Terapia Neurodesenvolvimental na Paralisia Cerebral

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Neurodevelopmental Therapy for
Cerebral Palsy: A Meta-analysis
Anna te Velde, BAppSc (Phty) Hons,a,b Catherine Morgan, BAppSc (Phty), PhD,a Megan Finch-Edmondson, BSc (Hons), PhD,a
Lynda McNamara, BPhty Hons,b Maria McNamara, BAppPsych, MPsych, PhD,a Madison Claire Badawy Paton,
BSc (Hons), PhD,a Emma Stanton, BHlthSc/MOT,a Annabel Webb, MRes (Stat),a Nadia Badawi,
MBBCh, DCH, MSc, PhD, FRCPI, FRACP,a,c Iona Novak, BAppSc, MSc Hons, PhD a,d
abstractBACKGROUND 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 5 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.
aCerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia;
bSpecialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia; cGrace Centre for Newborn Intensive Care,
Sydney Children’s Hospital Network, The University of Sydney, Westmead, NSW, Australia; and dFaculty of Medicine & Health, The University of Sydney, Sydney, NSW, Australia
Ms te Velde conceptualized and designed the study, completed searches, extracted data, conducted analyses, prepared data visualization, and drafted and
revised the manuscript; Dr Morgan conceptualized and designed the study, extracted data, oversaw analyses, and drafted, critically reviewed, and revised the
manuscript; Dr Finch-Edmondson supported searching, extracted data, prepared data visualization, and critically reviewed and revised the manuscript; Ms
McNamara, Dr McNamara, and Ms Stanton extracted data and critically reviewed and revised the manuscript; Dr Paton extracted data, prepared data
visualization, critically reviewed and revised the manuscript; Ms Webb supported formal analysis and critically reviewed and revised the manuscript; Prof.
Badawi critically reviewed and revised the manuscript; Prof. Novak conceptualized and designed the study, extracted data, oversaw analyses, prepared data
visualization, drafted, critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable
for all aspects of the work.
DOI: https://doi.org/10.1542/peds.2021-055061
Accepted for publication Mar 16, 2022
To cite: te Velde A, Morgan C, Finch-EdmondsonM, et al. Neurodevelopmental Therapy for Cerebral Palsy: A Meta-analysis. Pediatrics. 2022;149(6):e2021055061
PEDIATRICS Volume 149, number 6, Month 2022:e2021055061 REVIEW ARTICLE
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https://doi.org/10.1542/peds.2021-055061
Bobath, or neurodevelopmental
therapy (NDT),1 is often described as
“usual care” in neurorehabilitation
despite evidence that more effective
alternatives for improving motor
function in cerebral palsy (CP) exist.
A consensus clinical framework1,2
outlines 3 primary principles of NDT,
which are (1) movement analysis of
task performance, (2) interdependence
of posture and movement, and (3) the
role of sensory information in motor
control.1,3 In practice, the elements of
NDT are (1) therapist-controlled
facilitation of movement via handling to
provide optimal sensory input to
improve postural control1,3 and (2)
training movement quality to normalize
motor patterns, currently termed
regaining “typical motor behavior” and
minimizing “atypical motor behavior.”1
This involves training movement
quality rather than using compensatory
or atypical strategies to complete a
task,1 which is discouraged in NDT.
NDT has many highly cited
publications,4 a testament to global
uptake. NDT has a strong following
among some practitioners
internationally. Use of NDT varies;
for example, 39% to 81% of
clinicians in the United Kingdom,5
13% to 18%6 up to 60%7 in Canada,
7% to 54% in Norway,8 8% to 33%
in Australia,9 3% of clinicians in
1 US hospital,10 and it is the
standard of care in Korea.11
NDT has evolved considerably since
its introduction,12 although this is
not the case globally. In many
settings, other contemporary
approaches have been incorporated
under the NDT banner. Theoretical
underpinnings of NDT have been
redefined to align with
contemporary approaches moving
from the traditional hierarchical
model to a systems-based model of
motor control.1 Aspects of NDT in
clinical practice have been altered in
response to evidence but practice is
eclectic.12,13
A paradigm shift started in the
1990s14 away from “bottom-up”
rehabilitation approaches, in which
a therapist generates and facilitates
normal movement patterns, as is
seen in NDT, to “top-down”
approaches in which the child sets
goals and self-generates movements
to actively practice and learn real-
life tasks14,15 incorporating natural
opportunities to learn.16 Top-down
approaches are based on activity-
dependent neuroplasticity
mechanisms,15 different from
bottom-up mechanisms. Training to
improve impairments (eg, high tone,
retained reflexes) and preparing the
body for normal movement as a
bottom-up approach17 has been
replaced with training to improve a
child’s activities and participation
through learning, a top-down
approach as conceptualized in the
International Classification of
Function, Disability and, Children
and Youth Version (ICF-CY).18
Numerous systematic reviews have
evaluated the effectiveness of NDT
compared with an array of
alternatives revealing no benefits of
increased NDT dose,19 marginal
benefits of NDT and casting over
regular occupational therapy,20 and
inconclusive findings for NDT versus
physiotherapy in CP.21 Variability of
NDT,1,12 insufficient evidence, and
underdosed studies are posed as
barriers to testing efficacy of NDT.
