Please proceed with caution Margaret Mayston1, Lewis Rosenbloom2 1 Division of Biosciences, University College, London; 2 Alder Hey Children’s NHS Foundation Trust, Liverpool, UK. Correspondence to: [email protected] doi: 10.1111/dmcn.12403
SIR–There is no doubt that a robust evidence base is needed to underpin the management of children and adults with cerebral palsy (CP), and the recent review by Novak et al.1 aims to makes a significant contribution to that literature. We are not experts on the methodology of a systematic review, let alone a systematic review of systematic reviews which includes lower levels of evidence in lieu of a systematic review. While the authors accept the limitations of the review, we consider that some comment or response is required. Firstly, the idea of a traffic light system seems very appealing but is surely vastly over-simplistic. The changing nature of the state of the evidence, and the potential for an overreadiness to rely on this simplistic system, warrants the use of caution. Young and less experienced professionals with little experience of the literature, analysing data and interpreting reviews, and those who lack time to do so, will be attracted by this simple directive system, but does it really provide a pathway for intervention? These categorizations will surely alter as new evidence emerges thus consideration needs to be given to the future use of such a review. Despite some interventions being given the green light (only 16%), all of the interventions presented need further research to enable professionals to decide what works best for whom and at what stage of their life. This question is not addressed. Secondly, we are concerned that although the review is embedded within the International Classification of Functioning, Disability and Health,2 it does not go as far as making recommendations for intervention on the basis of age, Gross Motor Function Classification System3 level, or type of CP (e.g. spastic hypertonic, dyskinetic). Neither does this traffic light system approach seem to consider the child holistically. For example, constraint-induced movement therapy is usually recommended for people with unilateral upper limb impairments; spasticity medications are only appropriate for those with spasticity as a primary impairment and it is highly doubtful that medication alone will achieve significant effect unless some type of activity training is provided. While on the surface the method of the review seems appropriate, a wide range of interventions are included,
some are a systems approach whereas others are specific interventions and these are hardly comparable, and some are not interventions at all (e.g. hip surveillance), which further limits confidence in the proposed traffic light system. Thus our third point is that sections of the discussion reflect a lack of understanding of some interventions and here we use as an example neurodevelopmental therapy (NDT; also known as Bobath), which is given the redlight. It is interesting that NDT was even included in this review, as whole discipline reviews were excluded (exclusion criterion 5 in Novak et al.1). NDT/Bobath is usually provided by an interdisciplinary team and is a system of therapy which advocates ‘CP therapists’ not individual discipline therapists. Another difficulty for any review of NDT/Bobath is that it is not practiced and taught uniformly throughout the world, thus studies of NDT/ Bobath intervention will also differ and cannot be viewed collectively. What perplexes us is that of the 64 interventions reviewed, at least 20 are included within and are integral to the NDT/Bobath approach, such as home programmes, parent training, and dysphagia management. Many are used to complement the use of NDT/Bobath such as the use of treadmill training, orthotics, and anti-spastic medication (the Bobaths could only recommend phenol in their working life in lieu of the currently used botulinum toxin). Bobath is a clinical approach, not ‘a treatment’, which utilizes scientific knowledge as available to support its practice, and accordingly applies current theories of motor control and learning, muscle physiology, and neuroplasticity to underpin its practice, therefore it is interesting that NDT/Bobath therapists are criticized in this review for using principles of motor learning. Novak et al.1 propose that their review ‘… could form the basis of policy, educational, and knowledge translation material because it is a comprehensive summary of the evidence base’. This should stir all professionals to reflect on their practice and to continue to evaluate the available intervention options, rather than simply accepting this review as the way forwards. It should especially challenge NDT/Bobath practitioners to review their practice and teaching of the approach. Ultimately what matters is that people with CP receive the interventions that give them the best possible chance to participate in daily life. This review should be given the orange light of caution and its shortcomings discussed openly.
Letters to the Editor
395
REFERENCES 1. Novak I, McIntyre S, Morgan C, et al. A systematic
2. World Health Organization. ICF: International Classifi-
system to classify gross motor function in children
review of interventions for children with cerebral palsy:
cation of Functioning, Disability and Health. Geneva:
with cerebral palsy. Dev Med Child Neurol 1997; 39:
state of the evidence. Dev Med Child Neurol 2013; 55:
WHO, 2001.
214–23.
885–910.
3. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a
Early intervention is more than motor treatment Alfred Scherzer Stony Brook University School of Medicine – Pediatrics, Stony Brook, NY,; USA. Correspondence to: [email protected] doi: 10.1111/dmcn.12402
SIR–I applaud the novel and, indeed, Herculean review of Novak et al. in putting into perspective the current evidence for the diverse interventions currently being pursued for children with cerebral palsy (CP).1 Nevertheless, I take exception to placing early intervention into the yellow light category. Without clarifying the concept of early intervention as being much more than simply motor treatment, this categorization could reinforce the often held notion that early involvement with the child who has CP is of questionable benefit.2 It would certainly be a disservice if this highly regarded paper accentuated that notion. Early intervention for children with developmental (including motor) delays would follow as a result of possible disability identification through regular clinic surveillance or periodic screening, and confirmed with subsequent appropriate evaluation.3 It should be considered as a process with four components. These include providing (1) family education concerning the child’s prob-
lem; (2) assistance in home management, such as handling, positioning, and daily care (bathing, dressing, feeding), and the possible use of simple aids;4 (3) family support that can positively affect family relationships;5 and (4) early motor treatment. Even in situations where educational, social, treatment, and rehabilitation services are limited or nonexistent, such as in some low-and middle-income countries, components 1–3 are recognized as a basic standard of care. The authors point out that there is good quality evidence for early motor treatment of the non-CP population, but is only emerging now for children with CP. As a result, they simply place early intervention in the yellow light category without making the distinction between the current status of early motor treatment in CP and its other well established components, for example between early intervention and early motor treatment. It is my hope that in future studies of CP interventions, Novak et al. will make this distinction and give recognition to early intervention as a process which has several facets shown to be effective for children both with and without CP, irrespective of inclusion of early motor treatment as well. This is a clarification much needed in order to strengthen the place of early intervention in early care.
REFERENCES 4. Scherzer AL. Therapy is more than treatment. Pediatrics
1. Novak I, McIntyre S, Morgan C, et al. A systematic
3. American Academy of Pediatrics, Council on Children
review of interventions for children with cerebral palsy:
with Disabilities, Section on Developmental Behavioral
state of the evidence. Dev Med Child Neurol 2013; 55:
Pediatrics, Bright Futures Steering Committee, Medical
5. Bailey DB Jr, Hebbeler K, Spiker D, et al. Thirty-
885–910.
Home Initiatives for Children with Special Needs Pro-
six-month outcomes for families of children who have
2005; 115: 792.
2. Scherzer AL, Chhagan M, Kauchali S, Susser E. Global
ject Advisory Committee. Identifying infants and young
disabilities and participated in early intervention. Pediat-
perspective on early diagnosis and intervention for chil-
children with developmental disorders in the medical
rics 2005; 116: 1346–52.
dren with developmental delays and disabilities. Dev
home: an algorithm for developmental surveillance and
Med Child Neurol 2012; 54: 1078–84.
screening. Pediatrics 2006; 118: 405–20.
396 Developmental Medicine & Child Neurology 2014, 56: 390–406
SIR–There is no doubt that a robust evidence base is needed to underpin the management of children and adults with cerebral palsy (CP), and the recent review by Novak et al.1 aims to makes a significant contribution to that literature. We are not experts on the methodology of a systematic review, let alone a systematic review of systematic reviews which includes lower levels of evidence in lieu of a systematic review. While the authors accept the limitations of the review, we consider that some comment or response is required. Firstly, the idea of a traffic light system seems very appealing but is surely vastly over-simplistic. The changing nature of the state of the evidence, and the potential for an overreadiness to rely on this simplistic system, warrants the use of caution. Young and less experienced professionals with little experience of the literature, analysing data and interpreting reviews, and those who lack time to do so, will be attracted by this simple directive system, but does it really provide a pathway for intervention? These categorizations will surely alter as new evidence emerges thus consideration needs to be given to the future use of such a review. Despite some interventions being given the green light (only 16%), all of the interventions presented need further research to enable professionals to decide what works best for whom and at what stage of their life. This question is not addressed. Secondly, we are concerned that although the review is embedded within the International Classification of Functioning, Disability and Health,2 it does not go as far as making recommendations for intervention on the basis of age, Gross Motor Function Classification System3 level, or type of CP (e.g. spastic hypertonic, dyskinetic). Neither does this traffic light system approach seem to consider the child holistically. For example, constraint-induced movement therapy is usually recommended for people with unilateral upper limb impairments; spasticity medications are only appropriate for those with spasticity as a primary impairment and it is highly doubtful that medication alone will achieve significant effect unless some type of activity training is provided. While on the surface the method of the review seems appropriate, a wide range of interventions are included,
some are a systems approach whereas others are specific interventions and these are hardly comparable, and some are not interventions at all (e.g. hip surveillance), which further limits confidence in the proposed traffic light system. Thus our third point is that sections of the discussion reflect a lack of understanding of some interventions and here we use as an example neurodevelopmental therapy (NDT; also known as Bobath), which is given the redlight. It is interesting that NDT was even included in this review, as whole discipline reviews were excluded (exclusion criterion 5 in Novak et al.1). NDT/Bobath is usually provided by an interdisciplinary team and is a system of therapy which advocates ‘CP therapists’ not individual discipline therapists. Another difficulty for any review of NDT/Bobath is that it is not practiced and taught uniformly throughout the world, thus studies of NDT/ Bobath intervention will also differ and cannot be viewed collectively. What perplexes us is that of the 64 interventions reviewed, at least 20 are included within and are integral to the NDT/Bobath approach, such as home programmes, parent training, and dysphagia management. Many are used to complement the use of NDT/Bobath such as the use of treadmill training, orthotics, and anti-spastic medication (the Bobaths could only recommend phenol in their working life in lieu of the currently used botulinum toxin). Bobath is a clinical approach, not ‘a treatment’, which utilizes scientific knowledge as available to support its practice, and accordingly applies current theories of motor control and learning, muscle physiology, and neuroplasticity to underpin its practice, therefore it is interesting that NDT/Bobath therapists are criticized in this review for using principles of motor learning. Novak et al.1 propose that their review ‘… could form the basis of policy, educational, and knowledge translation material because it is a comprehensive summary of the evidence base’. This should stir all professionals to reflect on their practice and to continue to evaluate the available intervention options, rather than simply accepting this review as the way forwards. It should especially challenge NDT/Bobath practitioners to review their practice and teaching of the approach. Ultimately what matters is that people with CP receive the interventions that give them the best possible chance to participate in daily life. This review should be given the orange light of caution and its shortcomings discussed openly.
