Effects of neurodevelopmental treatment (NDT) for cerebral palsy: an AACPDM evidence report. Annotation

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1 Effects of neurodevelopmentl tretment (NDT) for cerebrl plsy: n AACPDM evidence report Annottion Written by Chrlene Butler* EdD Johnn Drrh PhD Approved by AACPDM Tretment Outcomes Committee Review Pnel: Richrd Adms MD Henry Chmbers MD Mrk Abel MD Dine Dmino PhD Terence Edgr MD Michel Msll MD Lis Smson-Fng MD Ngire Susn Stott MD Mry Lw PhD Judy Lech PT Murry Goldstein DO Mureen O Donnell MD John McLughlin MD, Americn Acdemy for Cerebrl Plsy nd Developmentl Medicine, 6300 North River Rod, Suite 727, Rosemont, IL , USA. *Correspondence to first uthor t 1818 Westlke Avenue North, Suite 106, Settle, WA , USA. E-mil: rgonut@foxinternet.net The objective of the Americn Acdemy for Cerebrl Plsy nd Developmentl Medicine (AACPDM) evidence reports is to provide the biomedicl reserch nd clinicl prctice communities with the current stte of evidence bout vrious interventions for the mngement of developmentl disbilities. AACPDM evidence reports ggregte ll tht hs been published bout outcomes of n intervention for medicl condition, guge the credibility (i.e. strength of the internl vlidity) of tht evidence, nd identify gps in our scientific knowledge. The originl version of this report ws published in the AACPDM Dtbse of Evidence Reports on the internet ( where evidence reports re regulrly updted to include new reserch. The AACPDM reviews re not evidence-bsed prctice guidelines. As yet, the bodies of evidence in mny res of developmentl medicine re neither robust nor comprehensive enough to llow confident generliztion to popultionst-lrge: prerequisite for evidence-bsed prctice guidelines. Moreover, bsence of evidence of effectiveness in n evidence report should not be construed s proof tht tretment is not effective; rther, it my reflect res in which more meningful reserch is needed. In the menwhile, clinicins must be circumspect bout their tretment recommendtions, relying on current best evidence to inform individul choice. Every effort hs been mde to ssure tht AACPDM evidence reports re free from ny rel or perceived bis. The Best evidence is represented by the study (or studies) in the evidence report tht most closely pproximtes the ptient chrcteristics tht re of interest to the clinicin, tht uses therpeutic regime most like the one the clinicin cn provide, tht investigtes outcomes of gretest concern to ptient, nd tht provides the most credible or internlly vlid results. 778 Developmentl Medicine & Child Neurology 2001, 43:

2 Acdemy s editoril review pnel is multidisciplinry group comprised of the current members of the AACPDM Tretment Outcomes Committee who serve 3-yer rotting terms. This Committee my invite up to two dditionl reviewers to encourge substntive input by knowledgeble proponents of ll points of view. Potentil conflicts of interest of uthors nd reviewers hve been disclosed nd re documented in the AACPDM Dtbse of Evidence Reports. The Tretment Outcomes Committee is chrged nd overseen by the AACPDM bord of directors nd opertes under n pproved methodology of systemtic review of the scientific literture nd pproved procedures. 1,2 Finl snction for ech report is grnted by the Bord. The review uthors orgnize intervention outcomes in predefined mnner nd nswer predefined questions to describe the scientific evidence. Members of the review pnel give their input nd resolve ny differing opinions to rech greement bout sttements mde therein on behlf of the Acdemy. Nevertheless, the dt in n AACPDM evidence report cn be interpreted differently, depending on people s perspectives. Plese consider the conclusions presented crefully. Neurodevelopmentl tretment HISTORICAL PERSPECTIVE Bert nd Krel Bobth, physicl therpist nd neuropsychitrist respectively, were pioneers in the tretment of cerebrl plsy (CP). As erly s the 1940s, they begn to develop n pproch tht grew out of Bert Bobth s clinicl observtions nd ws initilly understood in the context of the reflex, hierrchicl, nd mturtion theories of neuroscience t tht time. Through their writing nd lectures, the trining courses given by them nd other trined instructors, the Bobth pproch lso known s neurodevelopmentl tretment (NDT) spred so widely tht NDT hs hevily influenced physicl, occuptionl, nd speech therpy for children with CP for hlf century. 3 According to the Bobths 4, the motor problems of CP rise fundmentlly from CNS dysfunction, which interferes with the development of norml posturl control ginst grvity nd impedes norml motor development. Their gol ws the estblishment of norml motor development nd function nd/or the prevention of contrctures nd deformities. Their neurodevelopmentl pproch focused on sensorimotor components of muscle tone, reflexes nd bnorml movement ptterns, posturl control, senstion, perception, nd memory (i.e. components thought most likely to be impired s result of CNS dmge). Hndling techniques tht controlled vrious sensory stimuli were used to inhibit spsticity, bnorml reflexes, nd bnorml movement ptterns, nd were lso used to fcilitte norml muscle tone, equilibrium responses, nd movement ptterns. The child ws reltively pssive recipient of NDT tretment. The norml developmentl sequence ws dvocted s frmework for tretment. As the Bobths gined experience through the yers nd s dditionl knowledge of neuroscience becme vilble, they chnged their pproch to, nd emphsis on, certin spects of the tretment. They described key points of how the tretment pproch hd evolved in their lst publiction bout NDT in In the beginning, they dvocted plcing children in reflex-inhibiting postures. While these postures did reduce spsticity, the Bobths cme to recognize in time tht there ws no crry over into movement nd function. They then promoted key points of control in which the therpist inhibited bnorml ptterns of movement nd fcilitted more norml movements while the child ws moving. Eventully, the Bobths cme to believe tht they hd concentrted too much on the fcilittion of utomtic righting rections under the fulty ssumption tht the child would spontneously trnslte this therpeutic experience into voluntry functionl movements. Herefter, they begn to pprecite tht it is necessry for children to, incresingly nd systemticlly, tke control of their own movement, especilly of blnce. The Bobths concluded, too, tht it hd been erroneous to promote the rigid following of the norml developmentl sequence. Finlly, the Bobths discussed their reliztion tht their tretment hd not utomticlly crried over into ctivities of dily life, s they hd expected it would. Consequently, systemtic preprtion for specific functionl tsks ws instituted with n im of treting the children in ctul settings where they live, ply, nd lern. IN THE FIELD Therpists who ttended n NDT trining course seldom hd continuing eduction in neurodevelopmentl tretment lthough they my hve joined the NDT Assocition. b Consequently, the prctice of NDT in the field hs not necessrily kept pce with the evolution experienced by the Bobths nd their closer ssocites. The literture reflects vrible stte of prctice in the field, 5 s well s confusion bout current NDT tretment principles nd their theoreticl construct. 