologic Examination, WDRP between groups in two studies that
supervised management by teacher or compared direct treatment with
aide, late PT using Vojta supervised, and PT with no treatment
L: 6 wks to 4 yrs
S: Clinic, home, or nr
Tirosh and Rabino29 9 5 Children with CP Bobath NDT, some rehabilitation and GM milestones: Sitting, crawling, walking, home Inconsistent results. Positive results for NDT
(1989) 4 excluded 4 RCTs, 1 other Age data not available surgery, NDT conducted by parents management (nonstandardized), motor and compared with no treatment, NDT by
Non-CP population design Control groups: Bobath NDT by teachers, no mental quotients, motor function parents compared with passive ROM
(n 195) (n 174) treatment, rehabilitation program (nature (nonstandardized), neurological status exercises, and treatment ensuing before
unspecified), passive ROM exercises, Vojta (nonstandardized), ROM, social development compared to subjects 6 mos of age
by parents, therapy by parents quotient treated with Vojta technique by parents
L: 6 12 mos (three studies). Two studies reported no
S: Home or nr effects for NDT (Bobath NDT by
physiotherapist compared to NDT by
parents, and NDT compared with
stimulation by parents with supervision by
therapists)
June 2008
Effectiveness of Interventions in CP
495
APPENDIX B Continued
Studies on Children with Diagnosed CP
Number of Studies, Excluded
Studies, a and Reasons for
Review (Year) Exclusion (n) Study Designs (n) Population Interventions, Length (L), and Settings (S) Outcome Measures Results
Strength training
Dodd et al.30 (2002) 10 9 Patients with CP Isokinetic, concentric and eccentric, 12-min wheelchair test, dynamic tapping, EEI, Impairment: Increases in muscle strength
1 excluded 1 RCT, 8 other (spastic, ataxic, isometric, free-weight, or fixed-weight GMFM, heart rate, MAS, perceived (effect size range from 1.16 to 5.27)
Population aged 12 47 designs (repeated dystonic and exercises competence, ROM (ankle, knee), Self- (8 of 9 studies), nonsignificant
(n 6) measures, single mixed types; di-, L: 6 10 wks, sessions 3 7 times per week. Perception Profile for Adolescents, Self- results (1 study, small population).
4 reviews group) hemi-, and Repetitions ranged from 1 set and 6 Perception Profile for Children, spasticity, No change in muscle spasticity (2
(n 124) quadriplegic; repetitions to 3 4 sets and 5 10 strength with isokinetic dynamometer, studies), increase in ROM (3 of 4
from repetitions (change in weight over 6RM, maximum studies), no change in ROM (1 of 4
ambulatory to S: Home-, clinic-, or community-based isometric contraction, maximum voluntary studies)
nonambulatory programs contraction, mean isometric maximal Activity (4 studies): Increases in walking,
or not specified, contraction, rate of torque development, running, and jumping (GMFM
or CP-ISRA peak torque and work) dimension E) (2 studies), and in
classes 7 8 standing (1 study), contradictory
Age: 4 20 yrs results on walking speed (2 studies)
Participation: Not measured
Contextual factors: Nonsignificant and
positive results with individual
exercise programs (6 studies),
positive results with group program
(1 study), nonsignificant and
positive results of home- and clinic-
based programs (3 studies), positive
results of a community-based
program (1 study)
Darrah et al.31 77 Isokinetic, concentric, eccentric, or Cybex II (peak torque, torque development, All studies reported positive effects on
Children and
(1997) 1 RCT, 6 case series adolescents with isometric exercises with Cybex, free endurance, movement time), degree of knee muscle strengthening on various
(n 74) CP weights, KIN-COM, Nautilus equipment, flexion at heel strike, energy expenditure, gait outcomes (movement time, increased
Age: 6 26 yrs training machine, pulley, or free weights analyses, GMFM, handheld dynamometer rate of torque development, quadriceps
Control groups: Isokinetic training without (quadriceps and hamstring), KIN-COM (peak strength, stride length, peak torque
resistance, or noneL: 2 10 wks torque, work of quadriceps and hamstrings), and work, strength and speed of
S: nr obstacle course video, ROM (knee extension), movement)
stride length, tensiometer (quadriceps), timed
fine motor tasks
Constraint-induced
movement
therapy
Hoare et al.32 33 Children with CP, Casting of the less involved hand and Assisting Hand Assessment, Box and Blocks test, 1 RCT: No effects on QUEST or CAUT,
(2007) 2 RCT, 1 CCT hemiplegic, or training (shaping), fabric glove with a CAUT, PMAL, EDPT, EBS, QUEST, WeeFIM positive effects on PMAL frequency of
(n 94) asymmetric built in stiff volar plastic splint and a use subscale and EBS at 3 and 6 wks
involvement of the motor learning treatment program, 1 CCT: Improvement in bimanual
upper extremities scotchcast from below elbow to fingertips performance at 2 and 6 mos
Age: 7 mos to 8 yrs and individualized functional OT, 1 RCT: Improvement in self care
stretching, and ADL practices component on the WeeFIM at 6 wks.