Letters to the Editor
395
REFERENCES 1. Novak I, McIntyre S, Morgan C, et al. A systematic
2. World Health Organization. ICF: International Classifi-
system to classify gross motor function in children
review of interventions for children with cerebral palsy:
cation of Functioning, Disability and Health. Geneva:
with cerebral palsy. Dev Med Child Neurol 1997; 39:
state of the evidence. Dev Med Child Neurol 2013; 55:
WHO, 2001.
214–23.
885–910.
3. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a
Early intervention is more than motor treatment Alfred Scherzer Stony Brook University School of Medicine – Pediatrics, Stony Brook, NY,; USA. Correspondence to: [email protected] doi: 10.1111/dmcn.12402
SIR–I applaud the novel and, indeed, Herculean review of Novak et al. in putting into perspective the current evidence for the diverse interventions currently being pursued for children with cerebral palsy (CP).1 Nevertheless, I take exception to placing early intervention into the yellow light category. Without clarifying the concept of early intervention as being much more than simply motor treatment, this categorization could reinforce the often held notion that early involvement with the child who has CP is of questionable benefit.2 It would certainly be a disservice if this highly regarded paper accentuated that notion. Early intervention for children with developmental (including motor) delays would follow as a result of possible disability identification through regular clinic surveillance or periodic screening, and confirmed with subsequent appropriate evaluation.3 It should be considered as a process with four components. These include providing (1) family education concerning the child’s prob-
lem; (2) assistance in home management, such as handling, positioning, and daily care (bathing, dressing, feeding), and the possible use of simple aids;4 (3) family support that can positively affect family relationships;5 and (4) early motor treatment. Even in situations where educational, social, treatment, and rehabilitation services are limited or nonexistent, such as in some low-and middle-income countries, components 1–3 are recognized as a basic standard of care. The authors point out that there is good quality evidence for early motor treatment of the non-CP population, but is only emerging now for children with CP. As a result, they simply place early intervention in the yellow light category without making the distinction between the current status of early motor treatment in CP and its other well established components, for example between early intervention and early motor treatment. It is my hope that in future studies of CP interventions, Novak et al. will make this distinction and give recognition to early intervention as a process which has several facets shown to be effective for children both with and without CP, irrespective of inclusion of early motor treatment as well. This is a clarification much needed in order to strengthen the place of early intervention in early care.
REFERENCES 4. Scherzer AL. Therapy is more than treatment. Pediatrics
1. Novak I, McIntyre S, Morgan C, et al. A systematic
3. American Academy of Pediatrics, Council on Children
review of interventions for children with cerebral palsy:
with Disabilities, Section on Developmental Behavioral
state of the evidence. Dev Med Child Neurol 2013; 55:
Pediatrics, Bright Futures Steering Committee, Medical
5. Bailey DB Jr, Hebbeler K, Spiker D, et al. Thirty-
885–910.
Home Initiatives for Children with Special Needs Pro-
six-month outcomes for families of children who have
2005; 115: 792.
2. Scherzer AL, Chhagan M, Kauchali S, Susser E. Global
ject Advisory Committee. Identifying infants and young
disabilities and participated in early intervention. Pediat-
perspective on early diagnosis and intervention for chil-
children with developmental disorders in the medical
rics 2005; 116: 1346–52.
dren with developmental delays and disabilities. Dev
home: an algorithm for developmental surveillance and
Med Child Neurol 2012; 54: 1078–84.
screening. Pediatrics 2006; 118: 405–20.
396 Developmental Medicine & Child Neurology 2014, 56: 390–406
