Evidence-based Approach to Physical Therapy in Cerebral Palsy

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Abstract

Physiotherapy plays a key role in the management of cerebral palsy (CP) and comprises of various therapeutic interventions in enhancing the various physiological and functional outcomes. Though physiotherapy is used widely and recommended by all members of the health-care team, the effectiveness of physiotherapy is inconsistent. The objective of this review was to summarize and evaluate the effectiveness of physiotherapy interventions in children with CP. PubMed and Cochrane database were searched from January 2006 to April 2017 using the Medical Subject Heading and general keywords. Only systematic reviews and meta-analysis on PT interventions in children diagnosed with CP were included. Two reviewers independently assessed the methodological quality and retrieved the results. Thirty-four systematic reviews were identified that distinguished 15 different interventions. Moderate evidence of effectiveness was found for constraint-induced movement therapy for upper limb recovery, goal-directed/functional training, and gait training to improve gait speed. Conflicting evidence was found for the role of exercises on strength training and cardiorespiratory training. Intervention such as neurodevelopmental therapy (NDT) was found ineffective. This review suffer from limitations such as including reviews that had small sample size and that had considered heterogeneity of treatment interventions. Hence, the effectiveness of most PT interventions is found to be limited. On the basis of the present evidence, functional goal-oriented approaches are found to be effective and future research is required to determine the best ways to improve functional outcomes in children with CP.

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A report: the definition and classification of cerebral palsy April 2006.

Peter Rosenbaum, Nigel Paneth, Alan Leviton … (2007)

For a variety of reasons, the definition and the classification of cerebral palsy (CP) need to be reconsidered. Modern brain imaging techniques have shed new light on the nature of the underlying brain injury and studies on the neurobiology of and pathology associated with brain development have further explored etiologic mechanisms. It is now recognized that assessing the extent of activity restriction is part of CP evaluation and that people without activity restriction should not be included in the CP rubric. Also, previous definitions have not given sufficient prominence to the non-motor neurodevelopmental disabilities of performance and behaviour that commonly accompany CP, nor to the progression of musculoskeletal difficulties that often occurs with advancing age. In order to explore this information, pertinent material was reviewed on July 11-13, 2004 at an international workshop in Bethesda, MD (USA) organized by an Executive Committee and participated in by selected leaders in the preclinical and clinical sciences. At the workshop, it was agreed that the concept 'cerebral palsy' should be retained. Suggestions were made about the content of a revised definition and classification of CP that would meet the needs of clinicians, investigators, health officials, families and the public and would provide a common language for improved communication. Panels organized by the Executive Committee used this information and additional comments from the international community to generate a report on the Definition and Classification of Cerebral Palsy, April 2006. The Executive Committee presents this report with the intent of providing a common conceptualization of CP for use by a broad international audience.

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A systematic review of interventions for children with cerebral palsy: state of the evidence.

Iona Novak, Sarah McIntyre, Catherine Morgan … (2013)

The aim of this study was to describe systematically the best available intervention evidence for children with cerebral palsy (CP). This study was a systematic review of systematic reviews. The following databases were searched: CINAHL, Cochrane Library, DARE, EMBASE, Google Scholar MEDLINE, OTSeeker, PEDro, PsycBITE, PsycINFO, and speechBITE. Two independent reviewers determined whether studies met the inclusion criteria. These were that (1) the study was a systematic review or the next best available; (2) it was a medical/allied health intervention; and (3) that more than 25% of participants were children with CP. Interventions were coded using the Oxford Levels of Evidence; GRADE; Evidence Alert Traffic Light; and the International Classification of Function, Disability and Health. Overall, 166 articles met the inclusion criteria (74% systematic reviews) across 64 discrete interventions seeking 131 outcomes. Of the outcomes assessed, 16% (21 out of 131) were graded 'do it' (green go); 58% (76 out of 131) 'probably do it' (yellow measure); 20% (26 out of 131) 'probably do not do it' (yellow measure); and 6% (8 out of 131) 'do not do it' (red stop). Green interventions included anticonvulsants, bimanual training, botulinum toxin, bisphosphonates, casting, constraint-induced movement therapy, context-focused therapy, diazepam, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care, and selective dorsal rhizotomy. Most (70%) evidence for intervention was lower level (yellow) while 6% was ineffective (red). Evidence supports 15 green light interventions. All yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions should be discontinued since alternatives exist. © 2013 Mac Keith Press.

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Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis.

Leanne Sakzewski, Jenny Ziviani, Roslyn N. Boyd (2014)

Children with unilateral cerebral palsy present with impaired upper limb (UL) function affecting independence, participation, and quality of life and require effective rehabilitation. This study aims to systematically review the efficacy of nonsurgical upper limb therapies for children with unilateral cerebral palsy. Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, the Cochrane Central Register of Controlled Trials, and PubMed were searched to December 2012. Randomized controlled or comparison trials were included. Forty-two studies evaluating 113 UL therapy approaches (N = 1454 subjects) met the inclusion criteria. Moderate to strong effects favoring intramuscular injections of botulinum toxin A and occupational therapy (OT) to improve UL and individualized outcomes compared with OT alone were identified. Constraint-induced movement therapy achieved modest to strong treatment effects on improving movement quality and efficiency of the impaired UL compared with usual care. There were weak treatment effects for most outcomes when constraint therapy was compared with an equal dose (amount) of bimanual OT; both yielded similar improved outcomes. Newer interventions such as action observation training and mirror therapy should be viewed as experimental. There is modest evidence that intensive activity-based, goal-directed interventions (eg, constraint-induced movement therapy, bimanual training) are more effective than standard care in improving UL and individualized outcomes. There is little evidence to support block therapy alone as the dose of intervention is unlikely to be sufficient to lead to sustained changes in UL outcomes. There is strong evidence that goal-directed OT home programs are effective and could supplement hands-on direct therapy to achieve increased dose of intervention.

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Author and article information

Journal

Journal ID (nlm-ta): Indian J Orthop

Journal ID (iso-abbrev): Indian J Orthop

Journal ID (publisher-id): IJOrtho

Title: Indian Journal of Orthopaedics

Publisher: Medknow Publications & Media Pvt Ltd (India )

ISSN (Print): 0019-5413

ISSN (Electronic): 1998-3727

Publication date (Print): Jan-Feb 2019

Volume: 53

Issue: 1

Pages: 20-34

Affiliations

[1] Department of Physical Medicine and Rehabilitation, Swami Vivekanand National Institute of Rehabilitation Training and Research, Cuttack, Odisha, India

[1 ] Department of Physiotherapy, Composite Regional Centre for Persons with Disabilities, Lucknow, Uttar Pradesh, India

Author notes

Address for correspondence: Mr. G. Shankar Ganesh, Department of Physiotherapy, Composite Regional Centre for Persons with Disabilities, Lucknow - 226 017, Uttar Pradesh, India. E-mail: shankarpt@ 123456rediffmail.com

Article

Publisher ID: IJOrtho-53-20

DOI: 10.4103/ortho.IJOrtho_241_17

PMC ID: 6394183

PubMed ID: 30905979

SO-VID: 99203169-a1d4-4fac-9b67-7c0c527432bc

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Evidence-based Approach to Physical Therapy in Cerebral Palsy

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Most cited references 52

A report: the definition and classification of cerebral palsy April 2006.

A systematic review of interventions for children with cerebral palsy: state of the evidence.

Efficacy of upper limb therapies for unilateral cerebral palsy: a meta-analysis.

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