In the past decade, 2 systematic
reviews of systematic reviews
recommended ceasing NDT for
children with CP to improve motor
function, contracture, and self-care
skills because effective top-down
alternatives exist.22,23 With earlier
diagnosis24 being standard of care
in many countries, a shift toward
early interventions that harness
neuroplasticity based on infant self-
generated movements is occurring.
A recent clinical guideline has a
strong recommendation against
passive, therapist-controlled
handling techniques for skill
development during infancy,25 the
critical time of brain development.
However, NDT, which is ineffective,is still used with infants.7,11 Despite
advances in neuroscience and
knowledge of effective interventions,
NDT remains widely used in
infants and children with CP.
Limited meta-analyses assessing
the efficacy of NDT are available.
Thus, there is a case for a broad-
ranging review.
OBJECTIVES
Our objective was to determine the
efficacy of NDT for any outcome in
children and infants with CP and
infants with a high risk of CP.
We hypothesized that (1) NDT is no
more effective in improving
outcomes in children and infants
with CP than no intervention or
passive approaches (hereby termed
“control”), (2) NDT is less effective
than activity-based approaches to
improve motor function, (3) NDT is
less effective than body function and
structures-based approaches for
body function and structures
outcomes, (4) NDT is less effective
than environment-based approaches
on environment-based outcomes, (5)
higher-dose NDT is no more
effective than lower-dose NDT, and
(6) NDT is not effective for
improving motor function in infants
with CP or risks for CP.
METHODS
A systematic review and meta-
analysis was conducted by using
Cochrane methodology26 and
reported by using the Preferred
Reporting Items for Systematic
Reviews and Meta-Analyses
statement.27
Inclusion criteria using population,
intervention, comparison, and
outcome were (1) CP or high risk of
CP based on diagnostic risk markers
consistent with the era and >75%
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of participants <18 years, (2)
intervention specified as Bobath,
NDT, neurodevelopmental therapy,
or “treatment,” (3) any comparison,
(4) any outcome, (5) randomized
controlled trial (RCT), and (6)
published in English. No limits were
placed on outcomes or date of
publication. Exclusion criteria were
(1) NDT versus NDT plus adjunct
therapy (2) intervention not
described as Bobath, NDT,
neurodevelopmental therapy or
treatment, (3) comparison of NDT at
equal total dosage hours, but
different frequencies, and (4) gray
literature and conference abstracts.
Search terms are presented in
Supplemental Table 2.
Cumulative Index to Nursing &
Allied Health Literature, Cochrane
Library, Embase, and Medline
databases were searched to March
10, 2021, with no lower date range.
Studies were screened for eligibility
by title and abstract by the first
author and checked by 2 reviewers.
Hand searching included the
scanning of reference lists of all
identified systematic reviews. Study
characteristic extraction was divided
between the authors and checked by
the first author. Study quality was
assessed at a domain level by using
Cochrane Risk of Bias tool 2
(RoB-2)28 by 2 independent raters
(divided between authors) and
discrepancies were resolved by a
third independent rater.
