Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis.

BACKGROUND AND OBJECTIVE: Bobath therapy, or neurodevelopmental therapy (NDT) is widely practiced despite evidence other interventions are more effective in cerebral palsy (CP). The objective is to determine the efficacy of NDT in children and infants with CP or high risk of CP. METHODS: Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Embase, and Medline were searched through March 2021. Randomized controlled trials comparing NDT with any or no intervention were included. Meta-analysis was conducted with standardized mean differences calculated. Quality was assessed by using Cochrane Risk of Bias tool-2 and certainty by using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: Of 667 records screened, 34 studies (in 35 publications, 1332 participants) met inclusion. Four meta-analyses were conducted assessing motor function. We found no effect between NDT and control (pooled effect size 0.13 [-0.20 to 0.46]), a moderate effect favoring activity-based approaches (0.76 [0.12 to 1.40]) and body function and structures (0.77 [0.19 to 1.35]) over NDT and no effect between higher- and lower-dose NDT (0.32 [-0.11 to 0.75]). A strong recommendation against the use of NDT at any dose was made. Studies were not all Consolidated Standards of Reporting Trials-compliant. NDT versus activity-based comparator had considerable heterogeneity (I2 = 80%) reflecting varied measures. CONCLUSIONS: We found that activity-based and body structure and function interventions are more effective than NDT for improving motor function, NDT is no more effective than control, and higher-dose NDT is not more effective than lower-dose. Deimplementation of NDT in CP is required.

Age of Diagnosis, Fidelity and Acceptability of an Early Diagnosis Clinic for Cerebral Palsy: A Single Site Implementation Study.

Cerebral palsy (CP) diagnosis is historically late, at between 12 and 24 months. We aimed to determine diagnosis age, fidelity to recommended tests and acceptability to parents and referrers of an early diagnosis clinic to implement a recent evidence-based clinical guideline for the early diagnosis of CP. A prospective observational case series of infants <12 months with detectable risks for CP attending our clinic was completed with data analysed cross-sectionally. Infants had a high risk of CP diagnosis at a mean age of 4.4 (standard deviation [SD] 2.3) months and CP diagnosis at 8.5 [4.1] months. Of the 109 infants seen, 57% had a diagnosis of CP or high risk of CP, showing high specificity to our inclusion criteria. Parent and referrer acceptability of the clinic was high. Paediatricians had the highest rate of referral (39%) followed by allied health (31%), primary carer (14%) and other health workers (16%). Fidelity to the guideline was also high. All infants referred <5 mths had the General Movements Assessment (GMA) and all except one had the Hammersmith Infant Neurological Examination (HINE) administered. N = 92 (84%) of infants seen had neuroimaging, including n = 53 (49%) who had magnetic resonance imaging (MRI), showing recommended tests are feasible. Referral to CP-specific interventions was at 4.7 [3.0] months, sometimes before referral to clinic. Clinicians can be confident CP can be diagnosed well under 12 months using recommended tools. This clinic model is acceptable to parents and referrers and supports access to CP-specific early interventions when they are likely to be most effective.

Rehabilitation Evidence-Based Decision-Making: The READ Model.

Evidence-based practice is the foundation of rehabilitation for maximizing client outcomes. However, an unacceptably high number of ineffective or outdated interventions are still implemented, leading to sub-optimal outcomes for clients. This paper proposes the Rehabilitation Evidence bAsed Decision-Making (READ) Model, a decision-making algorithm for evidence-based decision-making in rehabilitation settings. The READ Model outlines a step-by-step layered process for healthcare professionals to collaboratively set goals, and to select appropriate interventions. The READ Model acknowledges the important multi-layered contributions of client's preferences and values, family supports available, and external environmental factors such as funding, availability of services and access. Healthcare professionals can apply the READ Model to choose interventions that are evidence-based, with an appropriate mode, dose, and with regular review, in order to achieve client's goals. Two case studies are used to demonstrate application of the READ Model: cerebral palsy and autism spectrum disorder. The READ Model applies the four central principles of evidence-based practice and can be applied across multiple rehabilitation settings.

Linking data from a large clinical trial with the Australian Cerebral Palsy Register.

AIM: To link data from a large maternal perinatal trial with the Australian Cerebral Palsy Register (ACPR) to identify children with cerebral palsy (CP). METHOD: Deidentified data from the Australasian Collaborative Trial of Magnesium Sulphate (ACTOMgSO4 ) and the ACPR were linked. Children born from 1996 to 2000 at Australian hospitals who survived and had 2-year paediatric assessments were included. Children identified with CP in: (1) both the ACTOMgSO4 (2y) and the ACPR (5y), (2) the ACTOMgSO4 only, and (3) the ACPR only were compared. RESULTS: We included 913 children (492 males, 421 females; mean gestational age at birth 27.8wks [standard deviation 2.1wks]; range 23.0-40.0wks). Eighty-four children received a CP diagnosis: 35 by the ACTOMgSO4 and the ACPR, 29 by the ACTOMgSO4 only, and 20 by the ACPR only. The ACTOMgSO4 diagnosed 76.2% (95% confidence interval [CI] 65.9-84.1) and the ACPR identified 65.5% (95% CI 54.7-74.9). Children born in states/territories with long-standing versus more recently established registers were more likely to be included on the ACPR (p<0.05). INTERPRETATION: Linking deidentified perinatal trial data with the ACPR was achieved. Limitations of both strategies for identifying children with CP in this era (late 1990s and early 2000s) probably explain many of the differences observed, and inform future linkage studies and evaluations of CP-preventive interventions. WHAT THIS PAPER ADDS: Randomized trial data were linked with the Australian Cerebral Palsy Register. Trial (2y) and register (up to 5y) diagnoses of cerebral palsy (CP) differed. States with long-standing registers were more likely to include children with CP.

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy.

PURPOSE OF REVIEW: Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019. RECENT FINDINGS: Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.

Early Diagnosis and Classification of Cerebral Palsy: An Historical Perspective and Barriers to an Early Diagnosis.

Since the 1800s, there have been calls in the literature for the early diagnosis of cerebral palsy (CP). However, diagnosis still often occurs late, from 12 to 24 months in high income countries and as late as 5 years in low resource settings. This is after the optimal timeframe for applying interventions which could harness neuroplastic potential in the developing brain. Multiple barriers exist which affect clinicians' confidence in diagnosing CP early. These range from the lack of definitive biomarkers to a lack of curative treatments for CP. Further barriers to diagnosis are proposed including; (a) difficulty finding a congruent fit with the definition of CP in an infant, where expected activity limitations might not yet be apparent; and (b) differences in the presentation of motor type and topography classifications between infants and children. These barriers may affect a clinicians' confidence using "pattern recognition" in the differential diagnosis process. One of the central tenets of this paper is that diagnosis and classification are different, involving different instruments, and are more accurately conducted separately in infants, whereas they are fundamentally interconnected in older children and inform therapeutic decisions. Furthermore, we need to be careful not to delay early diagnosis because of the low reliability of early classification, but instead uncouple these two processes. Ongoing implementation of best practice for early detection requires creative solutions which might include universal screening for CP. Implementation and accompanying knowledge translation studies are underway to decrease the average age of diagnosis in CP.