Bobath Therapy for Children with Cerebral Palsy

National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Author: Dr M Webb, Public Health Practitioner Date: 14/05/08 Version: Version 2b Status: Approved Intended Audience: Local Health Boards Purpose and Summary of Document: Review of the evidence on the effectiveness of NDT/Bobath therapy and alternative treatments for children and adolescents with cerebral palsy to inform LHB commissioning decisions for this treatment. There was a lack of good quality evidence to support the use of NDT/Bobath therapy in children and adolescents with cerebral palsy. Of the available alternative treatments, evidence of effectiveness was only available for exercise programmes focussing on lower extremity muscle strength and /or cardiovascular fitness. Publication/Distribution:  Local Health Board Public Health, Medical and Nurse Directors

Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 1 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

CONTENTS

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

© 2008 National Public Health Service for Wales Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to the National Public Health Service for Wales to be stated.

Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 2 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy Executive summary

In the United Kingdom neurodevelopmental therapy (NDT) based on Bobath principles is currently used in many settings with the intent of improving the motor and functional deficits of children and adolescents with cerebral palsy (CP).

Bobath Cymru in Cardiff provides a service to Welsh residents with cerebral palsy and from May 2007 requested an increase in funding from the local health boards. There is a perception that the service is operating without a strong evidence base compared with other conventional therapies for children with CP offered within the National Health Service, although there are acknowledged difficulties in separating out ‘standard’ and Bobath treatments outside purist settings. The aim of the present document is to report the results of a rapid review of the evidence on the clinical and cost effectiveness of NDT/Bobath therapy for children and adolescents with CP.

The major health care databases were searched and high level searching using meta-search engines, other databases and the websites of relevant agencies was also performed to maximise identification of literature.

The searches resulted in 350 documents for NDT/Bobath and cerebral palsy. The abstracts and titles were screened for relevance and 23 articles contributed to this review. Several timely, high quality systematic reviews were identified in the scoping search and these were extensively used to inform the document.

There was good quality evidence (Levels 1 and 2) that did not provide support for the effectiveness of NDT/Bobath therapy for children and adolescents with CP.

It has been suggested that the randomised controlled trial is not an appropriate method to determine the effectiveness of NDT/Bobath therapy because of the problems of heterogeneity of the study population and the techniques used.

Published data on cost effectiveness of NDT/Bobath was not found.

Where alternative treatments are concerned, there was inconsistent evidence for the effectiveness of botulinum toxin A and speech and language therapy and further research is required. Evidence was lacking for acupuncture, rhizotomy and drug treatments and the planned Cochrane reviews on these treatments should provide further data.

Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 3 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy 1. Background

In the United Kingdom physiotherapists who treat children and adolescents with cerebral palsy (CP) generally use a form of therapy known as neurodevelopmental therapy/treatment (NDT), based on the work of the Bobaths. 1, 2 Bobath therapy aims to influence muscle tone and improve postural alignment by specific handling techniques and attempts to facilitate improved active participation and practice of relevant skills.3 The terms Bobath therapy and NDT are frequently used interchangeably and most practising physiotherapists will adopt some Bobath handling techniques whether working within or outside Bobath settings.

The voluntary sector service to Welsh residents with cerebral palsy is provided by Bobath Cymru, based in Cardiff. Bobath has recently requested increased funding from the local health boards (LHBs) and there are commissioning concerns about this service.4 One of these concerns is the recognition that there is not a strong evidence base for effectiveness and cost effectiveness of Bobath therapy compared with conventional treatment within the National Health Service (NHS). The National Public Health Service (NPHS) was therefore asked to investigate the evidence base for the effectiveness of Bobath therapy and alternative treatments for children and adolescents with cerebral palsy. 2. Aims

The purpose of the present document is to perform a rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy. The evidence for alternative treatments for CP was also evaluated. The paper did not seek to separately quantify or compare Bobath therapy as a wider holistic social intervention. 3. Research question

What is the evidence that Bobath therapy improves motor and functional outcomes for children and adolescents with cerebral palsy? 4. Methods

The research question in Section 3 was converted to a structured question for searching using the Population, Intervention, Comparison and Outcome (PICO)5 format.

