A Systematic Review of Common Physiotherapy

Interventions in School-Aged Children with

Cerebral Palsy
Liz Martin
Richard Baker
Adrienne Harvey
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ABSTRACT. This systematic review focused on the common conventional physio-

therapy interventions used with children with cerebral palsy (CP), aged 4 to 18 years,
and critically appraised the recent evidence of each of these interventions using the
Oxford Centre for Evidence-Based Medicine Levels of Evidence. The search strategy
yielded 34 articles after inclusion and exclusion criteria were applied. The investi-
gated physiotherapy interventions included strength and functional training, weight-
supported treadmill training (WBSTT), and neurodevelopmental treatment (NDT).
A category of treatment dosage was also included. Strength training was the most
For personal use only.

studied intervention with significant improvements found in the strength of selected

muscle groups using dynamometry, with fewer studies showing significant improve-
ment in function. Functional training showed improvements in gross motor function,
endurance, and temperospatial measures, such as gait speed and stride length. Non-
significant trends of improvement on the Gross Motor Function Measure (GMFM)
and gait velocity were found for WBSTT by a few studies with low levels of evidence
(case series). Of three studies that evaluated NDT, one high-level evidence study, i.e.,
randomized controlled trial (RCT) found significant improvements on the GMFM. All
studies reviewing treatment dosage had high levels of evidence (RCTs), yet found no
significant differences for different intensities of treatment. These results indicate that
the levels of evidence for physiotherapy interventions, particularly strengthening and
to a lesser extent functional training, in school-aged children with CP has improved;
however, further high-level evidence is needed for other interventions.

KEYWORDS. Cerebral palsy, physiotherapy interventions, school-aged children

Liz Martin, B App Sc (PT), is Physiotherapist, Yooralla, Belmore School, Balwyn, Australia.
Richard Baker, PhD, is Director, Gait CCRE, Murdoch Children’s Research Institute, Melbourne,
Australia.
Adrienne Harvey, PhD, is Physiotherapist, Hugh Williamson Gait Laboratory, Melbourne,
Australia.
Address correspondence to: Liz Martin, Physiotherapist, Yooralla, Belmore School, Stroud St.,
Balwyn, 3103, Victoria, Australia (E-mail: [email protected]).
Physical & Occupational Therapy in Pediatrics, Vol. 30(4), 2010
Available online at http://informahealthcare.com/potp

C 2010 by Informa Healthcare USA, Inc. All rights reserved.
294 doi: 10.3109/01942638.2010.500581
 Martin et al. 295

INTRODUCTION

Cerebral palsy (CP) has been defined recently as a “group of permanent disorders
of the development of posture and movement, causing activity limitations that are
attributed to non-progressive disturbances that occurred in the developing foetal or infant
brain. The motor disorders of CP are often accompanied by disturbances of sensation,
perception, cognition, communication, and behavior, by epilepsy, and by secondary
musculoskeletal problems” (Rosenbaum et al., 2007, p. 8). The physical manifestations,
both proximal and peripheral, can include altered muscle tone, impaired postural control,
and muscle synergy action. Secondary impairments can then arise, such as muscle
and joint contractures, because of altered biomechanics, muscle weakness, decreased
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exercise tolerance, and limitation of functional abilities (Barry, 1996). Children with
CP are also presenting with more complex and associated problems including visual
and hearing defects, seizures, and intellectual and communication impairments due to
survival of very low birth weight neonates (Craig, 1999). As the children transition into
adolescence and adulthood, it is necessary to minimize the secondary impairments of
CP to optimize their participation in life situations (Palisano, Snider, & Orlin, 2004).
Physiotherapy is one of the key services in the management of children with CP by
a multidisciplinary team (Craig, 1999). The general aims of physiotherapy have been
identified as increasing or improving motor skill repertoire, maintaining gross motor
functional level, and general management and minimization of contractures and defor-
mities (Hartley, 2002). Many physiotherapy approaches or interventions are directed
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at the “body functions and structures” domain of the International Classification of

Functioning, Disability and Health (World Health Organization, 2001), with the aim of
hopefully improving the activities and participation of the child. However, it is often not
known whether improvements at the impairment level actually transfer into functional
gains. Physiotherapy interventions can include more conventional treatments aimed at
the level of body structure and function or activities, such as stretching, strengthen-
ing, functional activities, and approaches, such as neurodevelopmental treatment (NDT;
Barry, 1996). Adjunct treatments to complement more conventional approaches include
hippotherapy, hydrotherapy, and electrical stimulation. Other therapies include Vojta
therapy, sensory integration, Rood, and patterning techniques.
Over the past 10–15 years, the literature on physiotherapy for children with CP has
produced increased numbers of studies on interventions including muscle strengthening,
body weight-supported treadmill training (BWSTT), and functional training. Functional
training, or task-oriented training, is consistent with modern principles of motor learning
and includes activities similar to those that are performed during daily activities, such
as climbing stairs, walking, and sit-to-stand (Salem & Godwin, 2009). Also of interest
has been the issue of optimal frequency or dosage of physiotherapy. It is important to
determine what are the most effective physiotherapy interventions so that children with
CP can receive maximum benefit. There have also been a number of reviews on different
types of interventions to provide therapists with evidence to guide clinical practice, as
well as reviews on physiotherapy in general.
Strengthening has been in focus recently, especially considering the previously held
view that strengthening techniques are detrimental to children with CP due to the risk of
increasing spasticity that has been challenged (Damiano, 2006). An earlier systematic
review of strengthening concluded that progressive resisted exercise of isolated muscle
groups increased muscle performance but the functional effects were unclear (Darrah,
Fan, Chen, Nunweiler, & Watkins, 1997). A more recent systematic review (Dodd,
 296 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

