| 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.
Keywords: Cerebral palsy, exercise therapy, muscle weakness, physical activity, physical therapy techniques, rehabilitation
|How to cite this article:|
Das SP, Ganesh G S. Evidence-based approach to physical therapy in cerebral palsy. Indian J Orthop 2019;53:20-34
| Introduction|| |
Cerebral palsy (CP) is one of the most common developmental disabilities. The incidence of CP is around 3 cases per 1000 live births in India, and the 2011 statistics indicate that there are about 25 lakh children with CP in India. CP is a bracket term given for a set of neurological disorders characterized by disorders of movement and posture causing activity limitation attributed to a static disturbance in the developing brain, often accompanied by associated impairments and secondary health conditions. CP is not a single pathological entity and encompasses disorders in various motor functions including but not limited to body movement, muscle control, muscle coordination, muscle tone, reflex, fine motor skills, gross motor skills, oral motor functioning, posture, and balance., This in turn leads to poor functional strength, sedentary behavior, and dependence on others to carry out activities of daily living and reduced activity in leisure and community activities.
Physiotherapy plays a key role in the management of CP and almost all persons diagnosed as CP receive physiotherapy services. The goals of physiotherapy are facilitating the participation needs of the child with CP and reducing the physical impairments of the symptoms. Physiotherapy helps children with CP to achieve their maximum potential for physical independence and fitness levels and improve the quality of life of the children and their family by minimizing the effect of their physical impairments.
Physiotherapists use various therapeutic interventions in enhancing the autonomy, strength, and coordination of voluntary movements. Physiotherapy literature for CP contains multiple interventions, expanding rapidly every year. Though physiotherapy is used widely and recommended by all members of health-care team, the effectiveness of physiotherapy is inconsistent. Health care around the world has shifted its focus toward evidence-based practice. Literature has shown that considerable amount of interventions currently used by clinicians are deemed to be ineffective and unnecessary. The professionals involved in providing therapy services have to consider the effectiveness of these interventions during clinical decision-making. Hence, we wanted to provide clinicians with the evidence for quick reference by comparing and contrasting the results of available systematic reviews to provide a summary of physiotherapy evidence. The objective of this work was to summarize and evaluate the evidence for the effectiveness of various therapeutic interventions employed in physiotherapy for children with CP.
| Materials and Methods|| |
The research question (what is the evidence that physiotherapy improves functional outcomes for patients with CP?)that could be answerable on the light of available evidence (systematic review and meta-analysis) was structured for searching using the population, intervention, comparison, and outcome format.
Population: Persons aged 0–20 years with a diagnosis of CP. Intervention: Use of any clinically proven physiotherapy interventions, or a combination of interventions. Comparison: Any other treatments or control groups including placebo, sham therapy, or other PT interventions. Outcome: Improved motor function, improved abilities in functional skills, and reduction in spasticity.
We searched computerized bibliographic databases for reviews on physiotherapeutic interventions in CP in English for the last decade (January 2006 to April 2017) to identify systematic reviews and meta-analysis to provide an overview of the current state of evidence using PubMed and the Cochrane Database of Systematic Reviews. These databases were searched using the Medical Subject Headings keywords (systematic review) AND cerebral palsy AND physiotherapy, physical therapy specialty, physical therapy modalities, exercise therapy, exercise movement technique, electric stimulation therapy, massage and general search terms such as exercise training (in combination with strength, fitness, working capacity, aerobic power, anaerobic power, endurance, cardiorespiratory physical training, or programme), functional training, functional therapy, neurodevelopmental treatment/Bobath, hydrotherapy, hippotherapy, and goal-setting. The search settings were kept to maximize the retrieval of references. In addition, the reference lists of identified articles and systematic reviews were screened for additional relevant publications.
Studies meeting the following criteria were included: (1) reviews should have been published between January 2006 and April 2017; (2) papers written in English; (3) the papers should have considered any physiotherapy interventions in the treatment of children and adolescents (age range: 0–20 years) with CP only; and (4) should be either systematic reviews or meta-analyses. Studies were excluded from the review if studies (1) were written with the perspective of diagnosis, prognosis, guidelines, or other interventions aimed at CP; (2) participants were adults with CP; (3) reviewed general medical neurological interventions (e.g., home care therapy, spastic medications/botulinum injections, and not physiotherapy-specific interventions); (4) if no specific outcome measures were mentioned/parents' or caregivers' experiences were considered as outcomes; and (5) if systematic reviews were identified in predatory journals.
All identified articles were judged for eligibility by title and abstract by two reviewers and differences any, when aroused regarding unclear articles, were resolved by consensus. The quality of the evidence obtained was graded using the National Institute for Health and Care Excellence protocol. Relevant studies to the research question were entered into an evidence table [Table 1].
| Results|| |
Considering the complexity and heterogeneous condition of CP, we included studies that considered children with CP of any classification and any functional ability level. The results of the search strategy are shown in [Figure 1]. The search yielded a total of 337 reviews, of which 18 reviews were retrieved from the Cochrane Database of Systematic Reviews and 319 from PubMed. Totally 298 articles were excluded based on the screening of their titles and abstracts; 34 articles were reviewed in full text.