L: 2 7 days/wk, 3 wks to 2 mos No effects in all other measures
S: Preschool or nr
496
Anttila et al.
Am. J. Phys. Med. Rehabil.

Vol. 87, No. 6
APPENDIX B Continued
Studies on Children with Diagnosed CP
Number of Studies, Excluded
Studies, a and Reasons for
Review (Year) Exclusion (n) Study Designs (n) Population Interventions, Length (L), and Settings (S) Outcome Measures Results
Postural control
Harris and 12 4 Spastic quadriplegia, NDT (to improve trunk and shoulder Area (where control became deficient during Externally generated movement on
Roxborough33 8 excluded 1 crossover cohort diplegia, hemiplegia. control, smoothness and efficiency of static sitting), autoregressive modeling for feet- development of postural control: Improved
(2005) Interventions on seating study, 3 case Severity: not provided, movement, ability to initiate reach); rocker related displacement, center-of-pressure sway area reactive balance, GMFM (1 study), postural
device, orthoses. or lycra studies (1 case could not sit platform movements; massed practice on a per second, GMFM (standing), independent sitting sway (1 study), independent sitting
garment series, 1 ABA, 1 BA independently, all moving platform; microprocessor-controlled for 30 secs, Kinematic analysis (Watsmart) of balance segmental level of control (1
(n 100) design (n 45) could walk or GMFCS artificial saddle riding using Brunel Active displacement of the head and trunk during reach, study)
33 healthy levels I and II Balance Saddle manual perturbation and voluntary movement; NDT vs. practice (1 wk): no effects on
Age: 2.5 15 yrs Control groups: Practice or none modified Posture Assessment Scale scored from posture and kinematic analyses
L: 4 5 sessions during 1 wk, nr, 4 6 video (head, neck, shoulder, scapula and trunk
perturbations per minute with rest after 20 items only), postural sway, time to stabilization
25 mins, 100 perturbations per day for 5 after a perturbation
days
S: nr
Soft-tissue treatment
Pin et al.34 (2006) 7 5 Children with CP Manual stretch, sinusoidal stretch by Passive torque (ankle joint), EMG, goniometer, ROM: One RCT showed no between-group
2 excluded 3 RCT , 1 before after (spastic, diplegia, specifically designed apparatus, standing Kin-Com dynamometer and surface electrodes differences in ROM (triceps surae).