Taylor, & Damiano, 2002) showed positive effects of strengthening; however, the authors
concluded that further studies were still required. Mockford and Caulton (2008) has
most recently reviewed progressive strength training studies in ambulant children with
CP with a focus on function and gait, and found improvements, particularly in pre-
adolescents (Mockford & Caulton, 2008).
Other reviews have evaluated motor intervention programs for children with CP
(Craig, 1999; Hartley, 2002; Parkes, Donnelly, Dolk, & Hill, 2002; Siebes, Wijnroks,
& Vermeer, 2002), concluding that improvements in study design would be further
enhanced by more sensitive and applicable outcome measures specific for children with
CP. Damiano (2009) conducted a systematic review on the effectiveness of treadmill
training with and without body weight support in a variety of conditions not specific to
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CP, and showed some positive effects but insufficient evidence for this intervention.
Two reviews on physiotherapy interventions overall (not specific to one type of
intervention) have been published recently. A review of systematic reviews on the ef-
fectiveness of physiotherapy and conductive education interventions concluded that
variations in review quality limited the interpretations that could be drawn from them
(Anttila, Suoranta, Malmivaara, Makela, & Autti-Ramo, 2008b). Another review only
included randomized controlled trials (RCTs) and consequently found limited available
evidence for the effectiveness of physiotherapy because of the limited number of studies
included (Anttila, Autti-Ramo, Suoranta, Makela, & Malmivaara, 2008a). Quality of the
available evidence is obviously important when making clinical decisions for interven-
tions. A systematic review of the quality of studies of the physiotherapy management
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of childhood CP found good to fair methodological quality but improvement was still
indicated for some areas of intervention (Kunz, Autti-Ramo, Anttila, Malmivaara, &
Makela, 2006). Other systematic reviews have found increasing quality with more recent
studies (Siebes et al., 2002), yet more scientifically rigorous studies are still required to
guide clinical judgements (Anttila, Malmivaara, Kunz, Autti-Ramo, & Makela, 2006).
Although there have been systematic reviews of physiotherapy interventions pub-
lished in recent years, the current review provides novel information. It is specific
to school-aged children with CP, includes studies other than RCTs, and covers only
primary studies (not reviews). Rather than focusing on one type of intervention, this
review provides a comprehensive but broad overall review of interventions commonly
being utilized now for children with CP. “Common interventions” were defined based
on the perspectives and views of the authors drawn from their clinical expertise. The
aims of this review were to (a) review the recent evidence on the common conventional
physiotherapy interventions used with children with CP aged 4 to 18 years over the last
15 years, and (b) critically appraise the evidence of each of these interventions. The
research question was, “What recent evidence exists for the effectiveness of commonly
used physiotherapy interventions for children with CP aged 4 to 18 years?”

METHOD

Search Strategy

The following electronic databases were searched in October 2009 for the time frame
from 1995 to October 2009: MEDLINE, CINAHL, Embase, Pedro, and the Cochrane
Library. Keywords used in the initial search were cerebral palsy and physiotherapy or
physical therapy. When the terms “interventions” and “treatment” were added, the same
 Martin et al. 297

number of articles were retrieved. These keywords were then matched with Medical
Subject Headings (MeSH) index and exploded or searched as keywords, as appropriate.
Reference lists from key articles were also checked to ensure all relevant articles had
been found. Two of the authors (LM and AH) reviewed the titles and abstracts to
determine whether the studies were eligible for inclusion in this systematic review.

Inclusion Criteria

The inclusion criteria for studies were those that (a) were full text papers published
in peer reviewed journals from 1995 to October 2009; (b) studied children with CP aged
4 to 18 years inclusive; (c) focused on physiotherapy interventions considered by the
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authors to be common conventional interventions, that is, considered mainstream and

utilized widely, thus excluding adjunct or alternative interventions, such as hippotherapy
and hydrotherapy. Children younger than 4 years were not included to focus the review
on school-aged children rather than early intervention strategies.

Exclusion Criteria

Studies were excluded if they (a) focused on early intervention treatments; (b) were
published prior to 1995; (c) investigated the effects of surgical or anti-spasticity med-
ication in isolation; (c) focused primarily on upper limb treatments; (d) were purely
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descriptive or epidemiological in nature; (e) were single-case studies; (f) were ab-
stracts or conference proceedings; or (g) were studies examining adjunct and alternative
treatments.