6 9 There is controversy bout whether the principles of NDT tretment influenced initilly by the reflex nd hierrchicl models of motor control re still vlid in light of current models which do not focus exclusively on neurl explntions of motor performnce. 8 Psychologicl components nd environmentl contexts re non-neurl explntions. In systems model of motor control, for exmple, the CNS is only one system mong mny tht influence motor behvior. ISSUES IN DETERMINING EFFECTIVENESS It is difficult to evlute the effectiveness of ny motor therpy pproch for host of resons. Chief mong them is tht these re not specific tretments tht re delivered in stndrdized mnner. In other words, there is no discrete dosge dministered under specific, invrible procedures in conditions tht re held constnt. The dosge or mount of time in therpy could be held constnt, but the procedures depend upon the therpists skill level nd specific ims nd vry ccordingly. While the tretment setting ( condition of tretment) could be stndrdized, the child s fmily (nother condition of tretment) could never be. Evluting the effectiveness of NDT is confounded further becuse the skill level of the therpists in these studies is seldom cler, the constructs of NDT itself hve chnged over time, nd NDT strtegies re commonly combined with other therpy techniques nd medicl tretments. There re, lso, ll the problems ttendnt on ny reserch involving low incidence nd highly heterogeneous b With the deth of the Bobths in 1991, the NDT Assocition, Inc. crries on the neurodevelopmentl pproch. Annottion 779

3 conditions complicted by ongoing chnge due to the process of growth nd mturtion. Finlly, there re issues of different outcomes of interest mong the reserchers nd the different wys chosen to mesure them. In spite of these obstcles, it is importnt to document wht hs been investigted bout NDT becuse of its continuing nd widespred influence in the mngement of CP nd becuse of the discrepnt prctice nd understnding bout it in the field. The conceptul frmework dopted by the AACPDM for reviewing tretment-outcomes literture my offer the best mens vilble for ggregting disprte reserch results to shed light on both biologicl nd socil outcomes of this intervention. 10 Method of review INCLUSION CRITERIA This review included studies in which the intervention (1) ws stted to be exclusively NDT, (2) ws stted to be NDT but combined with other sensorimotor techniques, or (3) could be identified by the review uthors s NDT-bsed therpy from the description of procedures tht specified inhibition of primitive responses nd pthologicl reflexes, fcilittion of posturl rections, nd normliztion of muscle tone. The review is limited to studies in which ll the prticipnts were dignosed with CP or studies in which there were specific dt for those with CP. The prticipnts my hve lso hd dditionl impirments common in CP, such s mentl retrdtion* or relted developmentl disbilities. LITERATURE SEARCH The literture serch included the following electronic dtbses: MEDLINE (1956 to April 2001), HelthSTAR (1975 to 2000), ClinPSYC (1989 to 2000), CINAHL (1982 to April 2001), Best Evidence (1991 to 2000), nd the Cochrne Dtbse of Systemtic Reviews (4th qurter 2000) for studies published in English. The electronic serch terms were NDT or neurodevelopmentl tretment nd therpy nd cerebrl plsy. Reference lists in studies nd review rticles nd reserchers knowledgeble bout this intervention were lso consulted. Sixty-five cittions were exmined. Of tht number, 44 rticles were excluded for one or more of the following resons: they were descriptive or review rticles, their dt contined children with dignoses other thn CP or before dignosis of CP, or their intervention could not be determined to be primrily NDT. Twenty-one studies met the inclusion criteri. *UK usge, lerning disbility. CLASSIFICATION OF THE RESULTS All reported results of NDT were clssified on the bsis of (1) wht kind of evidence there ws (i.e. dimensions of disbility) nd (2) how good or convincing the evidence is (i.e. levels of evidence). c Dimensions of disbility (Tble I) is concept nd clssifiction system tht fcilittes the mesurement, mngement, nd reserch of rehbilittion outcomes nd minimizes the brriers between medicl nd socil models of rehbilittion. Levels of evidence clssifictions nd other qulity-rting schemes re bsed on (1) hierrchy of reserch designs tht rnge from the gretest to lest ccording to bility to reduce bis combined with (2) mens of ssessing the thoroughness with which the prticulr reserch study ws conducted. d Generlly speking, level I studies produce the most credible evidence nd, thus, yield the most definitive results. 11 Level II studies, bsed on less convincing evidence, produce tenttive conclusions. Levels III nd IV reflect still less persusive evidence nd merely suggest custion. No conclusions regrding tretment efficcy cn be drwn from level V evidence. The AACPDM levels of evidence clssifiction (Tble II), unlike some other clssifictions, is limited to guging only the internl vlidity of study, i.e. its bility to demonstrte tht the intervention nd not other fctors in tht study ws responsible for the observed outcomes. Externl vlidity, or the confidence with which finding might be pplied to comprble popultions is not reflected in this clssifiction. Insted, whether finding cn be expected to generlize is believed to be more ppropritely determined by individul users of the evidence reports who will focus on only the specific spects of similrity between ptient of interest nd the people who hve been studied (e.g. their ge, type nd severity of CP, conditions of tretment). c The rtionle nd specific guidelines followed for clssifying the tretment outcomes re vilble on the Acdemy s Internet website t in the document titled AACPDM Methodology for Developing Evidence Tbles nd Reviewing Tretment Outcomes Reserch. d The concept of qulity determintion for rticles used in systemtic reviews is mtter of some debte. The science of criticl pprisl of reserch, initilly developed in internl medicine, is n on-going process. It is dditionlly difficult to pply this concept to reserch bout disbling conditions in developing children. Despite the considerble chllenge, there is greement tht tems developing systemtic reviews cn tke certin steps to ensure tht their pproches to grding the qulity of reserch meet current scientific stndrds. Tble I: Dimensions of disbility Dimension Pthophysiology Impirment Functionl Limittion/Activity Disbility/Prticiption Societl Limittion/Context Fctors Description Interruption or interference of norml physiology nd developmentl processes or structures Loss or bnormlity of body structure or function Restriction of bility to perform ctivities Restricted prticiption in typicl societl roles Brriers to full prticiption imposed by societl ttitudes, rchitecturl brriers, socil policies nd other externl fctors 780 Developmentl Medicine & Child Neurology 2001, 43:

4 Summry tbles Tble III summrizes the interventions, control conditions, nd prticipnts in the 21 studies. In deference to the ethicl concern of withholding tretment intervention from group of children for the formtion of no tretment control group, five studies 13, 14, 19, 27, 30 compred NDT to some other intervention, nd one compred greter intensity of NDT to lesser intensity 25. Two studies compred no tretment control period in group receiving NDT. 12, 15 Seven studies 16, 17, 22 24, 28, 29 used single subject methodology in which prticipnts cted s their own controls during reltively short phses of no tretment (i.e. 25 dys to 4 months), nd four compred motor sttus before nd fter tretment with no control condition. 18, 26, 32 In two studies, NDT ws the control for nother intervention investigting mternl nd child fctors. 21, 26 Tble IV summrizes the reserch methodologies. Level of evidence ws determined on the bsis of reserch design modified by the ctul conduct of the study to indicte qulity of the evidence. In other words, studies were first weighted by the type of reserch design used, then reduced one level if the prticulr study did not control threts to internl vlidity tht re theoreticlly possible within the reserch design. e Tble V summrizes 101 results from the studies nd shows the coding of ech for the dimension of disbility nd level of evidence it represents. Clinicl importnce or relevnce (seldom explicit in studies) nd sttisticl informtion re included, to the extent these re vilble. e The AACPDM methodology is bsed on current scientific stndrds for nlyzing nd weighting studies for bis nd error. This type of criticl pprisl is new endevor in medicine, in generl nd within the Acdemy, in prticulr. The AACDPM methodology will continue to evolve both with experience nd s the science of criticl pprisl improves. Therefore, the ssigned level of evidence should be regrded s n estimte, nd reltive to other studies, rther thn n bsolute. Evidence tble ORGANIZATION Tble VI ggregtes these 101 types nd frequencies of results in columns tht llow quick visul ssessment of the number of results tht fvored NDT (17) versus those tht fvored the control condition (12) versus those tht were either unchnged, not different between groups, or the difference ws not sttisticlly significnt (72). Ech result is entered s superscript cittion ssocited with level of evidence (I to V). By rows, one cn see which dimensions of disbility hve been trgeted for investigtion nd which types nd how often outcomes hve been mesured. For exmple, motor ctivities hve been investigted 14 times in eight different studies, with one result tht showed n dvntge for children who received NDT or more intensive NDT. The confidence with which one cn regrd these findings bout motor ctivities is reltively high considering tht ll but two of the results reflects level I or II evidence. MORE INDEPTH INTERPRETATION OF THE EVIDENCE One cn delve into ny dt in Tble VI by using the superscript cittions nd refer bck to the summry tbles to elborte the mening of dt point (romn numerls refer to the level of evidence). For exmple, in the row tht showed the effects of NDT on motor responses in the Impirment dimension of disbility, there is single entry (II 14 ) tht represents the strongest evidence tht NDT chnged or improved bnorml motor responses. Reference 14 in the summry of studies (see Tble III) shows tht this evidence cme from study reported in 1976 tht contined 20 children with CP, who vried from 5 to 17 months of ge t the time of entry, into one of two interventions given individully twice week for vried durtion of 7 to 21 months. Published results were ctully bsed on 22 children, two of whom did not hve CP. As the dignosis nd results for ech of the 22 were shown, however, the uthors of this review were ble to clculte the results for the 20 prticipnts with CP; Tble II: Levels of evidence. Mximum level of evidence is determined by reserch design; conduct of study my result in reduction of level of evidence by one level Level Non-empiricl Group reserch Outcomes reserch Single subject reserch I Rndomized controlled tril N-of-1 rndomized All or none cse series controlled tril II Non-rndomized controlled tril Anlytic survey ABABA design Prospective cohort study with Alternting tretments concurrent control group Multiple bseline cross prticipnts III Cse-control study ABA design Cohort study with historicl control group IV Before nd fter cse series AB design without control group V Descriptive cse series/cse reports Anecdotes Expert opinion Theories bsed on physiology, bench, or niml reserch Common sense/first principles Annottion 781

5 Tble III: Summry of studies interventions nd prticipnts Study NDT Control Popultion Totl Ages intervention intervention n 1973 Wright 12 Bobth method Untreted period Spstic type: 11diplegi, 16 hemiplegi, >6 mo 6 y qudriplegi; no mixed or postntl types, previous ortho surgery or intensive PT; 12 epileptic; 19 MR 1975 Crlsen 13 Fcilittion group Functionl Mild moderte spstic, thetoid or both, diplegi, y therpy 1h 2/wk hemiplegi, or qudriplegi 1976 Scherzer 14 Neurophysiologic Trditionl therpy Mild severe: 6 spstic, 13 thetoid, 1 txic, mo individul therpy 2/wk MR-norml IQ b 1981 Sommerfeld 15 NDT individul Group 1 Untreted Severe MR with mild severe CP: 15 spstic qudriplegi, y therpy 30 min 2/wk period. Group 2 c 11 other spstic types, 2 thetoid, 1 txic 1983 DeGngi 16 NDT individul Ply 1 mild hemiplegi, 1 qudriplegi, 1 mild diplegi, mo therpy 25 min 2/wk moderte hypotoni; 3 norml cognition, 1 borderline 1985 Lsks 17 NDT individul Ply Mild spstic qudriplegi; norml IQ nd receptive y therpy 20 min lnguge; delyed speech dily + 1 h/wk 1987 Herndon 18 NDT individul None 11 spstic, 1 thetoid: 7 mild, 2 moderte, 3 severe y therpy 1 h/dy 1988 Plmer 19 Prt 1: NDT individul Prt 1: Infnt Spstic diplegi by specified neurologicl/functionl mo therpy 1h/every 2 wk stimultion: mesures d ; moderte MR to norml IQ; + home progrm Lerningmes no confounding vribles e Prt 2: NDT continued Prt 2: sme s NDT protocol 1989 Hnzlik 20 NDT: OT 1h 1h mother child CP: hemiplegi, diplegi, qudriplegi; mild severe; 20 f 8 32 mo individul session interction mobile nd non-mobile instruction 1990 Plmer 21 NDT individul Infnt stimultion Sme Plmer 1988 study 47 f mo therpy 1h/2 wk Lerningmes 1990 Lilly 22 NDT individul Ply Spstic diplegi d ; ner or norml IQ 2 27, 32 mo therpy 1 nd 2h/wk 1990 Embrey 23 NDT individul None Ambultory spstic diplegi d 1 2 y therpy 20 min 1990 Kluzik 24 NDT individul None Spstic qudriplegi; mild moderte involvement y therpy 35 min 1991 Lw 25 Intensive NDT 45 min NDT 45 min 1/mo Spstic hemiplegi or qudriplegi; spsticity of 36 g 18 mo 8 y 2/wk + 30 min/dy to 1/wk + 15 min wrist nd hnd; no fixed wrist contrcture or home progrm 3/wk home progrm severe developmentl disbility 1994 DeGngi 26 NDT individul None Severe spstic qudriplegi; cognitive nd lnguge 1 2 y therpy 30 min 2/wk dely 1994 Bower 27 Bobth individul Group 1: Spstic qudriplegi: mild to severe mo 8 y therpy min Conductive ed. 1 2/wk Group 2: imoriented therpy Group 3: eclectic therpy 1996 Fetters 28 NDT individul Skill prctice Spstic qudriplegi, norml IQ, ble to sit, see nd y therpy 35min, 5X rech object, understnd nd crry out spoken directions, use computer 1997 Jonsdottir 29 NDT individul Skill prctice Sme prticipnts s Fetters study y therpy 35 min, 5X 1997 Lw 30 Intensive NDT 45 min Functionl skills Moderte severe upper-extremity involvement mo 4 y 2/wk + home progrm OT CP with flexed hnd posture; no fixed wrist 30 min/dy + UE cst contrcture, severe cognitive impirment, or 4 h/dy use of ntispsticity drugs 1999 Trhn 31 NDT individul therpy None Mild severe; 24 qudriplegi; 16 hemiplegi; mo 45min 2/wk 10 diplegi; no behvior problems 2000 Adms 32 NDT 1h 2/wk None 11 mbultory with ids; 18 spstic diplegi, y 11 hemiplegi, 3 triplegi; 5 txi; 3 thetoid; 15 severe, 19 moderte, 3 mild PT, physicl therpy; MR, mentl retrdtion (lerning disbility); OT, occuptionl therpy; ed, eduction; X, number of times; UE, upper extremity. Included neurodevelopmentl tretment principles dvocted by Bobth, Rood nd Ayres; b Two prticipnts without CP but, given individul dt reported, review uthors reclculted results on dt for 20 with CP; c Supervised PT mngement but no direct therpy; d Specific motor responses nd/or bilities detiled in rticle; e Absence of degenertive disorders, use of tone-ltering drugs, contrctures, hip disloction or subluxtion, severe phryngel impirment, previous PT or orthopedic surgery, hering or visul impirment, IQ lower thn 40, prents judged to lck complince; f Mother child dyds; g Totl n=76 in four groups, but results relted to the two other groups (with csting nd NDT) re excluded. 782 Developmentl Medicine & Child Neurology 2001, 43:

6 these re the results reflected in the summry tbles (Tble III V) nd evidence tble (Tble VI) in this review. The prticipnts with CP were heterogeneous group: six hd spsticity, 13 hd thetosis; one hd txi. The severity of their CP rnged from mild to severe; nd their intellectul sttus rnged from unknown to norml. The experimentl intervention, clled neurophysiologicl therpy, ws defined s using the neurodevelopmentl tretment principles dvocted by Bobth, Rood, nd Ayres. The control intervention ws trditionl therpy, undefined. From the summry of reserch methods (see Tble IV), this level II 14 evidence cn be further elborted: it cme from rndomized controlled tril which hs the potentil to produce the strongest or most vlid evidence (coded s level I). However, the level of evidence for this rndomized controlled tril is reduced one level becuse, ccording to the review uthors judgment bsed on criteri in the AACPDM methodology, the study ws not conducted with sufficient thoroughness to dispel some importnt threts to the internl vlidity of its results. One reson cn be seen in Tble IV, tht is, there were uneven numbers of prticipnts in ech group: 14 in the experimentl group nd six in the control group. Finl elbortion of this II 14 evidence from the summry of results (see Tble V) revels tht the outcome of interest ws composite reflection of physiologicl motor functions. The Motor Development Evlution ws creted by the investigtors to mesure this motor function. The investigtors indicted tht they regrded the improvement seen with NDT s cliniclly importnt, but they did not perform ny sttisticl evlution of this result. TARGETING EVIDENCE OF PARTICULAR INTEREST Reders cn lso focus only ny desired spect(s) of the dt included within the evidence tble (Tble VI). For exmple, clinicin my need to mke recommendtion bout intervention for n 18-month-old child with spstic diplegi in response to the prents specific questions bout wlking. Using the summry tble of studies (see Tble III), the reder will note tht there were four studies 19, pertinent to children with spstic diplegi who strted NDT therpy t bout this ge. Highlighting ll the results from the four studies in the evidence tble (Tble VI) shows tht these four studies yielded evidence relted to physiologicl motor responses, motor nd other spects of child development, contrctures nd deformities, mternl child behviors, nd motor skills or ctivities. There re four results bout ttinment of motor milestones including wlking: two fter 6 months nd two, fter 12 months. 19 Referring bck to the summry tbles (Tbles III V) to elborte, one cn identify tht two of these studies re ctully the sme study involving 48 children in which different Tble IV: Summry of studies reserch methods Study Reserch design Level of Tretment NDT Rx Control Rx evidence durtion n n 1973 Wright 12 RCT (3 groups) II Externl comprison 1 6 mo Externl comprison 2 12 mo 7 10 Internl comprison 6 mo Crlsen 13 RCT (Pired then ssigned to 2 groups) II 6 wk Scherzer 14 RCT (2 groups) II 7 21 mo Sommerfeld 15 Concurrent cohort study II 5 mo 10 Control group 1 9 Control group DeGngi 16 Multiple crossover tril II 5 wk Lsks 17 ABA design III 25 d Herndon 18 Before nd fter cse series without controls IV 6 wk 12 None 1988 Plmer 19 RCT (2 groups) Prt I I 6 mo Prt II I 12 mo Hnzlik 20 Concurrent cohort study II 2 wk 10 c 10 c 1990 Plmer 21 RCT (2 groups) I 12 mo 25 c 22 c 1990 Lilly 22 Multiple crossover tril II 12 wk Embrey 23 ABABCA tril II 15 wk Kluzik 24 AB design IV 4 wk Lw 25 RCT (2 of 4 groups reported: intensive vs regulr mount NDT) I 9 mo DeGngi 26 Cse study V 8 wk Bower 27 Concurrent cohort study (4 groups) III 1 6 mo Fetters 28 Multiple crossover tril II 4 wk Jonsdottir 29 Multiple crossover tril II 4 wk Lw 30 RCT (2 groups) crossover with wshout I 4 mo b Trhn 31 Before nd fter cse series IV 8 mo Adms 32 Before nd fter cse series IV 6 wk 40 0 Rx, tretment; RCT, rndomized controlled tril. Prticipnts were their own controls; b Ech group received 4 months of tretment then crossed over to opposite tretment fter 2-month wshout period; c Mother infnt dyds. Annottion 783