Non-CP population (spasticity design, 1 multiple hemiplegia, in tilt-table (in terms of torque, ankle angle and EMG), Observational studies showed reduction
in lower limbs, severe single-subject quadriplegia) L: Manual stretch with hold 60 secs or 15 Spastic Locomotion Disorder Index, specially in knee flexion contracture (one study),
physical and cognitive design (n 69) Age: 3 19 yrs 20 mins, 3 5 repetitions for each designed apparatus (measuring passive hip or no reduction in passive hip
impairment, and decreased 20 controls movement or joint, 1 time per week to 3 adduction angle, hypertonicity), tonic stretch abduction (one study)
joint ranges of lower limbs) times per day, 5 days/wk; sinusoidal reflex, video recording (gait analysis) Spasticity: Three RCTs and one single-
(n 20) stretch for 30 mins per session, 3 times subject study showed a reduction in
per week for average 42 days; standing in spasticity
tilt-table 30 mins Gait: No changes in gait pattern after 30
S: nr mins of stretching on a tilt table (one
study)
Hydrotherapy
Getz et al.35 (2006) 11 5 Children or Aquatic exercise (1 time per week) by Balance and equilibrium skills, bilateral activities, Inconsistent results. No differences
6 excluded 1 RCT, 1 quasi- adolescents with Halliwick method, combined land and function and coordination of extremity during between conventional aquatics program
Non-CP population experimental study CP, spastic, di-, aquatic exercise, swimming and water bilateral activities, GMFM, Leisure s Activity and adapted aquatics program (one
(neurological dysfunction, (same study in 2 hemi-, safety instruction Inventory, Matrinek-Zaickowsly Self-Concept RCT). One study: Likely improvements
spinal muscle atrophy, Rett reports), 2 case quadriplegia, ataxia, Control groups: Aquatic exercise (2 times Scale, promotion of positive self-image. in function, improvement in
syndrome, progressive reports athetosis per week) or none Rosenberg s Self-Esteem Scale, ROM (shoulder orientation skills, no improvement of
muscular dystrophy, high- (n 68) Age: 5 17.3 yrs L: 6 wks to 6 mos; 1 time per week, joint), SWIM, VC, water orientation self-concept. Case reports:
risk infants) sessions: 30 55 mins Improvement in SWIM, GMFM,
(n 59) S: nr standing, balance, VC, shoulder flexion
and abduction ROM, arm swing during
ambulation, use of right extremity in
ADL, back and side stroke, and crawl
June 2008
Effectiveness of Interventions in CP
497
APPENDIX B Continued
Studies on Children with Diagnosed CP
Number of Studies, Excluded
Studies, a and Reasons for
Review (Year) Exclusion (n) Study Designs (n) Population Interventions, Length (L), and Settings (S) Outcome Measures Results
Hippotherapy
Snider et al.36 99 Children with CP Hippotherapy (and riding therapy) by Bertoti Posture Assessment Scale, BOTMP, CBC, Hippotherapy: Increased muscle symmetry
(2007) 3 RCT, 4 quasi- (spastic, di-, and physical or occupational therapist, EMG (trunk ab/adductors), energy of the trunk and hip ab/adductors (one
experimental, 2 hemiplegia, therapeutic horseback riding (THR) by a expenditure, gait (velocity, cadence, average RCT); improved posture (one study),
case studies moderate to severe) trained riding instructor stride length), GMFCS, GMFM, HSPS, GMFM-E (one study), GMFM and PEDI
(n 99) 9 Age: 2.3 12 yrs L: From 1 session (8 mins) to 6 mos; kinematic analyses by peak 5 motion analyzer, (one study). energy expenditure (one