Patient: children and adolescents aged 0 -20i years with a diagnosis of cerebral palsy Intervention: use of Bobath/NDT as a primary intervention Comparison: alternative treatments – e.g. conventional physiotherapy/exercise training; botulinum toxin; acupuncture; surgery. Outcome: improved motor function, improved abilities in functional skills, decrease in contractures and/or deformities

4.1 Identifying existing and ongoing research

4.1i Literature searching

Systematic searching: As per the protocol contained in The evidence checklist 6 a scoping search was initially performed to identify major papers on published evidence and refine the final search strategy. For the present overview, search terms contained in the search strategies were used from published reviews and they were kept broad to maximise retrieval of references. The basic search strategy is shown in Appendix 1. The type of literature on NDT/Bobath therapy necessitated the use of a pragmatic approach to searching for evidence in order to achieve production of the review within the short timescales for delivery. It is clear that there had to be a balance between timeliness and rigour and high quality evidence and systematic reviews, meta-analyses, health technology assessments and clinical guidelines were identified first. It should be emphasised that the review is not a systematic review of primary studies.

High level searching: It is well known that the classical databases for medical literature, such as Medline, do not adequately index all relevant literature. The reviewer used validated methods that involved the use of meta-search engines and other databases for ‘high level’ searching to quickly identify relevant evidence. (Appendix 2)

For critical appraisal, the tables recommended for use in the National Institute for Health and Clinical Excellence guideline development methods manual 7 were modified to accept the type of studies identified for cerebral palsy and Bobath therapy. The quality of the evidence was graded using the NICE hierarchy of evidence and the quality checklists. Evidence was rejected if graded as poor quality, apart from where it was of Level 1 type (see Appendix 3 for explanation of evidence grading system) and was highly relevant to the questions. The data relevant to the research question was entered into an evidence table. (Appendix 4) Due to practical limitations a single reviewer performed the final selection, critical appraisal and data extraction.

Inclusion criteria

i Published papers on ‘children’ with CP contained a mix of age ranges and therefore the age range chosen was broad. Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 5 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Search period January 1995 – May 2008 Papers in English, German, French or Spanish Interventions relating to Bobath therapy in the treatment of children and adolescents (age range 0-20 years) with cerebral palsy. Randomised controlled trials Systematic reviews Meta-analyses Guidelines Observational studies (where higher quality evidence was not available) 5. Results

The scoping search revealed several key evidence documents and these high quality secondary sources were used to inform this paper. The searches revealed 350 documents for NDT/Bobath therapy and cerebral palsy. A total of 40 citations was downloaded into Reference Manager Software and critically appraised; 23 articles were selected to inform this review.

5.1 NDT/Bobath therapy

The evidence for the effectiveness of NDT/Bobath therapy was scoped by the NPHS in 2007 and there was a lack of good quality evidence to support the effectiveness of such therapy in either stroke or cerebral palsy. 8

A good quality (Level 2++) systematic review of studies where NDT was stated to be the primary intervention was performed by the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) in 2001 to inform an AACPDM evidence report. 9 The outcomes considered were motor responses, contractures and deformity, motor development, quantity of therapy, functional limitation/activity, and other domains of child development (cognitive, language, social, emotional etc The authors conclude that although there are still concerns regarding how to effectively measure the effectiveness of NDT in academic studies, it is time to investigate new approaches in therapy that are more effective than NDT in promoting motor and functional improvements in children with CP. A subsequent systematic review (Level 2 ++) with some methodological problems concludes that the evidence for the effectiveness of NDT in children with CP was inconclusive and inconsistent. 10

A systematic review (Level 1+) of the effects of early intervention on motor development in children with CP or Downs syndrome was published in 2005 11 that included studies of NDT. Eight studies evaluated the effects of NDT or physiotherapy, mainly on the basis of the principles of NDT. Only one study reported a better motor outcome in the experimental group than in the control group. 12 The ‘positive effect’ of this study differed from the other studies in being the only one that compared intensive NDT treatment with less intensive Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 6 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

NDT. The other seven studies compared NDT with infant stimulation or with a form of standard care that was not defined further. In six of the seven studies, motor outcome in the NDT group was similar to that of the control group. In the seventh study, motor development was worse in children treated in accordance with the principles of NDT than in children who received an infant stimulation programme. The authors conclude that the studies indicate that NDT during the first years of life does not have a measurable positive effect on motor development.