7 Tble V: Summry of studies: outcomes, mesures, nd results. These results reflect effects of NDT when compred to nother condition, to sttus before tretment, to period of no tretment when prticipnts cted s their own controls, or when greter intensity of NDT ws compred to lesser intensity Study Outcome of interest Dimension Mesure Result Clinicl Sttistics Level of of disbility importnce evidence 1973 Wright 12 Automtic reflexes I Rted observtion ND ns II ROM (2 movements) I Not specified ND ns II Gross motor ctivities FL/A Rted observtion ns II 1975 Crlsen 13 Motor ge I Byley Motor Scle + p<0.05 II Gross motor ge I DDST, Motor Scle + p<0.05 II Fine motor ge I DDST, Fine Motor Scle + ns II Socil ge I DDST, Socil Scle + ns II Lnguge ge I DDST, Lng. Scle + ns II 1976 Scherzer 14 Physiologic function I Motor Development Evlution + yes II Socil ctivities FL/A Questionnire ND II Home mngement SL/C Questionnire ND II 1981 Sommerfeld 15 Developmentl reflexes I Wilson Developmentl Reflex Test ns II Gross motor ge I Gross Motor ns II ROM (6 movements) I ROM Scle ns II 1983 DeGngi 16 Positioning/ctivities FL/A Rted observtions ns II 1985 Lsks 17 ROM (dorsiflexion) I Biofeedbck instrument + p=0.00 III ROM (heel strike) I Biofeedbck instrument + yes b III 1987 Herndon 18 ROM (hip flexion) I Goniometer ND IV ROM (hip bduction) I Goniometer ND IV ROM (knee) I Goniometer ND IV ROM (dorsiflexion) I Goniometer + yes IV Rising from chir FL/A Video nlysis ND ns IV Wlking FL/A Video nlysis ND ns IV Turning FL/A Video nlysis: wlking ND ns IV Trunk rottion I Video nlysis: wlking ND ns IV Trunk rottion I Video nlysis: sitting ND ns IV Posturl lignment I Video nlysis: sitting ND ns IV Weight shift I Video nlysis: sitting ND ns IV Assuming position FL/A Video nlysis: sitting ND ns IV 1988 Plmer 19 Prt I: c Motor ge I Byley Motor Scle p=0.02 I Motor milestones FL/A Attinment defined skills ND ns I Wlking ttinment FL/A Observtion/defined skill ND ns I Tone/spsticity/reflexes I Neurologicl exm ND ns I Mentl ge I Byley Mentl Scle + ns I Socil ge I Vinelnd Socil Mturity Scle ND ns I Prt II: Motor ge I Byley Motor Scle p<0.01 I Spsticity I Neurologicl exm ns I LE reflexes I Neurologicl exm p<0.05 I Joint limittion/rom I Brcing recommended ND ns I Contrctures/ROM I Surgery recommended ND ns I Motor milestones FL/A Attinment defined skills ns I Age/independent wlking FL/A Observtion/defined skill p=0.01 I Mentl ge I Byley Mentl Scle ND ns I Socil ge I Vinelnd Socil Mturity Sc. ND ns I 1989 Hnzlik 20 Infnt complince I Video nlysis: DMIB p<0.05 II Infnt responsiveness I Video nlysis: DMIB p<0.003 II Independent ply FL/A Video nlysis: DMIB ND p=0.18 II Mternl directness SL/C Video nlysis: DMIB p<0.02 II Mternl initition SL/C Video nlysis: DMIB p<0.001 II Mternl responsiveness SL/C Video nlysis: DMIB p<0.05 II Adptive seting provision SL/C Video nlysis: DMIB p< II Mternl holding SL/C Video nlysis: DMIB ND p=0.199 II Fce to fce contct SL/C Video nlysis: DMIB p< II Physicl contct SL/C Video nlysis: DMIB p<0.002 II 784 Developmentl Medicine & Child Neurology 2001, 43:

8 Tble V: continued Study Outcome of interest Dimension Mesure Result Clinicl Sttistics Level of of disbility importnce evidence 1990 Plmer 21 Infnt ctivity I CITQ ns I Infnt rhythmicity I CITQ + ns I Infnt dptbility I CITQ ns I Infnt pproch I CITQ + ns I Infnt threshold I CITQ ND ns I Infnt intensity I CITQ + ns I Infnt mood I CITQ ND ns I Infnt distrctibility I CITQ + ns I Infnt persistence I CITQ + ns I Mternl cceptnce SL/C RMCRE ns I Mternl overprotection SL/C RMCRE + ns I Mternl overindulgence SL/C RMCRE + ns I Mternl rejection SL/C RMCRE ns I Mternl responsiveness SL/C HOME + no p>0.04 I Mternl involvement SL/C HOME + ns I Restriction voidnce SL/C HOME + ns I Environment orgniztion SL/C HOME + ns I Ply mterils SL/C HOME + ns I Vriety of stimultion SL/C HOME + ns I 1990 Lilly 22 Physiologicl function I Rte of movements ND b II 1990 Embrey 23 ROM (knee flexion) I Goniometer; video + b II 1990 Kluzik 24 UE movement time I Video; kinemtics + p<0.025 IV UE movement unit I Video; kinemtics + p<0.075 IV % of rech in 1st unit I Video; kinemtics + p=0.025 IV UE ssocited rections I Video; kinemtics ND ns IV 1991 Lw 25 Fine motor ge I Pebody FM Scle p=0.63 ns I c Physiologic hnd function I QUEST ND p=0.82 ns I 1994 De Gngi 26 Qulittive movement I Video nlysis; checklist + yes V 1994 Bower 27 Gross motor skills FL/A Gol setting/gmfm + smll ns III Prent stisfction SL/C Questionnire + ns III 1996 Fetters 28 UE movement time I Kinemtic nlysis: rech ND ns III UE movement unit I Kinemtic nlysis: rech ND ns III UE rection time I Kinemtic nlysis: rech ND ns III UE displcement I Kinemtic nlysis: rech ND ns III 1997 Jonsdottir 29 Posturl lignment I PAS ND ns III Posturl lignment I Kinemtic nlysis ND ns III 1997 Lw 30 Fine motor ge I Pebody Fine Motor Scle ND no ns I Physiologic UE function I QUEST ND no ns I Hnd ctivities FL/A COPM ND no ns I Prent stisfction SL/C Rting scle ND no ns I 1999 Trhn 31 Gross motor ctivities FL/A GMFM + p< Adms 32 Git: stride length I Pedogrphs + smll p=0.003 IV Git: step length I Pedogrphs + smll p=0.001 IV Git: cdence I Pedogrphs + smll ns IV Git: velocity I Pedogrphs + smll p=0.001 IV Git: foot ngle I Pedogrphs + smll p=0.036 IV Git: bse of support I Pedogrphs + smll ns IV I, Impirment; ND, Result not different between groups or fter tretment; FL/A, Functionl Limittion/Activity; SL/C, Societl Limittion/Context Fctors; DDST, Denver Developmentl Screening Test; ROM, rnge of movement; UE, Upper extremities; LE, lower extremities; DMIB, Dictionry of Mother Infnt Behviors; CITQ, Crey Infnt Temperment Questionnire; RMCRC, Roth Mother Child Reltionship Evlution; HOME, Home Observtion for Mesurement of the Environment; QUEST, Qulity of Upper Extremity Skills Scle; GMFM, Gross Motor Function Mesure; PAS, Posturl Assessment Scle; COPM, Cndin Occuptionl Performnce Mesure;, Result did not fvor NDT; +, Result fvored NDT; ns, Result not sttisticlly significnt. Results of tretment group compred with ggregted control groups. b Trend nd level nlysis. c Power clcultions reported, but smple size not chieved. Annottion 785

9 types of outcomes were published 2 yers prt (i.e. motor nd lerning outcomes 19 nd mother infnt interction outcomes 21 ). Another study 22 looked t the effects of short-term therpy (1 to 2 hours/week for 12 weeks) using crossover design in which two children cted s their own controls producing level II evidence suggesting there ws no difference between physiologicl motor function following NDT versus ply. The fourth study 23 lso investigted short-term effects of NDT using single subject design with one prticipnt. Knee flexion during wlking ws repetedly mesured in tril tht lsted 15 weeks. Trend nd level nlysis of mesures of knee flexion during wlking compred lternting NDT nd no tretment phses through 15-week period nd showed there ws improved rnge of motion with NDT. The evidence from the ltter two studies hs little externl vlidity (or bility to be generlized to popultion-t-lrge) becuse it comes from only one 23 nd two 22 prticipnts. However, it hs good internl vlidity (or bility to demonstrte tht the findings reflect the effect of the intervention in tht study nd were not contminted by other fctors) becuse they used single subject designs tht cn produce level II confidence bout results nd conducted the study thoroughly so tht threts to its internl vlidity were controlled. CAUTION Cution is dvised concerning the correct interprettion of results tht re not sttisticlly significnt (ns). Results my be ns becuse of lck of dequte power in the study smple nd design. The power of study is the probbility tht the study, given its design nd smple size, cn detect true difference