nondisabled sessions from one 8-min visit to 1 hr, 2 MAS, PDMS, PEDI, Qualitative information, study), and trunk coordination (one
controls times per week trunk coordination (kinematics), VABS ADL/ study)
S: nr socialization, WeeFIM Therapeutic horseback riding: Positive
changes in GMFM, no changes in
muscle tone (one RCT), improvements
in grasping (PDMS), but not for
posture, self-esteem, or global behavior
(one RCT); improvement in GMFM
(one study) and more likely to respond
with normal equilibrium reactions to
the pelvic displacement of the horse in
diplegia, than in children with
quadriplegia (one study)
Sterba37 (2007) 11 9 Children with CP Hippotherapy by licensed health GMFM, kinematic measurement from Hippotherapy (5 studies): Improved
2 excluded 3 cohort designs, 1 (spastic, mild to professionals, recreational horseback- videography, PEDI, test for scoring posture posture (one study), weight bearing
Non-CP population (various single-case design, severe, ambulatory riding therapy by riding instructors with a four-point scale for five measurements (one study), gross motor function
developmentally delayed 2 before after to nonambulatory, L: 6 26 wks; sessions for 45 120 mins, 1 (head/neck, shoulder/scapula, trunk, spine, (GMFM-E) (one study), coordination
children, down syndrome, designs, 3 case di-, hemi, and time per week and 30 60 mins, 2 times pelvis), the riders lateral trunk displacement, and functional mobility (PEDI) (one
autism, spina bifina, and studies (n 85) quadriplegia) per week weight bearing of arms and legs study), and in functioning (GMFM and
traumatic brain injury) 7 without CP Age data not available S: nr PEDI) (one study)
(n 26) HBRT (3 studies): Inconsistent results. No
changes in GMFM (one study),
improvements in walking, running, and
jumping (GMFM dimension E) (one
study) and in GMFM total score (one
study)
Conductive education
Darrah et 15 14 Children with CP (di-, CE by physical or occupational therapist, Basic Math test, CMMS, CRT, DMT, DP2 CAS, The majority of the results of the
al.38(2003) 1 excluded 1 RCT, 1 CCT, 3 hemi-, and teacher, professional trained therapist DP2 PAS, DP2 SHAS, DSI, ECFAT, GMFM, methodologically stronger studies
Non-CP population (mothers of cohort studies quadriplegic; mild, teachers, conductors, nurses, mothers, survey to parents, observation, parent reveal no difference in outcome
children with CP) with concurrent moderate, or caregivers. Rhythmical intention perception of goal achievement, PIAT, PPVT, between CE intervention group and the
(n 36) controls, 2 cohort severe; spastic or Control groups: Training programs in QRS, rating scale, RDLS, SB subtest, task control group or pre post CE group
studies with dystonic; orthopedic residential schools, center- analysis, task series, VAB BR (video), VAB CR, results (of 20 outcomes, 10 favored CE
historical controls, intellectual based early intervention, individual PT, VABS CE, VABS IE, video ratings, VLDS, and 10 favored the control group; no
7 case series disability: mild, special education, individual therapy, WBSI, WPPSI outcome of interest showed
(n 1038) moderate, severe, traditional therapy, or none improvement in the CE group across
or normal) L: nr, session lengths ranged from 2.8 hrs/ studies). The majority of outcomes of
Age: 1 13 yrs wk to 13.5 hrs/day interest in methodologically weaker
S: Various schools, Petö Institute, spastic studies showed some improvement for
centre, Move and Walk Institute the CE group.
498
Anttila et al.
Am. J. Phys. Med. Rehabil.