A 2007 health technology assessment {HTA}, (Level 1++) describing the results of an RCT of additional therapy for children and adolescents with CP also summarises the existing literature on NDT/ Bobath1 and found that the published studies fell into three categories:-

a) comparison of NDT with other therapeutic approaches.

The authors of the HTA conclude that there was a lack of evidence to support the efficacy of any particular physical therapy and that it was difficult to establish the advantages of one particular therapeutic method over another.

b) evaluation of the effectiveness of NDT

Conclusions from the included studies are that there was a lack of valid and objective outcome measures and power calculations. One well designed (Level 1+), but small RCT 13demonstrated that the group that received a programme of infant stimulation followed by NDT progressed more quickly (measured using the Griffiths Development Test) than the group who received NDT alone. There were no significant differences between the groups in the incidence of contractures, or the need for orthopaedic interventions. The result emphasises the importance of measuring outcomes other than locomotion and the inputs from local services.

c) investigation of the nature and intensity of NDT

In spite of the lack of evidence for the effectiveness of NDT/Bobath, many parents and professionals believe that the therapy works for children with CP and that the more sessions the child receives the more effective is the treatment. The HTA again found that the published studies had methodological problems, particularly with sample size and power, lack of controls, sample heterogeneity, confounding and length of follow up. One RCT (Level 1- ) found no benefit of intensive NDT 14 and another RCT (Level 1 - ) found that there was a non significant trend for benefit for the intensive group when additional covariates of age and severity were introduced, not in the primary analysis and the effect was short lived. 15 Another RCT ( Level 1-) reported that the change scores for children in the intensive NDT group were higher than those of the standard group. 16 The statistical methods however, used to analyse the results of this latter trial were not appropriate. The multi- Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 7 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

centre RCT 1 ( Level 1++) to evaluate the effect of increasing the frequency of NDT with blinded assessments and a cost effectiveness analysis reported in 2007 demonstrates that there was no evidence that additional physical therapy helped the motor or general development of children with CP. The authors stress that research is required into what is the optimum level of provision, since they suggest that there is a sufficiency of therapy that will be helpful and above that there is no effect. They also raise the possibility that the RCT may not be an appropriate study design when an intervention is focussed on a heterogeneous population such as children with CP.

No studies were found assessing cost effectiveness of NDT/Bobath or physiotherapy. The costs of general services for each child ranged from £250 to £6750 with higher costs associated with more severely impaired children. 1

An RCT comparing a task/content focussed treatment approach with a child focussed treatment approach for children with CP is currently being performed in North America. The rationale behind the design of this trial is the questioning of some therapists of the emphasis on obtaining ‘normality’ with the NDT approach and whether this explores all options for functional success. It may be more important to be able to perform the functional task rather than to attain normal patterns of movement. The trial is due for completion in August 2008. 17

5.2 Alternative treatments

5.2i Exercise programmes

The results of a small RCT (Level 1 - ) of an exercise training program demonstrated an improvement in physical fitness, participation level, and quality of life in children with cerebral palsy when added to standard care. 18

A good quality systematic review (Level 1 +) of all types of exercise programmes for children and adolescents with CP was published in 2008. 19 Only five RCTs investigating the efficacy of exercise training in children with CP could be included and these trials had some methodological problems. However from an evaluation of the available data it appears that children and adolescents with CP may benefit from exercise programmes that focus on lower extremity muscle strength and/or cardiovascular fitness.

5.2ii Botulinum toxin

Botulinum toxin A (BtA) injections are being used more frequently to treat upper and lower extremity spasticity and hypertonia in children with CP. Two Cochrane reviews (Level 1+) did not find sufficient evidence to support or refute the use of intramuscular injections of BtA as an adjunct to managing the upper or lower limbs in children with spastic cerebral palsy. 20 21 Further

research incorporating larger sample sizes, rigorous methodology, measurement of upper limb function and functional outcomes is essential.