of predetermined mgnitude (effect size). In the bsence of power clcultion in study description, there is lwys the possibility tht true difference existed between the two tretments being compred, but tht there ws indequte power to detect the difference. However, if power clcultion is reported nd the smple size needed to produce the power is obtined, then ns result sttisticlly supports the conclusion tht there is no difference between the two tretments compred. Only two studies in this body of evidence reported power clcultions. Plmer nd collegues 19 reported tht smple size of 100 would be needed for full evlution of tretment differences mong ll the outcome vribles, but hd to proceed with only 48 children. Lw nd coworkers 25 clculted tht 76 prticipnts were needed to provide sufficient power to detect difference tht they regrded s cliniclly importnt. However, clcultions mde fter the study using the observed effect confirmed tht the 73 prticipnts hd provided dequte power to detect tht difference if it hd existed (Mry Lw, personl communiction). Unfortuntely, the mjority of studies in this review do not report power clcultions nd smple sizes were often smll enough tht dequte power is questionble. Anlysis of the evidence bout NDT 1. WHAT KIND OF EVIDENCE IS THERE ABOUT EFFECTS ON MOTOR IMPAIRMENT OR ABOUT IMPAIRMENT IN OTHER DOMAINS OF DEVELOPMENT? Motoric responses The primry gol of NDT is to chnge the neurl-bsed motoric responses of the CNS. Thirty mesures hve evluted vrious spects of motoric response nmed s qulittive movement or physiologicl motor function (i.e. composite of muscle tone, spsticity, reflexes, etc.), reflex ctivity, weight shift, posturl lignment, trunk rottion, ssocited rections, nd severl spects of upper-extremity (UE) movement nd git. Eight results showed tht better motoric response ws ssocited with NDT: physiologicl motor function (II 14 ) or qulittive movement (V 26 ), movement time (IV 24 ), percent of rech (IV 24 ); nd git stride (IV 31 ) nd step (IV 31 ) length, velocity (IV 31 ), nd foot ngle (IV 31 ). However, this evidence of improvement in physiologicl motor function nd qulittive movement is not consistent. There were five contrsting findings with stronger vlidity tht tone, spsticity, nd/or reflex responses (I 26, 30, II 14, 17, 23 ) were either not different or were improved in the children who received the control tretment (I 19 ). More intensive NDT interventions (shown in bold type in the evidence tble VI) produced no better results. Contrctures nd deformity Another mjor gol of NDT is to slow or prevent progressive deformity. Mesures of joint rnge of motion nd/or recommendtions for brcing or surgery were used to probe the presence nd degree of contrctures fter exposure to NDT. NDT consistently conferred n dvntge in the three mesures of dynmic joint rnge of motion t the nkle nd knee (II 23, III 17, 17 ). In other words, joint limittion ws less when it ws repetedly ssessed immeditely following 20- to 25- minute therpy session. NDT lso conferred benefit in one sttic mesure mde fter 6-week tretment period (IV 18 ). Conversely, no difference between tretment conditions ws detected in six other results of sttic rnge of motion tht represented overll stronger evidence (i.e. level II); these mesures of lower-extremity joints ssessed effects of tretment periods tht lsted up to 12 months. Due to the fct tht spsticity nd discomfort my often pper to be incresed by ordinry hndling during cregiving ctivities, this finding bout dynmic rnge of motion my explin the clinicl perception tht therpeutic hndling using NDT techniques reduces spsticity nd discomfort during hndling (Pm Mullens, personl communiction). This, in turn, my lso explin the clinicl impression tht individuls re lso more ble to ctively prticipte during therpeutic cregiver-ssisted movement. Motor development Stndrdized tests re designed to smple selected ctivities in prticulr developmentl domin, yielding developmentl quotient or ge tht reflects the extent to which development is impired compred with norml. Motor ge hs been mesured eight times in five studies. All three mesures of fine motor ge (I 25, 30 nd II 15 ) found no dvntge conferred by NDT. Two mesures of gross motor ge were not consistent: one fvored NDT (II 13 ); the other showed no difference between NDT nd the control condition. Three mesures of overll motor ge (i.e. verge of gross nd fine motor ges) were lso not consistent: one fvored NDT (II 13 ) but two more convincing results fvored the control condition (I 19 nd I 19 ). Surprisingly, the I 19 result shows tht 6 months of n infnt stimultion progrm ws ssocited with greter gins in overll motor development thn six months of NDT. In Prt II of this study, the infnt stimultion group subsequently received six months of NDT while the NDT group continued with NDT. Assessment t the end of Prt II of the tril showed tht the group with lesser exposure to NDT still mde greter 786 Developmentl Medicine & Child Neurology 2001, 43:

10 gins in overll motor development (I 19 ). Other domins of child development nd function In developmentl theory, physicl nd psychologicl development re interrelted. Thus, other lines of development my lso be ffected when bnorml motor behvior improves through n intervention. Seventeen results re consistent in not finding n dvntge in cognitive, lnguge, socil, or emotionl domins of development for children exposed to NDT. In most instnces, there were no differences between the NDT nd control groups, but in two instnces the control intervention ws ssocited with better outcomes tht re relted to infnt temperment (i.e. infnt complince nd responsiveness). Quntity of therpy Three studies investigted whether more intensive intervention demonstrted greter reductions in mesures of impirment. 19, 25, 30 These results (see Tble VI) re concerned with motoric responses, contrctures, motor nd Tble VI: Evidence tble outcomes of NDT for CP. Ech outcome is indicted by superscript tht is the cittion number of ech study tht produced this result ssocited with level of evidence (coded I V) Outcomes by dimensions Results fvoring Results fvoring NDT Results fvoring Results not different of disbility NDT (sttisticlly (but not sttisticlly control (sttistic. or not sttisticlly significnt) evluted ) significnt) significnt PATHOPHYSIOLOGY IMPAIRMENT Motoric responses: physiologicl motor IV 24, 24, 31, 31, 31, 31 II 14 I 19 I19, 19, 25, 30 function, qulittive movement; tone; V 26 II12, 15, 18, 18, 18, 18, 22 spsticity; reflexes; weight shift; posture, III28, 28, 28, 28, 29, 29 posturl lignment; trunk rottion; IV24, 24, 31, 31 UE ssocited rections, rection time, displcement, movement time, movement units, % of rech; git stride length, step length, velocity, foot ngle, cdence, bse of support Contrctures nd deformity: rnge of motion II 23 IV 18 I19, 19 or joint limittion of hip, knee, nkle III 17, 17 II12, 15, 18, 18, 18 Motor development: motor ge, gross II 13, 13 I 19, 