Data Extraction and Quality Assessment

A customized data extraction form was designed specific to the research question
and was used to record all relevant information from each article. The primary areas for
data extraction were as follows: study aims; subject details and characteristics including
Gross Motor Function Classification System (GMFCS) level (Palisano et al., 1997), if
stated; recruitment and sampling of the subjects; inclusion and exclusion criteria; inter-
vention details including type, intensity, frequency, duration, and follow-up; outcome
measures used; and results including statistical analysis, clinical significance, and indi-
vidualized conclusions. The customized data extraction form included items matched
to each data extraction theme that assessed the quality of each area.
In addition, all studies were graded according to the therapy/prevention arm of
the Oxford Centre for Evidence-Based Medicine Levels of Evidence (www.cebm.net;
retrieved May 2001) (Table 1). Two independent reviewers (LM and AH) reviewed
each article separately, retrieved all appropriate information, and graded the level of
evidence. A consensus meeting was held and a third reviewer (RB) was used where any
disagreements occurred between the two primary reviewers.

RESULTS

The electronic search yielded 786 articles, of which 44 were potentially appropri-
ate for the study. When the inclusion and exclusion criteria were applied, 32 papers
 298 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

TABLE 1. Oxford Centre for Evidence-Based Medicine Levels of Evidence (May 2001)

Level Therapy/Prevention, Aetiology/Harm

1a SR (with homogeneity) of RCTs.
1b Individual RCT (with narrow confidence interval).
1c All or none.
2a SR (with homogeneity) of cohort studies.
2b Individual cohort study (including low-quality RCT, e.g., <80% follow-up).
2c “Outcomes” research; ecological studies.
3a SR (with homogeneity) of case-control studies.
3b Individual case-control study.
4 Case series (and poor quality cohort and case-control studies).
5 Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first
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principles.”
Grades of Recommendation
A Consistent level 1 studies.
B Consistent level 2 or 3 studies, or extrapolations from level 1 studies.
C Level 4 studies, or extrapolations from level 2 or 3 studies.
D Level 5 evidence.

SR: systematic review; RCT: randomized controlled/clinical trial.

were included. Targeted hand searching of key articles further retrieved two articles.
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The primary physiotherapy interventions investigated included strength, functional, and

treadmill training, and NDT, with a further group of studies exploring treatment dosage.
There were 14 RCTs, 17 case series, and three other studies including matched pairs, a
cohort study, and a within-participant design.
Table 2 summarizes the subject characteristics, including age, gender, CP classi-
fication, and the recruitment and sampling of the 34 included studies. Eleven of the
34 studies calculated or justified the power analysis for the sample size. Sampling pro-
cedure was not stated in 11 of the studies and a convenience sample was used in 12 of
the remaining studies. Recruitment was frequently from one center or organization (17
studies). Overall, inclusion and exclusion criteria were not well-defined with only nine
studies describing these fully.
Table 3 summarizes the quality and the strength of the evidence as graded by the
Oxford Centre for Evidence-Based Medicine Levels of Evidence. Table 4 summarizes
the treatment protocols, outcome measures used, and results and follow-up for each
intervention category.
Sixteen papers reviewed the effect of strength training on children with CP and
five studies focused on functional training. The strengthening studies were further
separated into subgroups of progressive-resisted strength training, isokinetic strength
training, free ankle weights/theraband exercises, circuit-based exercise programs, cy-
cling strengthening, and post-operative exercise programs. One paper was a qualitative
analysis of the benefits of strength training for young people with CP (McBurney, Tay-
lor, Dodd, & Graham, 2003). Sample sizes ranged from 7–19 subjects in the treatment
group. No increase in spasticity was found in participants undergoing strengthening
(Fowler, Ho, Nwigwe, & Dorey, 2001; Lee, Sung, & Yoo, 2007; Morton, Brownlee, &
McFadyen, 2005; Patikas et al., 2006a; Seniorou, Thompson, Harrington, & Theologis,
2007), supporting the idea that strengthening does not have an adverse effect on muscle
spasticity.
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TABLE 2. Studies on Physiotherapy Interventions in Children with Cerebral Palsy, Aged 4 to 18 Years.

Sample Size Power Inclusion Age Gender

Study Study Type Control Analysis Sampling Recruitment Exclusion (Years) M:F CP Classification

Strengthening
Dodd (2003) RCT Rx: 11 Y Random allocation 1 hospital Stated Rx: 12.7 10:11 I: 7, II: 5, III: 9
C: 10 Stated C: 13.5
(8–18)
Engsberg (2006) RCT 12 N Random NS Detailed 9.7 ± 3 3:9 I: 5, II: 5, III: 2
C: 3 Minimal
Lee (2007) RCT Rx: 9 Y Random allocation 1 outpatient Stated 6.3 ± 2.1 10:7 D: 9, H: 8
clinic
C: 7 Stated (4–12)
Liao (2007) RCT Rx: 10 Y Stratified 7 centers Minimal 5–12 12:8 I: 10, II: 10
randomization
C: 10 Stated
Patikas (2006a) RCT Rx: 19 Y Random 1 hospital Minimal 6–16 27:12 I: 12, II: 18, III: 9
C: 20 Minimal SD: all
Patikas (2006b) RCT Rx: 19 N Random allocation 1 hospital Minimal 9.7 ± 2.8 NS All SD
C: 20 Minimal (6–16)
Seniorou (2007) RCT Rx1: 11 N Random allocation NS Minimal 12.5 ± 2.5 10:10 I: 3, II: 13, III: 4
Rx2: 9 Minimal (7–16)
Fowler (2001) Cohort Rx: 24 N Purposive 1 hospital & Detailed 11.5 NS SD: all
referrals
C: 12(ND) NS (7–17)
Damiano (1998) Case series 11 Y Convenience Rehab center, at Stated 8.81 NS D: 6, H: 5
hospital
N NS (6–12)
Damiano (1995a) Case series 14 N Convenience 1 rehab center NS 9.1 ± 2.5 10:4 SD: all
N Minimal (6–14)
Damiano (1995b) Case series 14 N NS NS Minimal 9.1 ± 2.5 10:4 SD: all
C: 25 (ND) Minimal (6–14)
Eagleton (2004) Case series 7 N NS NS Stated 12–20 NS NS
N Minimal
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299
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TABLE 2. Studies on Physiotherapy Interventions in Children with Cerebral Palsy, Aged 4 to 18 Years. (Continued)