5.2iii Acupuncture

Acupuncture has been used to treat children and adolescents with CP for more than 20 years. Benefits claimed for acupuncture have included warmer extremities, a decrease in painful spasms, improvement in the use of arms or legs, more restful sleep, improvement in mood and better bowel function. A Cochrane protocol aims to review all RCTs of acupuncture for children with CP. 22

5.2iv Drug therapy

Three drugs diazepam, dantrolene and baclofen have been commonly used to alleviate spasticity in cerebral palsy; and debate remains about their usefulness and there is a Cochrane protocol to assess the absolute, and comparative, efficacy of baclofen, dantrolene and diazepam for spasticity in cerebral palsy.23 Intrathecal baclofen, a much more invasive treatment has been recently introduced and a separate Cochrane protocol will review the evidence for the effectiveness of intrathecal baclofen. 24

5.2v Surgery

A surgical method to reduce spasticity by selective posterior nerve root division was first described in 1913 and reintroduced in the 1970s. Numerous studies with confounding, selection bias, lack of controls and use of variable surgical techniques, and application of subjective outcome measures have reported good results leading to the widespread use of this technique. 25 The absence of good evidence to support its efficacy and the lack of information about safety and long term consequences has led to some controversy and the role of this technique, which is expensive and very demanding of the child, family, surgeon and therapist, needs to be justified. 26 There is a Cochrane protocol designed to determine the effectiveness of selective dorsal rhizotomy in the management of children with spastic cerebral palsy. Error: Reference source not found

5.2vi Speech and language therapy

Firm evidence of the positive effects of speech and language (SLT) for children with cerebral palsy was not demonstrated in a Cochrane review. However, positive trends in communication change were shown. 27 The authors conclude that research is needed to investigate the effectiveness of new and established interventions and their acceptability to families.

6. Conclusions

 Despite the widespread use of NDT/Bobath in children and adolescents with CP the existing published evidence, some of which is good quality Level 1, does not provide support for the effectiveness of the NDT/Bobath treatment approach.  Little information was found on service input and costs for children and adolescents with CP who receive NDT/Bobath therapy.  It has been suggested that the RCT may not be an appropriate method to evaluate the effectiveness of NDT/Bobath due to the heterogeneity of children with CP and the use of different treatment strategies. However, one high quality RCT that used additional methodologies to study the effectiveness of intense levels of therapy failed to demonstrate an effect on outcomes.  There was limited evidence for the effectiveness of alternative treatments (exercise programmes; botulinum toxin, medication, acupuncture, surgery, speech and language therapy) used to treat children and adolescents with CP.  There is research in progress that will add to the evidence base for NDT/Bobath and other treatments used for children and adolescents with CP.  The present review has methodological limitations in that, whilst every effort was made to maximise retrieval of relevant references, it is not a systematic review of primary studies and was performed by a single reviewer.  Lack of evidence for effectiveness of Bobath Therapy for cerebral palsy as a healthcare intervention does not preclude consideration of Bobath Therapy as a form of social care.

7. References

Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 11 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy Appendix 1 Main search strategy

Search terms included subject headings and text words based on: cerebral palsy; neurodevelopmental training; NDT; Bobath therapy; occupational therapy; exercise ( in combination with strength, fitness, working capacity, aerobic power, anaerobic power, endurance, cardiorespiratory physical training or programme); motor intervention; early intervention; surgery; complementary therapy; alternative therapy.

The search terms meta.ab; synthesis.ab; literature.ab; randomized.hw; published.ab; meta-analysis pt; trials.hw; controlled.hw; medline.ab; selection.ab; sources.ab; trials.ab; review.ab; review.pt; articles.ab; reviewed.ab were used to retrieve RCTs, metanalyses and systematic reviews from Medline.

Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 12 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy Appendix 2 High level search strategy

Agency for Healthcare Research and Quality Chronic Care (AHRQ) Audit Commission Agency for Quality in Medicine (AZQ) Canadian Coordinating Office for Health Technology Assessment (CCOHTA) Centre for Health Services Research - Population and Health Sciences - University of Newcastle Centre for Reviews & Dissemination Clinical Evidence Department of Health Effective Practice & Organisation of Care Group Guidelines International Network Google Google scholar Health Evidence Bulletin Wales Health Management Information Consortium Health Technology Assessment Programme Kings Fund National Assembly for Wales National Library for Health ( NLH) – Children’s Health Specialist Library National Guideline Clearinghouse National Institute for Health and Clinical Excellence National Public Health Service for Wales NHS Centre for Reviews and Dissemination NHS Modernisation Agency PEDro Scottish Intercollegiate Guidelines Network (SIGN) Social Science I Centre SUMSearch Turning Research Into Practice (TRIP) Database UpToDate

Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 13 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy Appendix 3 Evidence levels and quality grading modified from NICE Guideline Methodology Manual) ref 7

Level of Evidence Type of evidence 1++ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well-conducted meta-analyses, systematic reviews of RCTs,or RCTs with a low risk of bias 1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias 2++ High-quality systematic reviews of case–control or cohort studies. High- quality case–control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal 2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal 2- Case–control or cohort studies with a high risk of confounding bias, or chance and a significant risk that the relationship is not causal 3 Non-analytic studies (for example, case reports, case series) 4 Expert opinion, formal consensus

Quality grading

++ = good quality + = fair +/- = fair to poor - = poor

Appendix 4 Evidence table

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments Ade-Hall RA, Moore Children Systematic Motor Three eligible Poor quality Systematic 1- AP. Botulinum toxin between the review of function studies were found trials with review type A in the ages of 0 RCTs to measures each with small potential for treatment of lower and 19 years determine including numbers of confounding limb spasticity in old with CP effectiveness disability subjects. One and cerebral palsy. who had of BtA. rating & gait study of twelve heterogeneity + Cochrane Database been treated analysis. ambulant children, of Systematic for lower limb Sub- compared BtA with Reviews 2000, Issue spasticity. measures injection of a 1. Art. No.: included placebo and found CD001408. DOI: spasticity, non-significant 10.1002/14651858.C range of improvements D001408. movement, in gait in the BtA quality of life, group compared to parental the placebo group. opinion and Two studies cost compared BtA with effectiveness. the use of casts and there were no significant differences between the groups in either trial Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 15 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

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

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

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments for Spasticity in CP assess the no Cerebral Palsy. absolute, and publication? (Protocol) Cochrane comparative, Database of efficacy of Systematic Reviews baclofen, 2000, Issue 2. Art. dantrolene and No.: CD002260. DOI: diazepam for 10.1002/14651858.C spasticity in D002260. cerebral palsy. . Knox V; Lloyd Evans Children with Preliminary Motor 20 children were Small Case 3 A. Evaluation of the CP aged 2- study to function; recruited but only numbers with series functional effects of a 12 years evaluate of the mobility; self 15 children were high risk for course of Bobath functional care and enrolled for a 6 bias. therapy in children effects of social week course of Preliminary + with cerebral palsy: a Bobath function. therapy. study but no preliminary study. therapy. Parents and Participants follow up Dev Med Child therapists demonstrated a publication Neurol 2002; 44: 447- perceptions of significant was identified. 60. change. improvement in scores for motor function (p=0.001); self care skills ( p=0.086) and caregiver Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 18 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments assistance ( p=0.012) Law M; Russell D; Children with RCT to Hand function, 50 children Insufficient RCT 1- Pollock N et al. A CP aged 18 compare the secondary completed the details of comparison of months – 4 effectiveness outcomes study. There were randomisation intensive years of intensive were upper no significant process neurodevelopmental NDT and limb differences in therapy plus casting casting with movement outcomes between and a regular regular OT and parents’ the groups. occupational therapy programme perception of program for children improvement + with cerebral palsy. Dev Med Child Neurol 1997;39: 664– 70. Law M; Darrah J; Children with RCT to Motor Planned to recruit Trial finished RCT ? Pollock N et al. CP aged 1 – compare a function, 220 children. 2007. Focus on function – a 5 years. task /content disability Publication ? randomized focussed measures, controlled trial treatment QOL comparing two approach with rehabilitation a child interventions for focussed young children with treatment. cerebral palsy. BMC Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 19 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments Pediatrics 2007; 7:31.