Vol. 87, No. 6
APPENDIX B Continued
Studies on Children with Diagnosed CP
Number of Studies, Excluded
Studies, a and Reasons for
Review (Year) Exclusion (n) Study Designs (n) Population Interventions, Length (L), and Settings (S) Outcome Measures Results
Ludwig et al.39 9 6 Children with CP CE, or programs based on CE CMMS, GMFM, Parenting Stress Index, PPVT, Inconsistent results. No differences
(2000) 3 excluded 1 RCT, 3 CCTs, 2 Age: 1 12 yrs L: Ranged from 26 wks to 2 yrs; sessions QRS, RDLS, VAB, WPSSI between the groups (three studies),
Non-CP population (parents) descriptive studies from 3 hrs/wk to 3 6 hrs/day (nr for all improved motor performance and
(n 57) (n 203) studies) parental coping in CE group, improved
S: UK Birmingham- and Manchester-area cognitive variables in control group
special schools, and 5 Australian schools (one study); positive results in selected
in Tongala and Melbourne, Victoria; early skills (one study); in mobility and
interventions in Brisbane eating skills (one study); decreased
mobility in CE group (one study)
Pedersen40 (2000) 9 8 Children with CP CE or programs based on CE principles nr Inconsistent results. Positive results in
1 excluded 1 RCT, 7 studies with Age: 1 15 yrs (age nr L: 26 wks to 2 yrs; sessions: 13.5 hrs/day (1 favor of CE on social skills (one study),
Non-CP population control groups from all studies) study). Other session lengths nr motor skills , parental coping (one
(children with mental (n 243) S: nr study) and motor, social and cognitive
retardation or multiple skills (one study); no effects (five
handicaps) studies)
(n 10)
French and 6 5 Children with CP nr from all studies. Feeding and drinking Bayley Scales, checklist of skills (basic motor, fine Inconsistent results. From gross motor,
Nommensen41 1 excluded 5 quasi-experimental Age: 3 13 yrs program, daily program, plinth, sitting, finger, GM, eating, grooming, helping, social ADL, play, language, and
(1992) Non-CP population (children studies hand, standing and walking programs responsibilities, nonstandardized), CWPAC, personal/social skills and parent
with profound, multiple (n 244) L: 6 22 mos Comparative Appraisals Scale, ECFAT, EDPT, outcomes one variable of each
handicaps) S: nr modified VAB, Parent Child Interaction Scale supported CE significantly. From gross
(n 10) Q (nonstandardized), QRS, RDLS, motor two variables and from ADL and
RDLS Zinkin, SBIS, VAB personal/social skills and parent
outcomes one variable supported
comparison groups significantly.
Nonsignificant differences where in one
GM and play variables, in two
cognitive, language and personal/social
skills variables, and three fine motor
and ADL variables
Various interventions
Steultjens et al.42 17 8 CP (spastic, diplegic, Intensive NDT with or without cast, Bayley Scales (motor), DDST, Independent NDT casting: No between-group
(2004) 9 excluded 6 RCTs, 1 CCT, 1 or nr) individually sensory perceptual motor Behaviour Assessment Scale (IBAS), Klein Bell differences in dexterity or upper
Interventions on assistive other design. Age: 1.5 8 yrs training (SPM) home program, tracing scale, observation of independent play, PFMS, extremity function (two RCTs)
devices or splints (n 334) auditory feedback, dressing and Physical ability test, QUEST, SCMAT Sensorimotor functions: Nonsignificant
(n 102) undressing during play, facilitation result (one RCT), nr (one CCT)
sensory organization postural stability, Training of skills: No improvement in
verbal instruction, distance training functional ability (one study)
urban/rural Training of sensorimotor function vs
Control groups: Regular NDT with or without training of skills: Nonsignificant results
cast, regular OT, group SPM home on motor skills (one RCT)
program, tracing without feedback, Parental counseling: Nonsignificant
functional approach self-care, NDT results on functional ability (two RCTs)
instruction, mother child group training
urban/rural, or none
L: Sessions varied from 2 10 mins, 5 times
per week, to 3 1.5 hrs, 1 time per week;
intervention length: 4 wks to 9 mos
S: Outpatients, home or school
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Effectiveness of Interventions in CP
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APPENDIX B Continued
Studies on Children with Diagnosed CP
Number of Studies, Excluded
Studies, a and Reasons for
Review (Year) Exclusion (n) Study Designs (n) Population Interventions, Length (L), and Settings (S) Outcome Measures Results
Boyd et al.43 (2001) 56 13 Children with CP PT, OT, NDT, motor learning, CE, strength COPM, PEDI, PFMS, QUEST, ROM (wrist), VAB Inconsistent results
43 excluded 3 RCTs, 10 other (quadri-, di-, and training, constraint-induced therapy Impairment outcomes: Positive findings
Interventions on orthoses, designs with hemiplegic) Control groups: nr (five studies), no difference between