An overview of the included studies is presented in [Table 1]. [Table 2] provides a summary of the most significant findings that health care providers may wish to consider in their practice based on this review. The 34 studies included children with all types of CP classification and levels of gross and fine motor function. Out of the 34 reviews, 11 reviews appraised exercises including studies that considered processing sensory information, early intervention, upper limb training, and reaching activities. Five reviews were found that evaluated constraint induced movement therapy (CIMT); 3 reviews each on gait training, electrical stimulation, and physiotherapy in general and 2 reviews each on cardio-respiratory training and animal assisted training. Single review was identified each on whole body vibration, aquatic training, taping, passive stretching, and virtual training.
Exercises and cerebral palsy
Eleven reviews appraised the effectiveness of exercises on functional outcomes in CP. Six reviews directly evaluated the role of exercise training in CP population. Only the review by Arpino et al., 2010, had claimed modest evidence for the effectiveness of exercises. Results by Mockford and Caulton, 2008, suggested that exercises can foster functional improvement without any adverse effects. One review suggested that a combination of botulinum toxin and occupational therapy is more effective than occupational therapy alone in improving upper-limb outcomes and there is an overall moderate evidence to suggest that intensive activity based, goal directed interventions are effective in promoting functional outcomes.
No studied interventions have been found to be superior to another in improving trunk control and it is also not sure if improvement in postural control would lead to improvement in functional activities. Appraisal by Arpino et al., 2010, and Myrhaug et al., 2014, suggested that improvements may be expected from intensive exercise interventions. However, a high quality review by Scianni et al., 2009, reported that exercises do not improve strength or functional activities in children with CP.
The effectiveness of early interventions seems to be mixed, with Morgan et al., 2016, suggesting that child-initiated movement, environment modification/enrichment, and task specific training have moderate to large effect on motor outcomes (Cohen's effect size >0.7) and Hadders Algra et al., 2017, reporting poor effect for early interventions. However, from the evaluation of the available data, it appears that children and adolescents with CP may benefit from exercise programs that focus on lower extremity.
Exercises, gait, and cerebral palsy
A systematic review by Moreau et al., 2016, concluded that, among the available evidences, gait training appears to be the most effective intervention in improving gait speed in children with CP who are ambulatory. Other interventions, including strength training, have a negligible effect on gait speed and exhibit poor effectiveness. Review by Mutlu et al., 2009, could not conclude the effectiveness of partial bodyweight supported treadmill training in children with CP. Based on these reviews, it may be concluded that gait training alone is an effective intervention to improve gait speed in CP ambulatory children.
Constraint-induced movement therapy
Four out of the five reviews included in this review,,, concluded that there is a definite role for CIMT to improve upper limb functions in children with CP. However, the Cochrane database, highest level of research evidence, reported limited evidence for the effectiveness of CIMT. Based on the results, we may conclude that there is moderate evidence for the effectiveness of CIMT on functional hand use.
Physiotherapy approaches including neurodevelopmental therapy
Reviews that had evaluated the effectiveness of commonly used physiotherapy interventions for children with CP reported that strengthening targeted muscle groups and functional training have the strongest evidence. These results are supported by the results of Franki et al., (2012) that concluded that goal oriented therapy and functional training were effective on the attainment of functional goals and participation. On the other hand, appraisal by Anttila et al., (2008) reported moderate evidence for the effectiveness of upper limb treatments, while the effectiveness of strength training was found limited for gross motor function.
NDT is a holistic and interdisciplinary clinical practice model that emphasizes individualized therapeutic handling based on movement analysis for habilitation and rehabilitation of individuals with neurological disorders. Novak et al., (2013) performed a systematic review of systematic reviews published on the effectiveness of NDT. Despite the widespread popularity, the authors of this review concluded the clinical evidence of NDT as poor and unfavorable.
Cardiorespiratory training and cerebral palsy
Reviews that have looked into the effects of cardiorespiratory training in children with CP have concluded that, though the training may improve aerobic fitness, the overall evidence about the effect of cardiorespiratory training in these populations is limited. Similar result is reflected by Rogers et al., (2008) that aerobic training can improve physiological outcomes, but the influence of these changes may not be translated in activity and participation domains in children with CP.
Electrical stimulation and cerebral palsy
Chiu and Ada, (2014) evaluated the effectiveness of functional electrical stimulation on activities in children with CP. The results of this systematic review showed that functional electrical stimulation has a similar effect as activities. Cauraugh et al., (2010) performed a systematic review on the effect of electrical stimulation on gait outcomes. This review identified 17 studies, and meta-analysis of the available data revealed medium effect sizes for electrical stimulation on gait outcomes. Wright et al., (2012) studied the performance of electrical stimulation on gait or upper-limb function in children with CP. The results of this review concluded that there is moderate evidence for electrical stimulation in improving muscle strength, range of motion, and function in children with CP. Electrical stimulation along with dynamic splinting has been shown to be further effective in improving function and posture. Though two of the three reviews showed moderate evidence for the role of electrical stimulation, these results may be subjected to study bias and we may conclude that the evidence to be limited.