Mayo NE. The effect Children with RCT to Motor function The average Insufficient RCT 1- of physical therapy CP aged 0 – determine the proportional change details of for children with 18 months effectiveness in aggregate motor randomisation motor delay and of intensive development for the . Problems cerebral palsy: a versus regular 17 infants on the with +/- randomized clinical physiotherapy. weekly (intensive) methodology. trial. Am J Phys Med regimen was Rehabil 1991; 70: substantially better 258-67. than that for the 12 on the monthly (basic) regimen, after adjusting for the child's age. A statistical test led to an equivalent of a Student's t = 3.49, which with 24 df was associated with P = 0.0019 (two-sided).

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments Narayanan U, Children with Systematic Protocol listed Howard A. Selective CP review to 2001. dorsal rhizotomy in determine the the management of effectiveness children with spastic of selective cerebral palsy. dorsal (Protocol) Cochrane rhizotomy in Database of the Systematic Reviews management 2001, Issue 3. Art. of children with No.: CD003360. DOI: spastic 10.1002/14651858.C cerebral palsy. D003360. Palmer FB; Shapiro Children with RCT to Motor 48 children were Well RCT 1+ BK; Wachtel RC et al. CP aged 12 evaluate the quotient, studied. After six designed trial The effects of – 19 months. effectiveness motor ability, months, the infants but with small physical therapy on of either 12 and mental in Gp A had a lower numbers cerebral palsy: a months (Gp A) quotient mean motor controlled trial in of physical quotient than those infants with spastic therapy or 6 in Gp B (49.1 vs. + diplegia. NEJM months of 58.1, P = 0.02) and 1988; 318: 803-8. physical were less likely to therapy walk (12 vs. 35 preceded by 6 percent, P = 0.07). months (Gp B) These differences Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 21 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments of infant persisted after 12 stimulation months of therapy [NDT] . (47.9 vs. 63.3, P less than 0.01, and 36 vs. 73 percent, P = 0.01, respectively)

Pennington L, Children with Systematic Eleven studies Poor quality Systematic 1- Goldbart J, Marshall CP review to were included in studies review J. Speech and determine the the review. Seven language therapy to effectiveness studies evaluated improve the of SLT that treatment given communication skills focuses on the directly to children, of children with child or their four investigated cerebral palsy. familiar the effects + Cochrane Database communication of training for of Systematic partners, as communication Reviews 2003, Issue measured by partners. No 3. Art. No.: change in conclusions could CD003466. DOI: interaction be made about the 10.1002/14651858.C patterns. effectiveness of D003466.pub2. • To determine SLT due to if individual methodological types of SLT problems with the Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 22 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments intervention studies. are more effective than others in changing interaction patterns.

Rice JE, O'Donnell Children with Systematic ME. Intrathecal CP review to Baclofen for treating determine the spasticity in children effectiveness with cerebral palsy. of intrathecal (Protocol) Cochrane baclofen in Database of treating Systematic Reviews spasticity in 2004, Issue 1. Art. children with No.: CD004552. DOI: CP. 10.1002/14651858.C D004552.

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments Tsorlakis N; Children with RCT to Motor function 34 children were Inappropriate RCT 1- Evaggelinou C; CP aged 3 – determine the randomised to statistical Grouios G et al. 14 years effect of intensive NDT methods. Effect of intensive intensive NDT (5/week) or regular ANCOVA not neurodevelopmental compared with NDT (2/week). used. Authors treatment in gross regular Motor function conclusions +/- motor function of schedules. improved in both not supported children with cerebral groups. Children by results. palsy. Dev Med receiving intensive Child Neurol 2004; NDT performed 46: 740-45. better ( p<0.05) that regular NDT group. Verschuren O; Children and RCT to Aerobic and 86 children were RCT 1- Ketelaar M; Gorter adolescents determine the anaerobic randomly assigned JW et al. Exercise with CP aged effect of an capacity to an exercise training program in 7 – 18 years exercise training programme children and training or no training. A adolescents with programme significant training + cerebral palsy: a effect was found for randomized aerobic (P < .001) controlled trial. Arch and anaerobic Pediatr Adolesc Med capacity (P = .004). 2007; 161: 1075-81. A significant effect was also found for agility (P < .001), Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 24 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments muscle strength (P < .001), and athletic competence (P = . 005).