Coding for synthesis and meta-
analysis was decided by group
consensus. The International
Classification of Function, Disability
and Health, Children and Youth
Version18 was used to code
comparison interventions into
activity, body structures and
function, and environmental-based
groups. Additional comparators
considered were NDT versus
control, higher- versus lower-dose
NDT, and NDT versus any
intervention in infants. Active
(child-generated and -controlled)
and passive (therapist-generated
and -controlled) components
of NDT and comparator
interventions were extracted. Motor
function was defined as motor
development and the acquisition of
motor skills.29
Inclusion criteria for meta-analysis
included (1) 2 or more studies
revealing similar outcomes,
(2) mean and standard deviation
outcome score and participant
number could be extracted or
calculated, (3) comparable outcome
timeframe (long-term versus short-
term), and (4) sufficient
homogeneity of participants,
interventions and outcomes to
provide a meaningful summary.26
Meta-analysis exclusion criteria
were (1) no common outcome and
for dose comparator only (2) both
groups of NDT <30 hours dosage to
exclude underdosed studies. This
dosage threshold was based on
evidence suggesting 30 to 40 hours
of activity-based interventions are
required to improve motor
function.20,30
Meta-analyses were conducted by
using Review Manager 5.4.1.
Estimates of effect were assessed by
using the standardized mean
difference between comparison
groups of posttest or change scores,
with change scores preferentially
used in meta-analyses. Effect size
was considered small (0.2),
moderate (0.5), large (0.8) and very
large (1.3).31 Random effects were
used because of the varied nature of
outcome measures with 95%
confidence intervals (CI) for
certainty and I2 for heterogeneity.
Sensitivity analysis using fixed
effects was also conducted. Clinically
relevant subgroup analyses were
conducted.
When mean and standard deviation
were not available in text or from
other systematic reviews, where
possible, missing values were
calculated by using REVMan using
other variables. PlotDigitizer
(version 2.6.9) was used to extract
data from figures. If data were not
retrievable using these methods,
studies were excluded from the
meta-analysis. If meta-analyses had
considerable heterogeneity
(I2 >75%)26 subanalyses were
conducted to determine the
heterogeneity source. Risk of
publication bias was assessed by (1)
visually inspecting funnel plots of
each comparator meta-analysis for
symmetry and (2) if >10 papers
were included in a meta-analysis;
Egger’s test was used to assess
potential publication bias.
Additionally, RoB-2 tool Domain 5
was used to assess reporting bias
risk. The quality and strength of
recommendations were further
evaluated by using Grading of
Recommendations Assessment,
Development and Evaluation
(GRADE).32 A protocol was not
prepared.
RESULTS
In total, 667 studies were screened
and 35 studies met inclusion criteria
with 2 studies33,34 written about a
single cohort (Fig 1). Studies
included 1332 participants (n 5 578
infants <2 years, n 5 754 children
$2 years). Of these, 21 studies
(including 667 participants) met
inclusion for meta-analysis (Fig 1).27
Participants varied in terms of
motor severity, motor type,
and topography, reflecting
known heterogeneity of children
with CP.
Risk of Bias
Of 35 studies included, 114,35–44
were assessed as low risk of bias,
1014,33,34,45–51 were assessed as
having some concerns, and 1452–65
were assessed as high risk of bias.
Domain level and overall risk of bias
for studies are presented in Fig 2
and Supplemental Figs 4 and 5.
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Results of Individual Studies
Results of all studies are reported in
Table 1. Of 35 studies, 6 of 35
(17%) favored NDT, 2 of 35 (6%)
partially favored NDT, and 27 of 35
(77%) did not favor NDT (Table 1).
Of 6 reports that favored NDT, 4
were assessed as high risk of bias.
Active and passive components of
interventions are described in Table 1.
Motor function was the most
common reported outcome (n 5 28
studies)4,14,34–39,41–44,46,49–52,54–63,65
followed by general development
(n 5 4),34,50–52 reflex status
(n 5 4),55,57–59 cognition
(n 5 3),41,57,62 social development
(n 5 3),41,50,60 mobility/walking
capacity (n 5 3),14,39,40 quality
of upper limb movement
(n 5 2),35,44 muscle length
(n 5 2),55,56 strength (n 5 2),46,47
tone/spasticity (n 5 2),58,59
mechanical efficiency (n 5 2),36,38
sitting function (n 5 2),48,61 and
self-care (n 5 2).49,60
Synthesis of Results
NDT Versus Control
We identified 9 studies (in 10
publications)33–35,45,52–57comprising 418 participants
(Table 1) that compared NDT
against a control. Controls consisted
of no therapy (6 studies in
FIGURE 1
Results of search strategy in PRISMA27 flowchart. aTwo studies reporting on single group.33,34 NDT, neurodevelopmental therapy; RCT, randomized controlled trial.