300
Sample Size Power Inclusion Age Gender
Study Study Type Control Analysis Sampling Recruitment Exclusion (Years) M:F CP Classification

McBurney (2003) Case series 11 N NS From another Minimal 12.8 ± 2.8 4:7 I: 2, II: 2, III: 7
study
N NS (8–18)
McPhail (1995) Case series 17 N NS NS Stated NS 15.8 ± 3 7:10 SD: 7, SH: 9, SQ: 1
N
Morton (2005) Case series 8 N Convenience 2 special schools Stated 8.5 4:4 III: all
N Stated (6.1–11.2)
Williams (2007) Case series 11 Y NS 1 special school Stated 12.6 ± 1.3 1:10 SD: 1, SQ: 10
N Minimal (11–15)
Functional Training
Crompton (2007) RCT Rx: 16 Y Convenience NS Minimal 10.6 ± 2.2 6:9 I: 12, II: 12, III: 1
C: 7 Stated (6–14)
Ketelaar (2001) RCT Rx: 28 N Stratified From pediatric Stated 2–7 33:22 SD: 11, SH: 32,
randomization centers SQ: 12
C: 27 NS
Salem (2009) RCT 5 N Convenience Advertising in Stated 6.53 6:4 D: 8, Q: 2, I: 2, II: 6,
the area III: 2
5 Stated (4.9–10.2)
Blundell (2003) Case series 8 N Convenience 1 school Minimal 6.3 ± 1.3 7:1 SD: 7, SQ: 1
N Minimal (4–8)
Gorter (2009) Case series 13 N Convenience 1 special school Stated 9.9 ± 1.15 8:5 I: 12, II: 1
N Stated (8–13)
Treadmill Training
Dodd (2007) Matched 7 Y Convenience 2 schools Stated 9 10:4 III: 4, IV: 10
pairs
C: 7 Stated (5–18)
Begnoche (2007) Case series 5 N Convenience 1 outpatient NS 2.3–9.7 4:1 D: 4, Q: 1, I: 2, III:
clinic 1, IV: 2
N NS
Cherng (2007) Within 8 N NS NS Stated 3.5–6.3 6:2 II: 2, III: 6
participant
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N Minimal
Phillips (2007) Case series 6 N NS Rehab centers Stated 10.5 4:2 I: all. H: 4, D: 2
N Stated (6–14)
Provost (2007) Case series 6 N NS 1 hospital & Stated 6–14 4:2 I: all, H: 4, D: 2
referrals
N Stated
Schindl (2000) Case series 10 N NS 1 outpatient Stated 11.5 4:6 D: 3, Q: 4,
clinic Q(ataxic): 3
N Stated (6–18)
Neurodevelopmental Treatment
Tsorlakis (2004) RCT Rx: 17 Y Stratified 1 organization Detailed 7.3 ± 3.5 22:12 I: 10, II: 10, III: 14
randomization
C: 17 NS (3–14) D: 12, H: 10, Q: 12
Knox (2002) Case series 15 N Convenience 3 centers Stated 7.3 ± 2.8 9:6 I: 1, II: 4, III: 5, IV:
4, V: 1
N N (2–12)
Adams (2002) Case series 40 N Convenience 1 organization Minimal 6 18:22 D: 18, H: 11, T: 3
N NS (2.6–10.2) At: 5, Ath: 3
Treatment Dosage
Bower (1996) RCT 4 groups of 11 Y Stratified 14 health Minimal 3–11 NS Q: all
each randomization districts
NS
Bower (2001) RCT 4 groups of 13, Y Stratified 33 health Minimal 3–12 31:25 III: 17, IV: 29, V: 10
15, 15, 13 randomization districts
NS
Christiansen (2008) RCT Intermittent: 10 N Stratified 1 rehab center Minimal 3.2 16:9 NS
randomization
Continuous: 14 Stated (1–9)
Steinbok (2002) RCT 28 N NS NS Stated 3–7 NS NS
C: 14 NS

RCT: randomized controlled/clinical trial; Y: yes; N: no; Rx: treatment; C: control; NS: not stated; M: male; F: female; CP: cerebral palsy; (S)D: (spastic) diplegia; (S)H: (spastic) hemiplegia;
(S)Q: (spastic) quadriplegia; (R)Q: (rigid) quadriplegia; I, II, III, IV, V: GMFCS levels; At: ataxic; Ath: athetoid; Rehab: rehabilitation.