Verschuren O; Children with Systematic 5 trials on children Some trials Systematic 1+ Ketelaar M; Takken T CP aged 6 – review of the with CP met the had review et al. Exercise 20 years literature on inclusion criteria. methodologic programs for children the The results suggest al problems. with cerebral palsy: a effectiveness that exercise systematic review of of exercise programmes that the literature. Am J programmes focus on lower + Phys Med Rehabil extremity muscle 2008; 87:404-417. strength and /or cardiovascular fitness may be of benefit. Wasiak J, Hoare B, Children with Systematic Motor 2 trials were Systematic 1+ Wallen M. Botulinum CP review to outcomes included. The review toxin A as an adjunct assess the results from the 2 to treatment in the effectiveness trials were management of the of inconsistent and no Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 25 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments upper limb in children intramuscular conclusions can be + with spastic cerebral BtA injections made palsy. Cochrane as an adjunct Database of to managing Systematic Reviews the upper limb 2004, Issue 4. Art. in children with No.: CD003469. DOI: spastic CP. 10.1002/14651858.C D003469.pub3. Weindling AM; Children Multicentred Motor 79 families started Well designed RCT 1++ Cunningham CC; aged < 3 RCT to function; the intervention and trial with Glenn SM et al. years. determine developmenta 76 completed the 6 adequate Additional therapy for whether l status; month intervention. details of young children with additional adaptive Participants were methodology. spastic cerebral support for functioning; randomised to 3 Qualitative + palsy: a randomised children with parent interventions :- studies were controlled trial. CP and their satisfaction. 1. CG= routine also Health Technol falilies physiotherapy and performed. Assess 2007; 11(16). improves support outcomes 2. PAG = one extra session physiotherapy 3. FSWG = weekly home visits from a family social Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 26 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments worker. Follow up was at 12 and 18 months. The detailed analyses of found no significant effect of extra intervention in the form of physiotherapy or extra social worker input. . Zhang MM, He J, Ai Children with Systematic CL, Li J. Acupuncture CP review to for children with determine the cerebral palsy. efficacy and (Protocol) Cochrane safety of Database of acupuncture Systematic Reviews therapy for 2008, Issue 2. Art. children with No.: CD007127. DOI: CP including 10.1002/14651858.C spastic D007127 cerebral palsy, athetoid cerebral palsy and ataxic Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 27 of 30 Intended Audience: Local Health Boards National Public Health Service for Wales A rapid review of the evidence for the effectiveness of Bobath therapy for children and adolescents with cerebral palsy

Study Population/ Intervention/ Outcomes Results Comments Design Evidence setting aim italics= level/ reviewers quality comments cerebral palsy