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FIGURE 2
Meta-analyses showing pooled effect size of NDT versus comparator interventions on motor outcomes. Left-hand panel: (A) NDT versus control, (B) NDT ver-
sus activity-based approaches, outlier excluded, (C) NDT versus body function and structures-based approaches, (D) NDT higher dose versus NDT lower
dose. aAnalysis based on post-test scores. bAnalysis based on change scores. Right-hand panel: Studies stratified by overall risk of bias using Cochrane Risk
68 TE VELDE et al
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7 publications)33,34,45,53,55–57 or
passive movement approaches with
no child self-generated movements
(n 5 3).35,52,54 In total, 6 publications
did not meet inclusion for meta-
analysis for the following reasons:
(1) data not extractable
(n 5 4),53,55–57 (2) no common
outcome (n 5 1),45 and (3) outcome
timeframe not comparable (n 5 1).33
Four publications34,35,52,54 (n 5 138
participants), 2 of which had high risk
of bias,52,54 met inclusion criteria for
meta-analysis for motor function
outcome (Fig 2A). No difference was
found between NDT and control for
motor function with a pooled effect
size of 0.13 (95% CI 5
�0.20 to 0.46), I2 5 0%.
NDT Versus Activity-Based Approaches
We identified 9 studies14,37–41,48,49,61
comprising 307 participants
(Table 1) for NDT versus activity-
based approaches. In total,
8 studies14,37–41,48,49 comprising
255 participants met inclusion for
meta-analysis for motor function
outcomes. A moderate pooled effect
size of 0.76 (0.12 to 1.40), I2 5 80%
was observed, favoring activity-
based approaches for motor
function (Fig 2B). One outlier61 was
excluded from meta-analysis
because the intervention was
primarily activity-based but used
facilitation techniques. A meta-
analysis with this outlier included
is available in Supplemental Fig 4A.
On subanalysis to account for het-
erogeneity, when studies with
norm-referenced outcome meas-
ures14,41,49 were excluded, both
heterogeneity and pooled effect size
decreased (0.42 [�0.08 to 0.93], I2
5 36%) favoring activity-based
interventions (Supplemental
Fig 4B).
Subanalysis of 2 studies37,39 (n 5 38
participants) that tested upper limb
interventions and were analyzed for
upper limb motor outcomes
revealed activity-based approaches
improved upper limb motor function
over NDT with a large, pooled effect
of 0.83 (0.16 to 1.50) I2 5 0%
(Supplemental Fig 4C). However,
there was no difference of effect for
lower limb interventions for lower
limb motor function outcomes from
4 studies14,38–40 (n 5 165 partici-
pants, outlier61 excluded), with a
pooled effect of 0.68 (�0.18 to
1.54), I2 5 82% (Supplemental
Fig 4D). No change in results were
seen when norm-referenced out-
come measures14,39 were excluded
accounting for heterogeneity in
lower limb motor function (0.03
[�0.39 to 0.46],
I2 5 0%) (Supplemental Fig 4E). All
studies were rated low risk of bias
or some concerns, except for the
outlier61 which was assessed as high
risk of bias.
NDT Versus Body Function and Struc-
tures-Based Approaches
We identified 7 studies36,46,47,58–60,65
with 175 participants (Table 1) that
tested NDT versus body function
and structures-based approaches.
Only 1 study60 did not meet
inclusion criteria for any meta-
analyses in this comparator because
data were not extractable. Motor
function was the most common
outcome reported. In total, 5
studies36,46,58,59,65 met inclusion for
a motor function outcome meta-
analysis, with a moderate pooled
effect size of 0.77 (0.19 to 1.35), I2
5 61% favoring body function and
structures approaches (Fig 2C).
Other outcomes were muscle
strength, muscle tone, and primitive
reflex status. In total,
2 studies were combined for
strength outcomes46,47 with no
effect found (0.02 [�0.56 to 0.61])
(Supplemental Fig 4F). In addition,
n 5 2 studies,58,59 which tested the
neurofacilitation of developmental
reaction (NFDR) approach, were
combined and analyzed for effect on
muscle tone and primitive reflex sta-
tus. NFDR was favored for improv-
ing muscle tone outcomes (0.97
[0.43 to 1.51]) (Supplemental
Fig 4G); however, no effect was
found for primitive reflex status
(0.35 [�0.16 to 0.86])
(Supplemental Fig 4H). Notably,
both these studies58,59 were
assessed as high risk of bias.