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TABLE 3. Quality and Level of Evidence

Oxford
Study Design Additional Information EBMLE

Strengthening
Dodd (2003) RCT No CIs. Measured “combined extensor” 2b
strength
Engsberg (2006) Small RCT 4 groups of 3 participants 2b
Lee (2007) RCT 2b
Liao (2007) RCT Narrow CIs 1b
Patikas (2006a) RCT Wide variation in surgical procedures 1b
Patikas ((2006b) RCT 1b
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Seniorou (2007) RCT 2 different treatments assessed 2b

Fowler (2001) Cohort Control of TD children 4
Damiano (1998) Case series No blinding of assessors 4
Damiano (1995a) Case series Sample limited to mild CP only 4
Damiano (1995b) Case series Control of TD children 4
Eagleton (2004) Case series Equipment failure in 5/7 participants 4
McBurney (2003) Case series Qualitative, not statistical, analysis used 4
McPhail (1995) Case series 4
Morton (2005) Case series Partial blinding of assessors 4
Williams (2007) Case series No blinding of assessors. Did not measure 4
strength directly
Functional Training
Crompton (2007) RCT 2b
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Ketelaar (2001) RCT High initial GMFM & PEDI may not have 2b
detected changes
Salem (2009) RCT Small group sizes 2b
Blundell (2003) Case series No blinding of assessors 4
Gorter (2009) Case series Blinding of assessors not stated 4
Treadmil Training
Dodd (2007) Matched pairs No blinding of assessors 2b
Begnoche (2007) Case series No blinding of assessors 4
Cherng (2007) Within participant Statistical test used not stated. Large SDs 4
Phillips (2007) Case series No statistical analysis b/c small sample 4
Provost (2007) Case series 4
Schindl (2000) Case series Small group sizes 4
Neurodevelopmental
Treatment
Tsorlakis (2004) RCT 2b
Knox (2002) Case series No blinding of assessors 4
Adams (2002) Case series No blinding of assessors. Large SDs 4
Treatment Dosage
Bower (1996) RCT 2b
Bower (2001) RCT 2b
Christiansen (2008) RCT Actual treatment techniques used not 2b
stated
Steinbok (2002) RCT Minimal background information 2b

EBMLE: Evidence-Based Medicine Levels of Evidence; RCT: randomized controlled/clinical trial; GMFM: Gross Motor
Function Measure; PEDI: Pediatric Evaluation of Disability Inventory; Rx: treatment; TD: typically developing; SD:
standard deviation; CIs: confidence intervals.
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TABLE 4. Outcome Measures, Results, and Follow-up

Outcome on Completion Significant

Outcomes at Level of
Study Intervention GMFM Dyn TSP End. EE Spast. Other Follow-up (wks) Evidence

Strengthening
Dodd (2003) PRST loaded backpack; 3 × 8–10 ↑ ↑↑ ↑ Dyn (12) 2b
reps, 3×/wk for 6 wks
Engsberg (2006) PRST Isokinetic: ankle; 3 × 5 ↑↑ ↑↑ ↔ ↓↓ ↑↑ Peds QL No follow-up 2b
reps, 3×/wk for 12 wks
Lee (2007) Free weights; 1 hr, 3×/wk for 5 ↑↑ ↑↑ ↑↑ ↔ Dyn, TSP (6) 2b
wks
Liao (2007) PRST loaded sit to stand; 3× ↑↑ ‡ ‡ ↓↓ No follow-up 1b
8–10 reps, 3×/wk for 6 wks
Patikas ((2006a) Post-op resisted ex; 30–45 min, ↑↑C ‡ ↓↓ No follow-up 1b
3–4×/wk for 38 wks
Patikas (2006b) Post-op resisted ex; 30–45 min, ↑† ↑† ↔ ↓↓ TSP (111) 1b
3×/wk for 40 wks
Seniorou (2007) Post-op PRST or active ex; 3 × ↑↑† ↑↑R ↑↑R TSP (52) 2b
10 reps, 3×/wk for 6 wks
Fowler (2001) Knee isokinetic, isotonic, ↔ No follow-up 4
isometric: 5 reps each ex in 1
session
Damiano (1998) PRST free weights: hip, knee, ↑↑ ↑↑ ↑↑ ↔ No follow-up 4
ankle; 4 × 5 reps, 3×/wk for 6
wks
Damiano (1995a) PRST free weights: knee: 4 × 5 ↑↑ ↑↑ No follow-up 4
reps, 3×/wk for 6 wks
Damiano (1995b) PRST free weights: knee; 4 × ↑ ↔ No follow-up 4
5reps, 3×/wk for 6 wks
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304
TABLE 4. Outcome Measures, Results, and Follow-up (Continued)

Outcome on Completion Significant

Outcomes at Level of
Study Intervention GMFM Dyn TSP End. EE Spast. Other Follow-up (wks) Evidence