Author: Dr M Webb, Public Health Date: 14/05/08 Status: Approved Practitioner Version: 2b Page: 28 of 30 Intended Audience: Local Health Boards 1 Weindling AM; Cunningham CC; Glenn SM et al. Additional therapy for young children with spastic cerebral palsy: a randomised controlled trial. Health Technol Assess 2007; 11(16). Available at: http://www.ncchta.org/fullmono/mon1116.pdf. [Accessed 1st May 2008] 2 Bobath K; Bobath B. The neurodevelopmental treatment In: Scrotton D, ed. Management of the motor disorders of children with cerebral palsy. Oxford: Blackwell Scientific Publications Ltd; 1984. cited in 3 3 Knox V; Lloyd Evans A. Evaluation of the functional effects of a course of Bobath therapy in children with cerebral palsy: a preliminary study. Dev Med Child Neurol 2002; 44: 447- 60. 4 Regional Commissioning Support Unit (SE). Scoping brief: Bobath therapy. NPHS 2008; unpublished 5 Sackett DL; Richardson WS; Rosenberg W et al. Evidence based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone; 1995. 6 National Public Health Service. Evidence checklist. Available at: http://www.nphs.wales.nhs.uk. [Accessed 10th May 2008] 7 National Institute for Health and Clinical Excellence. Guideline development methods. Available at: http://www.nice.org.uk. [Accessed 10th May 2008] 8 National Public Health Service. Bobath therapy. Cardif:NPHS; 2007. [unpublished] 9 Butler C; Darrah J. Effects of neurodevelopmental treatment (NDT) for cerebral palsy; an AACPDM evidence report. Dev Med Child Neurol 2001;43: 778-90. 10 Brown GA; Burns SA. The efficacy of neurodevelopmental treatments in children: a systematic review. British Journal of Occupational Therapy 2001; 65:235-44. 11 Blauw-Hospers CH; Hadders-Algra M. A systematic review of the effects of early intervention on motor development. Dev Med Child Neurol 2005; 47: 421-32. 12 Mayo NE. The effect of physical therapy for children with motor delay and cerebral palsy: a randomized clinical trial. Am J Phys Med Rehabil 1991; 70: 258-67. 13 Palmer FB; Shapiro BK; Wachtel RC et al. The effects of physical therapy on cerebral palsy: a controlled trial in infants with spastic diplegia. NEJM 1988; 318: 803-808. 14 Law M; Russell D; Pollock N et al. A comparison of intensive neurodevelopmental therapy plus casting and a regular occupational therapy program for children with cerebral palsy. Developmental Medicine Child Neurology 1997; 39: 664–70. 15 Bower E; Mitchell D; Burnett M et al. Randomized controlled trial of physiotherapy in 56 children with cerebral palsy followed for 18 months. Dev Med Child Neurol 2001;43: 4–15. 16 Tsorlakis N; Evaggelinou C; Grouios G et al. Effect of intensive neurodevelopmental treatment in gross motor function of children with cerebral palsy. Dev Med Child Neurol 2004; 46: 740-45. 17 Law M; Darrah J; Pollock N et al. Focus on Function – a randomized controlled trial comparing two rehabilitation interventions for young children with cerebral palsy. BMC Pediatrics 2007; 7:31. Available at: http://www/biomedcentral.com/1471-2431/7/31. [Accessed 12th May 2008] 18 Verschuren O. Ketelaar M; Gorter JW et al. Exercise training program in children and adolescents with cerebral palsy: a randomized controlled trial. Arch Pediatr Adolesc Med 2007; 161: 1075-81. 19 Verschuren O; Ketelaar M; Takken T et al. Exercise programs for children with cerebral palsy: a systematic review of the literature. Am J Phys Med Rehabil 2008; 87:404-17. 20 Ade-Hall RA; Moore AP. Botulinum toxin type A in the treatment of lower limb spasticity in cerebral palsy. Cochrane Database of Systematic Reviews 2000, Issue 1. Art. No.: CD001408. DOI: 10.1002/14651858.CD001408. 21 Wasiak J; Hoare B; Wallen M. Botulinum toxin A as an adjunct to treatment in the management of the upper limb in children with spastic cerebral palsy. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD003469. DOI: 10.1002/14651858.CD003469.pub3. 22 Zhang MM; He J; Ai CL. Et al. Acupuncture for children with cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007127. DOI: 10.1002/14651858.CD007127. 23 Howard DC. Anti Spastic Medication for Spasticity in Cerebral Palsy. (Protocol) Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD002260. DOI: 10.1002/14651858.CD002260. 24 Rice JE; O'Donnell ME. Intrathecal Baclofen for treating spasticity in children with cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004552. DOI: 10.1002/14651858.CD004552. 25 Narayanan U; Howard A. Selective dorsal rhizotomy in the management of children with spastic cerebral palsy. (Protocol) Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD003360. DOI: 10.1002/14651858.CD003360. 26 Landau WM, Hunt CC. Dorsal rhizotomy, a treatment of unproven efficacy [comment] [see comments]. J Child Neurol 1990;5:174-8. Cited in 22 27 Pennington L; Goldbart J; Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003466. DOI: 10.1002/14651858.CD003466.pub2.