Hippotherapy and cerebral palsy
Hippotherapy is commonly used to improve balance, posture, and gross and fine motor skills by placing the person on a horse's back and/or using equine movements with an objective to control the horse. Tseng et al., (2013) evaluated if hippotherapy or horseback riding is effective in improving the motor outcomes and body functions in children with CP. The results of the metaanalysis showed that 8–10 min of horse riding reduced asymmetrical activity of hip adductor muscles and improved postural control. However, the results showed that long term riding did not produce any statistically significant effect on improving gross motor activity status. A previous review had concluded that hippotherapy improved muscle symmetry in the trunk and hip, but the effectiveness was no more better compared to other therapies in improving muscle tone in children with CP. The results of this review have to be taken with caution as the methods were not properly explained and the articles considered for this review did not consider abstracts/conference proceedings and gray literature. Given the potential for error and bias and heterogeneity of interventions provided, the results may not be reliable.
Results of other studied reviews
Though the studies included in this review showed effectiveness for taping, aquatic therapy, whole-body vibration, virtual reality, and stretching, low quality of studies included in these reviews, multiple outcomes measured, and heterogeneity of interventions offered imply that these results have to be approached with caution.
| Discussion|| |
This study was conducted with intent to examine only the highest level of evidence by including systematic reviews or meta-analyses to provide a summary of the existing research on the effectiveness of various interventions on CP. This review of systematic reviews found that there is a lack of effectiveness in majority of the physiotherapy interventions studied. This review analyzed 34 systematic reviews on physiotherapy interventions in children with CP published after 2006. Fifteen different types of intervention categories were identified. The interventions and outcomes differed in all categories, which may limit our comparisons in the evidence synthesis.
CP is usually classified into various heterogeneous diagnostic subgroups as spastic diplegia, hemiplegia, tetraplegia, ataxic, or mixed. The study population included in this review had representations from all types of CP and it is difficult to conclude if different subtypes would respond differently to various interventions. Based on the overall results of the study, it may be concluded that intensive functional-based training will benefit this population irrespective of the type of CP., CIMT results in greater improvements in improving the functions of impaired arm in children with hemiplegic CP.,, As the goals of rehabilitation in CP are not intended at treating the primary central neurological deficit, health-care professionals shall first determine the most appropriate functional goal and then may utilize a single or combination of therapeutic approaches that are individually tailored to achieve the goals.
CIMT for upper limb recovery, goal directed/functional training, strength training for lower limb, and gait training to improve gait speed are the interventions recommended based on the available evidence. The evidences are not strong for hippotherapy, virtual training, whole body vibration, early intervention (for motor outcomes), and functional electrical stimulation. When used, these interventions should be based on clinical judgment, child and family preferences, and the child's motor control and functional abilities. Interventions such as NDT have not shown any effectiveness and may be withdrawn from standard care.
The earlier consensus that exercises in this population has to be avoided because of the adverse impact exercise on spasticity and movement patterns has been rebuked. Research has shown that children with CP require more energy for walking compared to healthy children., This reduced ability has been attributed to below-average aerobic and anaerobic capacity found in these populations.,, This reduced physical fitness, lower health status, and well-being lead to the development of disorders such as obesity or diabetes,, and a sedentary adulthood. Results of this review that cardiorespiratory training does not result in anticipated benefits are a problem for people with CP, health-care providers, and policymakers.
There are several potential limitations worth mentioning with the current review. Only PubMed and Cochrane database were searched, excluding EMBASE, Sports Discus, CINAHL, and PEDro. We did not include reviews that included children with CP along with persons suffering from other neurological disorders as part of their inclusion criteria. Similarly, we had excluded studies that included adult CP population. Another limitation is that we considered systematic reviews that had been published within the last 10 years. The search was limited to reviews published in English only because of our limited language skills. These factors might have drastically limited the numbers of systematic reviews analyzed. Further, a review of systematic reviews is a study limitation in its own right as it does not provide any new information that is not available at the first place and we have not performed any re-synthesis of the data.
| Conclusion|| |
It has been widely accepted that children with CP lack motor skills, and physiotherapy interventions should try to improve both the quantity and quality of motor control. Despite having analyzed the evidence of various techniques, it is not yet known the types of activities and/or approaches that should be encouraged and whether or not there is a need for external equipment to augment motor acquisition. Based on the results, it may be concluded that CIMT, task-oriented functional training, and gait training to be effective in this population. Other interventions have very low-quality evidence. Contrary to popular beliefs, interventions such as NDT are not backed sufficiently by evidences. Considering the importance of the role played by physiotherapy profession in the management of CP, it is of foremost importance that all clinicians involved in treating these children need to base their therapy based on the recent evidences. More research using rigorous designs is urgently needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Mr. G Shankar Ganesh
Department of Physiotherapy, Composite Regional Centre for Persons with Disabilities, Lucknow - 226 017, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]