19 I25, 30 motor ge, fine motor ge II13, 15 Other domins development nd function: II 20, 20 I19, 19, 19, 19 socil ge, mentl ge, lnguge ge, I21, 21, 21, 21, 21, 21, 21, 21, 21 temperment (complince, responsiveness, II13, 13 ctivity, rhythmicity, dptbility, pproch, threshold, intensity, mood, distrctibility, persistence) FUNCTIONAL LIMITATION/ACTIVITY Motor ctivities: Gross motor milestones IV 31 I 19 I19, 19, 19, 30 nd ctivities, wlking, turning, rising from II 12, 16, 18, 18, 18, 18, 20, III 27 sitting, hnd ctivities, independent ply Socil ctivities II 14 DISABILITY/PARTICIPATION SOCIETAL LIMITATION/CONTEXT FACTORS Mternl behviors: Home mngement; I 21 II 20, 20, 20, 20, 20 I21, 21, 21, 21, 21, 21 mternl responsiveness, overprotection, II14, 20 cceptnce, overindulgence, rejection, involvement, restrictions, directiveness, positive inititions, holding; fce-to-fce nd physicl contct with infnt Environment: Arrngement, ply mterils, II 20 I21, 21, 21 vriety of stimultion, dptive seting use Prent stisfction I 30 Ech entry reflects how NDT fred when compred with nother condition, to sttus before tretment or to period of no tretment when prticipnts cted s their own controls, or when greter intensity of NDT ws compred to lesser intensity (see items I 19, 25, 30 ). Multiple results pper when study investigted the sme outcome of interest in different wys or investigted outcome in the short nd long term. III 27 Annottion 787

11 other domins of development, nd ttinment of motor skills or ctivities. Intensive NDT in one study 25 ws defined s 45 minutes twice week plus 30-minute--dy home progrm, nd it ws compred with less intensive NDT regime given 45 minutes once week or no less thn once month plus 15-minute, three-times--week home progrm. Intensive therpy (s defined bove) ws compred in nother study 30 with regulr occuptionl therpy progrm given 45 minutes once week or no less thn once month. In the third study, intensive NDT ws defined s 1 hour twice week plus n uncler home progrm which lsted for 12 months, this ws compred with less intensive NDT in which the sme mount of therpy ws given for only six months. No sttisticlly significnt beneficil effect of NDT ws detected either when the mount of therpy ech week ws incresed or when the number of months of tretment ws extended. 2. WHAT EVIDENCE IS THERE ABOUT EFFECTS IN DIMENSIONS OF DISABILITY OTHER THAN IMPAIRMENT? Pthophysiology There is no evidence regrding effects on cellulr or moleculr structure or function in individuls s result of NDT. Functionl Limittion/Activity Wheres stndrdized tests tht yield developmentl ges nd reflect impired development include ctivity or skill ttinment items, the Functionl Limittion/Activity dimension is concerned with common functionl ctivities themselves, such s sitting, wlking, dressing, plying, or intercting with other people. There were 14 mesures tht investigted the effect of NDT on functionl motor ctivities including vrious types of moving round, using hnds, nd plying nd one mesure tht documented effect on ctivities of socil nture. Only one mesure (IV 31 ) demonstrted incresed gross motor function of NDT, but this study included no mens to differentite ny gins from mturtion. Surprisingly, in nother robust study, more children ttined wlking erlier in the control group tht ws exposed to 6 months of n infnt stimultion progrm followed by 6 months of NDT, compred with the experimentl group which received 12 months of NDT (I 19 ). Disbility/Prticiption Effects of NDT on prticiption in fmily, school, or community roles were not ddressed in these studies. Societl Limittion/Context Fctors Given the intensive prentl involvement dvocted in the NDT pproch, it might be expected tht NDT would indirectly benefit children by improving the prent child reltionship or by reducing the stress prents experience in cring for child with typicl motor function. It might improve the prents understnding of how to rrnge the environment to stimulte the children nd mximize their bility to ccess objects nd people. Finlly, being n integrl prt of the therpeutic endevor, insted of n outsider in the child s tretment might increse the prent s sense of stisfction bout the intervention. Only one of 14 results supports the expecttion tht NDT would confer greter benefit to mternl child interction. Although greter mternl responsiveness to the child (I 21 ) ws reflected by sttisticlly significnt higher scores for mothers in one NDT group, it ws not in nother group (II 20 ). NDT did not confer ny dvntge to the environment of children in ny of the four mesures tht probed vriety of stimultion, ply mterils, rrngement of environment, or use of dptive seting. There ws no difference in stisfction between prents whose children were in NDT progrms versus nother intervention in either of two results bout this outcome. Other societl or fmily effects, such s the finncil cost of long-term NDT, or cost in terms of fmily time, energy or reltionships (i.e. wht hppens to the prent reltionship when the prent ssumes role of therpist) hve not been ddressed by ny of these studies. 3. WHAT LINKAGES EXIST FOR TREATMENT EFFECTS ACROSS THESE DIMENSIONS? No linkges hve been reported or cn be determined given the inconsistent findings nd/or generl lck of tretment effect documented in ny dimension. 4. ARE THERE SUBGROUPS FOR WHOM NDT MAY BE MORE OR LESS EFFECTIVE OR HAS CONTEMPORARY NDT BEEN MORE EFFECTIVE THAN EARLIER NDT? Although the informtion is not shown in ny of the tbles, six of the 21 studies nlyzed potentil fctors expected to identify subgroups of children who might experience greter or lesser benefit from NDT: ccording to ge t entry to tretment, type nd severity of disbility, intelligence, mternl eduction, fmily income, nd prentl complince with home progrms. 12, 14, 15, 25, 32 Four studies nlyzed ge s vrible, 14, 15, 25, 31 but the expected ssocition between younger ge nd positive outcome ws sttisticlly significnt in only one of the four. 25 Severity of disbility did not identify ny subgroups in one nlysis 14, but children mildly ffected did better thn those severely ffected in nother study. 19 Children with spstic diplegi (one type of CP) benefited most ccording to two studies. 31, 32 However, when one of these studies went further to nlyze only motor behviors tht would be expected to chnge in children with diplegi versus hemiplegi versus qudriplegi, it found tht the percent of men chnge ws not different. 31 The effect of intelligence ws sttisticlly significnt in only one 14 of three nlyses. 12, 14, 25 Fmily fctors were lso exmined: mternl eduction, 25 nd fmily income 25 filed to identify ny subgroups, but prentl complince with the home progrm in one nlysis ws sttisticlly significnt. 25 Given tht NDT evolved over time, lter studies might be expected to reflect more positive results thn erlier studies. Contemporry NDT, s described by the Bobths in their finl publiction 4 in 1984, should hve been reflected in clinicl prctice nd reserch by An nlysis compring the 10 studies published before 1990 with the 11 published between 1990 nd 2000 showed tht the lter studies, presumbly using contemporry NDT, hd greter percentge of results tht fvored NDT (10 of 47) thn did the erlier studies (six of 54 results). When only motor impirment or motor ctivity mesures were considered, NDT showed still more positive results for lter studies (10 of 18 results) compred with erlier studies (seven of 31). 5. WHAT MEDICAL COMPLICATIONS AND ADVERSE EFFECTS HAVE BEEN DOCUMENTED? None were reported in these studies. 788 Developmentl Medicine & Child Neurology 2001, 43:

12 6. WHAT IS THE STRENGTH OF THE EVIDENCE? How convincing body of evidence my be depends on severl fctors: the levels of evidence (i.e. strength of the internl vlidity of the results), how extensively the popultion hs been smpled (i.e. number of different studies nd number of prticipnts), s well s the number of times outcomes hve been mesured nd the consistency of their results cross the studies. A relted nd importnt issue is whether the mgnitude of chnge ws lrge enough to be cliniclly importnt. The levels of evidence guge the extent to which the studies re more likely to inform thn to misled in regrd to the likelihood tht the observed chnges re ttributble to the interventions nd not to extrneous fctors. Fourteen of the 21 studies were coded s level I (definitive) evidence19, 21, 25, 30 or level II (tenttive) evidence 12 16, 20, 22, 23, 28, 29 suggesting this body of evidence cn be regrded s reltively credible. Sttisticl evlution ws vilble for lmost ll the results; however, the smple sizes themselves re ll reltively smll clling into question the power of the studies to detect effects tht did exist. Power clcultions were reported for only two studies, nd only one of them contined the prescribed number of prticipnts. The wekest spect of this body of evidence is the limited popultion tht hs been smpled nd its considerble heterogeneity. The 21 studies include only 416 different individuls who vried considerbly in their type of CP nd its severity, ssocited disbilities, nd ge t tretment. Such heterogeneity in study prticipnts cn obscure tretment effects in group nlysis. Consistency of outcomes mesured nd consistency of the results cross studies is importnt. Although the specific outcomes tht hve been mesured vry, the sme type of outcomes hve been mesured cross severl studies nd there is considerble consistency in those results. Eighty-six of the 101 results did not confer n dvntge to NDT. Nevertheless, there is some question bout whether mny of the mesures were vlid nd/or sensitive enough to detect chnges tht my hve occurred. Finlly, the clinicl importnce of chnge observed ws seldom reported. To the extent it could be determined from the published reports, only four of the 16 results fvoring NDT were cliniclly significnt. 14, 17, 18, 26 The mgnitude of chnge ws smll in ech cse. Summry nd directions for future reserch The prepondernce of results in the evidence tble (Tble VI) did not confer ny dvntge to NDT over the lterntives to which it ws compred. With the exception of immedite improvement in dynmic rnge of motion, there ws not consistent evidence tht NDT chnged bnorml motoric responses, slowed or prevented contrctures, or tht it fcilitted more norml motor development or functionl motor ctivities. More intensive therpy did not seem to confer greter benefit. There ws lso no cler evidence tht NDT produced other potentil benefits such s enhncement of socil emotionl, lnguge, or cognitive domins of development, better home environments, improved prent child interctions, or greter prent stisfction. Fourteen of the 21 studies were reltively robust, providing results tht cn be regrded s definitively or tenttively vlid (level I nd II evidence, respectively). The biggest threts to the vlidity of this body of evidence bout NDT re generlly smll smple sizes in the studies, lck of informtion bout power to detect true difference if there ws one, nd considerble heterogeneity of prticipnts in the studies s well s vrince in therpy tretment cross time nd cross therpists. Before one cn determine whether there is sufficient reson for choosing NDT over nother intervention, however, there re substntil gps in this body of evidence tht need to be ddressed by future reserch. Effects of NDT on posturl djustment hve not been investigted; there re only one or two mesures of mny of the outcomes, including muscle tone nd spsticity. There re too few dt to determine whether very erly tretment, severity of involvement, or other fctors influence the effect of NDT. There is consistent, lbeit scnty, evidence tht NDT produced n immedite improvement in dynmic rnge of motion; if this is so, links to reduced spsticity, greter comfort, nd ctive coopertion during ssisted movement need to be explored. Longer follow up on rnge of motion is needed becuse the current dt my be too short term to detect effects of NDT on development of contrctures. Clerly defined, homogeneous prticipnts, opertionlly defined tretment techniques, nd pproprite outcome mesures in smples with dequte power re sorely needed in future studies. Nevertheless, the distribution of dt in the evidence tble suggests tht it is lso time for concerted efforts to investigte other therpy pproches tht my prove more clerly beneficil. Such new pproches re being discussed in the literture. 8 They grow out of current theories of developmentl nd motor lerning nd skill cquisition nd include tsk-oriented pproches, dynmic systems concepts, nd other mens of rehbilittion such s strength nd endurnce trining s well s use of ssistive technologies. Use of NDT s control intervention in evlution of new pproches might mke it possible to increse the evidence bout NDT while simultneously investigting new pproches. Accepted for publiction 4th July Acknowledgment The uthors wish to thnk Pm Mullens PhD PT, (NDT Instructor) who cted s content expert nd consultnt during the development of this evidence report. References 1. Butler C. (1998) AACPDM Methodology for Developing Evidence Tbles nd Reviewing Tretment Outcome Reserch. Americn Acdemy for Cerebrl Plsy nd Developmentl Medicine. 2. Tretment Outcomes Committee. (2001) Committee Chrge nd Procedures for Promoting, Reviewing, nd Disseminting Evidence Reports. Americn Acdemy for Cerebrl Plsy nd Developmentl Medicine Brry M. (2001) Historicl perspective to current prctice: hbilittive services. In: Scherzer A, editor. Erly Dignosis nd Interventionl Therpy in Cerebrl Plsy. New York: Mrcel Dekker. p Bobth K, Bobth B. (1984) The neuro-developmentl tretment. In: Scrutton D, editor. Mngement of the Motor Disorders of Children with Cerebrl Plsy. Phildephi: JB Lippincott. p DeGngi G, Royeen C. (1994) Current prctice mong neurodevelopmentl tretment ssocition members. Americn Journl of Occuptionl Therpy 48: Bly L. (1991) A historicl nd current view of the bsis of NDT. Peditric Physicl Therpy 3: Annottion 789