Eagleton (2004) Free weights: hip, knee, ankle; ↑↑ ↑↑ ↓↓ No follow-up 4

40–60 min, 3×/wk for 6 wks
McBurney (2003) Qualitative analysis of PRST ∗ No follow-up 4
McPhail (1995) Isokinetic: knee; 3 × 5 reps, ↑↑ ↑↑ ↔ ↔ ↔ GMFM, Dyn (13) 4
3×/wk for 8 wks
Morton (2005) PRST free weights: knee; 3–4 × ↑↑ ↑↑ ↑↑ ↔ GMFM, Dyn (4) 4
5 reps, 3×/wk for 6 wks
Williams (2007) Static cycling: 30 min, 3×/wk for 6 ↑↑ GMFM (12) 4
wks
Functional Training
Crompton (2007) Circuit exercises; 1 hr, 2×/wk for ↔ ↑ ‡ ‡ Nil (6) 2b
6 wks
Ketelaar (2001) Repetitive practice; 45 min, ↑↑† No follow-up 2b
2–3×/month, for up to78 wks
Salem (2009) Circuit exercises; 2×/week for 5 ↑↑ ↓↓TUG No follow-up 2b
wks
Blundell (2003) Circuit exercises; 1 hr, 2 × wk for ↑↑ ↑↑ Dyn, TSP (8) 4
4wks
Gorter (2009) Group circuit & aerobic exercises; ↑↑ ↑↑ ↑↑ TUD, ↓ End, TUD (11) 4
30 min, 2×/week for 9 weeeks MoVra
Treadmill Training
Dodd (2007) PBWS; 30 min, 2 × day, 6×/wk ↑↑ ↑ No follow-up 2b
for 6 wks
Begnoche (2007) PBWS; 30 min, 2 × day, 6×/wk ↑ ↑↑ No follow-up 4
for 4 wks
Cherng (2007) PBWS; 30 min, 2 × day, 6×/wk ↑↑ ↑↑ ↔ Nil (12) 4
for 12 wks
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Phillips (2007) PBWS; 3 ×10 min, 2 × day, ↑ ↑ No follow-up 4

6×/wk for 2 wks
Provost (2007) PBWS; 30 min, 2 × day, 6×/wk ↑ ↑↑ ↑ ↑↑ No follow-up 4
for 2 wks
Schindl (2000) PBWS; 30 min, 2 × day, 6×/wk ↑↑ No follow-up 4
for 13 wks
Neurodevelopmental
Treatment
Tsorlakis (2004) Individualized Rx, 50 min, 2 or ↑↑ No follow-up 2b
5×/wk for 16 wks
Knox (2002) Individualized Rx, 75 min, 3×/wk ↑↑ ↑↑PEDI GMFM, PEDI (6) 4
for 6 wks
Adams (2002) Individualized Rx, 60 min, 2×/wk ↑↑ No follow-up 4
for 6 wks
Treatment Dosage
Bower (1996) Intensive Rx vs. routine Rx ‡ No follow-up 2b
Bower (2001) Intensive Rx vs. routine Rx ‡ Nil (26) 2b
Christiansen (2008) Intermittent Rx vs. continuous Rx, ‡ No follow-up 2b
45 min, 0–4×/wk for 30 wks
Steinbok (2002) Intensive vs. no pre-op Rx, 60 ‡ Nil (52–104) 2b
min, 2–3×/wk for 39 wks

PRST: progressive resisted strength training;GMFM: Gross Motor Function Measure; Dyn: dynamometry; TSP: temporal-spatial parameters; End: endurance; EE: energy expenditure;
Spast: spasticity; ↑↑: significant increase in value; ↑: increase in value but not significant; ↓↓: significant decrease in value; ↓: decrease in value but not significant; ↔: no change in
value; ‡: no difference b/n groups; †: both groups; R: resisted group; C: control group; No symbol: outcome measure not used; PEDI: Pediatric Evaluation of Disability Inventory; TUD:
Timed up and down stairs; TUG: timed up and go test; PedsQL: Pediatric Quality of life Inventory; ∗: interviews rated as positive by subjects (7.9/10) & by parents (8.9/10); wk: week;
Rx: treatment; MoVra: ambulation questionnaire.

305
 306 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

Strengthening

The most frequent outcome measures used in the strengthening studies were the
GMFM and dynamometry. Improvements were seen primarily in the strength of selected
muscle groups on dynamometry with some improvements seen on GMFM (including
both trends toward significant effects and statistically significant findings). There were
three strength training studies rated as level 1b evidence, four were rated as level
2b evidence, and nine were rated as level 4 evidence (case series). The three studies
examining strengthening following multilevel surgery were level 2b studies or higher
and all showed improvements in both treatment and control groups with no significant
differences in strength between the groups (Patikas et al., 2006a, 2006b; Seniorou
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et al., 2007). Follow-up occurred over a wide range of time with improvement being
sustained in six out of seven studies on at least one outcome measure. Therefore, some
improvements in muscle strength and function were sustained at follow-up (Dodd,
Taylor, & Graham, 2003; Lee et al., 2007; McPhail & Kramer, 1995; Morton et al.,
2005; Patikas et al., 2006b), indicating that subjects may have included the benefits of
the strengthening programs into their daily routines.