splints, lycra suits, special prospective data Age: 1.5 18 yrsb L: nr groups (two studies)
seating, electrophysical (n ?) S: nr Activity outcomes: Positive results (seven
agents, or drugs studies), no difference between groups
(n ?) (three studies)
Participation outcomes: Positive effects
(two studies), no difference between
groups (three studies)
Woolfson44 (1999) 9 9 Children with CP Group 1: Multidomain developmental Bayley scales, CITQ, DP 2, GMFM, HOME, MFD, Group 1: Improvement in infant
1 RCT (in 2 articles), (mild to severe stimulation programs (children placed in movement scale (nonstandardized), stimulation group in some outcomes
and 8 quasi- spastic diplegia in 2  confined space to inhibit abnormal observation and parental report of motor skill compared with NDT group, no
experimental studies; data nr for motor movements and to promote social attainment, Parent Q, PTI, QRS, RMCRE, differences in psychosocial variables
designs others) and language development), NDT, motor, Schedule of Growing Skills, semistructured (one RCT); progress in motor activity,
(n 399) Age: 1 7 yrs cognitive, language, and sensory activities interviews, VAB, VSMS fine motor skills, social skills,
stimulation program, interdisciplinary communication, comprehension, visual
developmental stimulation program and auditory understanding, interactive
(gross and fine motor, communication, social, and self-help (four studies)
cognitive, social, attention and self-help) Group 2: No between-group differences
Group 2: CE compared with traditional (three studies); greater mothers
special education, individual PT, aim- satisfaction with help in CE group,
oriented management, eclectic PT and improvement in object transfer,
NDT postural independence, hip mobility,
L: 4 12 mos (group 1), 1 24 mos (group 2) form discrimination and activities of
S: nr daily living in control group (one
study); improvements in motor skills,
ADL and parental coping in CE groups,
and in cognitive skills and social
interaction in the control group (one
study)
45
Hur (1995) 37 19 Children with CP Bobath PT, facilitation, NDT, vestibular nr RCTs: No between-group differences (three
18 excluded 5 RCTs, 1 (spastic, athetosis stimulation, direct therapy, semicircular RCTs), improvement in all areas (one
Non-CP population (evidence nonrandomized type, hemiplegic, canal therapy, interaction sessions, RCT), or in motor, social, and home
of brain insults, signs of group triplegic, balance training orthosis, exercise, PT management (one RCT)
cerebral neuromotor comparisons, 3 quadriplegic, head support device, visual training, Other designs: Positive resultsin various
disturbances, parents); before after dyskinesia, all reverse tailor sitting, head positioning, outcomes (13 studies), negative results
biofeedback, casts, braces, treatment categories, or nr) swimming (one study)
oral motor control, surveys comparisons, 4 Age: 8 mos to 22 yrs L: 4 wks to 6 yrs (nr for all studies).
(n 457) descriptive studies, Sessions: 15 mins, 4 times per week (1
4 single case, 2 study); 30 mins, 2 times per week (1
case studies study). Other session lengths nr
(n 270) S: nr
500
Anttila et al.
Am. J. Phys. Med. Rehabil.

Vol. 87, No. 6
APPENDIX B Continued
Studies on Children with Diagnosed CP
Number of Studies, Excluded
Studies, a and Reasons for
Review (Year) Exclusion (n) Study Designs (n) Population Interventions, Length (L), and Settings (S) Outcome Measures Results
Horn46 (1991) 28 26 Severe (51%) and Training of fine and GM skills (head control, Bayley scales (motor), Cattel Scale, developmental Neuromotor interventions: No difference
2 excluded 6 RCTs and 2 moderate (34%) global motor functions, reflexes, weight measure of motor function reflexes, (five studies), positive results (two
Non-CP (high risk infants) comparison group motor disabilities. shift/bearing, postural stability, upper developmental screening (with/without studies), three of seven children
(n ?) designs, 13 single- High tone extremity) reliability), direct observation, EIDP, EMG benefited (one study), no short-term
subject designs, 5 problems (70%), L: nr recording, GM evaluation, Kreutzberg Reflex, advantages (one study)
case studies quadriplegia (66%) S: nr mechanical count (no validity check), Sensory stimulation: No differences (one
(n ?) Age data not available mechanical device, motor development, motor study), improvements (three studies)
milestones, Motor Skills Test, neurological Behavior programming: No improvements
examination, PFMS, reflex test, ROM scale, (one study); improvements (11 studies)
SBIS, subject report, VSMS, WDRP Natural context treatment: Positive results
in accelerated acquisition (one study),
and in general positive changes (one
study)
a b
Descriptions of study designs are reported here as described in the reviews; characteristics of population reported only for RCTs.