Functional Training

The five studies examining the functional training included three level 2b and two
For personal use only.

level 4 studies. Significant differences were noted on GMFM dimensions D and E in

two of the higher level studies (Ketelaar, Vermeer, Hart, van Petegem-van Beek, &
Helders, 2001; Salem & Godwin, 2009), while the level 2b study found no difference
between groups (Crompton et al., 2007). Significant improvement in Timed Up and Go
(TUG) time was also reported (Salem & Godwin, 2009). One level 2b study analyzed
the effect of the age of the child on functional training and found the greatest effect with
younger school-aged children (Ketelaar et al., 2001). The two level 4 studies found sig-
nificant improvements in gait temperospatial measures, dynamometry, and endurance
following functional training (Blundell, Shepherd, Dean, & Adams, 2003; Gorter,
2009).

Body Weight-Supported Treadmill Training (BWSTT)

Six papers examined the use of BWSTT as a form of physiotherapy intervention

and all except one (Dodd & Foley, 2007) were level 4 studies. In all studies, a harness
system was used resulting in partial body weight support with varying treatment times.
All sample sizes were small ranging from 5 to 14 subjects. The most frequent outcome
measures used were gait parameters, such as velocity, and the GMFM. Although GMFM
showed significant improvement in two studies (Cherng, Liu, Lau, & Hong, 2007;
Schindl, Forstner, Kern, & Hesse, 2000) and nonsignificant improvement in another two
studies (Begnoche & Pitetti, 2007; Provost et al., 2007), these studies had low levels of
evidence. Velocity had a significant improvement in two studies (Provost et al., 2007;
Schindl et al., 2000) and nonsignificant improvement in another study (Phillips et al.,
2007). Follow-up was reported in only one study (Cherng et al., 2007) at 12 weeks post-
intervention, which showed regression of the immediate improvement in the GMFM
and gait. Despite the studies with lower levels of evidence finding improvements, the
 Martin et al. 307

only study with a higher level of evidence (level 2b) (Dodd & Foley, 2007) found
nonsignificant changes.

Neurodevelopmental Therapy (NDT)

The three papers evaluating NDT had sample sizes ranging from 15–40. Two studies
showed significant improvements on the GMFM (Knox & Evans, 2002; Tsorlakis,
Evaggelinou, Grouios, & Tsorbatzoudis, 2004). Only one of these had a high level of
evidence (level 2b), finding that both intensities of NDT (two or five times per week,
for 16 weeks) improved GMFM, with more improvement found for the more intense
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treatment group (Tsorlakis et al., 2004). The other study with a low level of evidence had
a follow-up of 6 weeks post-intervention and found maintenance of the improvements
on the GMFM and Pediatric Evaluation of Disability Inventory (PEDI) (Knox & Evans,
2002).

Treatment Dosage

In the treatment dosage category for general physiotherapy, two papers compared an
undefined routine versus an intermittent (1 hr per day, 5 days per week for 2 weeks)
treatment protocol (Bower, McLellan, Arney, & Campbell, 1996; Bower, Michell, Bur-
nett, Campbell, & McClellan, 2001). One study compared intermittent (three cycles of
For personal use only.

four times per week for 4 weeks followed by a 6-week break) and continuous (one to
two times per week for 30 weeks) treatment programs (Christiansen & Lange, 2008).
The fourth study compared the effect of intensive physiotherapy preoperatively with
no preoperative physiotherapy (Steinbok & McLeod, 2002). All studies had high lev-
els of evidence (level 2b); however, no significant differences were found for different
intensities of treatment in any study.
Overall, there were 15 studies, of level 2b or higher. Despite this body of evidence
containing a number of case series (level 4 evidence), there were also a number of
studies with higher levels of evidence.

DISCUSSION

This review found an increase in the number of studies on physiotherapy interventions

published in recent years with an increase of RCTs performed, as compared to the case
series, as has been more frequently reported in the past. This provides us with stronger
evidence to support clinical decision-making. Stronger evidence was particularly evident
in the areas of strength and functional training. The results from the studies on treadmill
training need to be interpreted with caution because five out of six studies had low levels
of evidence. With only three studies on NDT, it is difficult to make strong conclusions
on the evidence of its effectiveness. There was a higher level of evidence for treatment
dosage, yet overall there were no significant differences in intensity found in the studies.
Conducting the research with children with CP presents with many challenges, partic-
ularly because of the heterogenous nature of the condition. Common confounders were
found across many of the studies. One was the continuation of the subject’s “usual”
therapy and/or extra-curricular activities. Details of what this consisted of were often
not provided. Another common limitation was the small sample size and lack of power
 308 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

analyses in many of the studies (15 had group sizes of 10 or less and only eight studies
completed power of analysis). Follow-up to determine persisting effects of the inter-
ventions occurred only in a small number of studies. Lack of details in the studies was
another complicating factor. This was especially apparent in subject recruitment and
sampling procedures, and to a lesser extent for the inclusion and exclusion criteria. Also
common was the lack of blinding of assessors.
Most of the treadmill intervention studies lacked standardization and objective meas-
urement of the amount of body weight supported by the harness system, the amount of
external assistance given by assistants, treadmill velocity, and treadmill familiarization.
The NDT studies consisted of individualized treatments, at times in conjunction with
goal-directed therapy sessions, making comparison and interpretation of results more
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difficult. Therapist skill level confounded one study (Adams, Chandler, & Schuhmann,
2000) that was conducted during the NDT training course. It was difficult to compare
results for the studies evaluating treatment dosage because the treatments used were
not stated and the treatment intensity, frequency, and duration varied widely between
studies.

Clinical Significance

This review found that the strongest evidence for the effectiveness of strengthening
interventions is for individual muscle groups with some improvements in GMFM and
For personal use only.

function (Dodd et al., 2003; Lee et al., 2007; McPhail & Kramer, 1995; Morton et al.,
2005). A carryover into activities and gait parameters was not found; however, this may
be a result of the relatively short treatment periods in the studies. Most studies included
children classified in the GMFCS levels I–III, thus limiting the applicability of these
results to these groups of children. The effectiveness of strengthening in levels IV and V
has not been detailed. Strengthening had the greatest effect with more severely impaired
children in one study (GMFCS level III) (Lee et al., 2007) and in two studies, those
with diplegia had greater improvement compared to those with hemiplegia (Damiano
& Abel, 1998; McPhail & Kramer, 1995). A possible explanation is that children with
hemiplegic CP are able to use their non-affected side to achieve goals both before and
after interventions, thus the effects are not so evident (Damiano & Abel, 1998). It is also
possible that some outcome measures have a ceiling effect and are not sensitive enough
to detect changes in function for those children who already function at a high level.
Another recent review on progressive strength training in ambulatory children with
CP found similar results as to ours with mixed results for gait and functional parameters
(Mockford & Caulton, 2008). This review focused primarily on gait and functional
parameters and used a different method for assessing the quality of the studies. Over-
all strengthening in children with CP can be considered a safe and effective way to
strengthen individual muscle groups for children in GMFCS levels I–III and positively
influence function; however, the benefits on gait and mobility are less clear.
The studies on functional training showed improvements in both function and gait
parameters. There is some higher level evidence of functional training associated with
improvements at the activity and participation levels and not just at the impairment level
of the child. These studies also involved children in GMFCS levels I–III, and primarily
those in levels I–II. The results can therefore be generalized to this population. Other
benefits were also found from strengthening and functional training. Group training was
found to be a feasible, beneficial, and an enjoyable way to participate in strengthening
 Martin et al. 309

programs (Crompton et al., 2007; Gorter, 2009), whereas home exercise programs were
found to be a cost-effective method of strengthening and utilizing simple equipment
(Dodd et al., 2003; Liao, Liu, Liu, & Lin, 2007; McBurney et al., 2003; Patikas et al.,
2006a). There have been no systematic reviews on functional training to date.
The treadmill training studies generally had low levels of evidence with mixed results
and the only high-level study found nonsignificant changes. The lack of evidence thus
far for this treatment is disappointing because it has the potential to be a valuable form
of endurance exercise for children with a range of severity of CP. A recent systematic
review of the effectiveness of treadmill training and body weight support also came to
the conclusion that more large-scale controlled trials are needed to support its use in
populations other than Down Syndrome before practice guidelines can be formulated
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(Damiano, 2009). That was the broader review than the current review because it
included all pediatric motor disabilities and treadmill training, both with and without
body weight support. Our review was focused on BWSTT in children with CP. Until
further studies provide stronger evidence, treadmill training is not supported by research
studies as an effective method of treatment in children with CP.
There is inconclusive evidence to support NDT as an effective treatment for children
with CP, based on recent studies in this review with only one higher level study providing
evidence of improvement in gross motor function for both intensities of NDT, but
with greater effect for the more intensive program. The studies specifically looking at
dosage of general physiotherapy demonstrated no significant difference in outcome with
differing intensity, frequency, and duration of treatment. Within these studies, it was
For personal use only.

unclear as to what the treatments consisted of and these tended to use a combination
of treatment techniques. More research into effective dosage (including frequency,
intensity, and timing) of specific physiotherapy interventions is clearly required.
A limitation of this review is that it did not cover all physiotherapy treatments,
but focused on a number of conventional interventions. A common technique used by
physiotherapists not included was stretching, because the search did not find any recent
original study on stretching. There has been a recently published review on stretching
(Pin, Dyke, & Chan, 2006) but no recent original study. Another limitation is that the
inclusion and exclusion criteria were focused and precise, and may have excluded some
studies and interventions used by physiotherapists. There is the possibility that some
key articles may have been omitted from this review.
The strength of this review is that rather than focusing on one type of intervention,
it covers a range of interventions that have been used and are emerging as common
interventions in children with CP. It is different than other general reviews in that it
includes all studies other than just RCTs (Anttila et al., 2008a) and covers primary
studies rather than reviewing other reviews (Anttila et al., 2008b). It therefore gives a
good overall picture of the state of the evidence of currently used interventions.

CONCLUSION

This systematic review identified published studies of common physiotherapy inter-

ventions used in school-aged children with CP and critically appraised the evidence for
them. The evidence for strengthening the targeting muscle groups is strong, and there
is emerging evidence supporting the functional training. More high-level evidences are
required for treadmill training, NDT, and effective dosage of physiotherapy. Despite
 310 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

advances in the number and quality of studies in recent years, there is still a need to
improve the methodological quality with higher levels of evidence in many areas.

ACKNOWLEDGMENT

This paper was presented at the International Society for Prosthetics and Orthotics
(ISPO) Consensus meeting, Oxford, UK, September 2008.

Declaration of interest: The authors report no conflict of interest. The authors alone
are responsible for the content and writing of this paper.
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