ADL, activities of daily living; CP, cerebral palsy; RCT, randomized controlled trial; CCT, clinical controlled trial; NDT, neurodevelopmental therapy; CE, conductive education; PT, physiotherapy; OT,
occupational therapy; nr, not reported; CP-ISRA, Cerebral Palsy International Sport and Recreation Association Classification System (eight levels); EMG, electromyography; GM, gross motor; Q,
Questionnaire; BOTMP, Bruininsks-Oseretsky Test of Motor Proficiency; CAUT, Child Arm Use Test; CBC, Child Behavior Checklist; CHQ, Child Health Questionnaire; CITQ, Carey Infant Temperament
Questionnaire; CMMS, Columbia Mental Maturity Scale; COPM, Canadian Occupational Performance Measure; CRT, Comprehensive Reading Test; CWPAC, Cheyne Walk Physical Ability Chart; DDST, Denver
Developmental Screening Test; DMIB, Dictionary of Mother-Infant Behaviours; DMT, Diagnostic Mathematical Task; DP2 CAS, Developmental Profile 2 Communication Age Scale; DP2 SAS, Developmental
profile 2 Social Age Scale; DP2 SHAS, Developmental Profile 2 Self-help Age Scale; EBS, Emerging Behaviours Scale; ECFAT, Eau-Claire Functional Abilities Test; EDPT, Erhardt Developmental Prehension
Test; EEI, Energy Expenditure Index; EIDP, Early Intervention Development Profile; GMDS, Griffith s Mental Developmental Scale; GMFCS, Gross Motor Classification System; GMFM, Gross Motor Function
measure; GS, Gidoni Scale of Gross Motor Development; HOME, Home Observation for Measurement of the Environment; HSPS, Harter Self-Perception Scale; MAS, Modified Ashworth scale; MCMDST,
Milani-Comparetti Motor Development Screening Test; MFD, Munich Functional Diagnostic; MI, Malaise Inventory; PAS, Postural Assessment Scale; PCI, Physiological Cost Index; PDMS, Peabody
Developmental Motor Scales; PEDI, Pediatric Evaluation of Disability Inventory; PFMS, Peabody Fine Motor Scale; PIAT, Peabody Individual Achievement Test; PMAL, Pediatric Motor Activity Log; PPVT,
Peabody Picture Vocabulary Test; PTI, Pictorial Test of Intelligence; QRS, Questionnaire on Resources and Stress; QUEST, Quality of Upper Extremity Skills Scale; RDLS, Reynell Developmental Language
Scale; RM, repetition maximum; RMCRE, Roth Mother-Child Relationship Evaluation; ROM, range of motion; SCMAT, Southern California motor accuracy test; SBIS, Stanford-Binet Intelligence Scale; SWIM,
Swimming with Independent Measurement; VAB, Vulpe Assessment Battery (BR, behavior rating; CR, caregiver rating); VABS, Vineland Adaptive Behaviour Scales (IE, Interview edition; CE, classroom
edition); VC, Vital capacity; VLDS, Verbal Language Developmental Scale; VSMS, Vineland Social Maturity Scale; WeeFIM, Functional Independence Measurement for Children; WBSI, Wolfe-Bleuel
Sozialization Inventory; WDRP, Wilson Developmental Reflex Profile; WGME, Wolanski Gross Motor Evaluation; WPSSI, Weschler Pre-School Scale of Intelligence (revised).
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