NDT Versus Environmental-Based
Approaches
We identified 2 studies62,63
comprising 47 participants who
were all infants that compared NDT
to environmental-based approaches.
One study63 partially favored NDT
over a nonspecific handling
intervention and 1 study62 favored a
parent coaching model over NDT.
Comparison interventions of studies,
parent coaching, and passive
handling were not similar enough
for meaningful meta-analysis.
Additionally, both studies had a high
risk of bias.
NDT Higher Dose Versus Lower Dose
We identified 7 studies4,42–44,50,51,64
with 385 participants that compared
2 doses of NDT. In total,
3 studies4,44,51 met inclusion for
meta-analysis for motor function
outcomes. Average low dose was
35 (standard deviation 5 3) hours
versus 90 (36) hours high dose.
Reasons for exclusion from meta-
analysis included (1) data not
of Bias-2 tool. Risk of Bias Domains: (A) bias arising from the randomization process; (B) bias due to deviations from intended interventions; (C) bias due to
missing outcome data; (D) bias in measurement of the outcome; (E) bias in selection of the reported result, and (F) overall risk of bias. cCriterion-refer-
enced outcome measure. dNorm-referenced outcome measure AHA, Assisting Hand Assessment; BMS, Bayley Motor Development Scale CI, confidence inter-
val; DDST, Denver Developmental Screening Test; DHI, Duruoz Hand Index; GMFM, Gross Motor Function Measure; IV, inverse variance; NDT,
Neurodevelopmental Therapy; PEDI, Pediatric Evaluation of Disability Inventory; SD, standard deviation.
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r
de
sc
ri
pt
io
n
of
fu
nc
tio
na
l
pr
og
ra
m
Se
lf-
ca
re
tr
ai
ni
ng
do
es
no
t
ta
rg
et
m
ov
em
en
t
Im
pr
ov
ed
m
ot
or
(d
ev
el
op
m
en
t
ag
e
ca
lc
ul
at
ed
us
in
g
co
m
bi
na
tio
n
of
DD
ST
an
d
BM
S)
fa
vo
ri
ng
ND
T
Ye
s
2
d'
Av
ig
no
n
19
81
53
RC
T 3
gr
ou
ps
1
5
ND
T
2
5
Vo
jta
3
5
Co
nt
ro
l
Un
cl
ea
r
le
ng
th
of
ef
fe
ct
m
ea
su
re
d
30
CP
2–
6
y
M
ild
–
Se
ve
re
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
Dy
sk
in
et
ic
At
ax
ic
ND
T Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Vo
jta
Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Co
nt
ro
l
“L
es
s
st
ri
ct
ly
pe
rf
or
m
ed
ph
ys
io
th
er
ap
y”
Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ra
te
s
of
“u
nc
om
pl
ic
at
ed
CP
”
an
d
no
rm
al
de
ve
lo
pm
en
t
Un
cl
ea
r
No
ba
se
lin
e
eq
ui
va
le
nc
e
of
ri
sk
fa
ct
or
s
fo
r
CP
,n
o
be
tw
ee
n
gr
ou
p
an
al
ys
is
Di
ffe
re
nt
in
te
rv
en
tio
n
do
se
fo
r
in
fa
nt
s
w
ith
CP
an
d
no
rm
al
ou
tc
om
e
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
ra
te
s
of
“u
nc
om
pl
ic
at
ed
”
CP
be
tw
ee
n
Vo
jta
,N
DT
&
co
nt
ro
l
gr
ou
ps
No
70 TE VELDE et al
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on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
3a
,b
an
d
4b
Go
od
m
an
19
85
34
Ro
th
be
rg
19
91
c.
33
RC
T 4
gr
ou
ps
,
in
cl
ud
in
g
2
gr
ou
ps
ap
pr
op
ri
at
e
fo
r
cu
rr
en
t
qu
es
tio
n
1
5
At
-r
is
k
w
ith
ND
T
2
5
At
-r
is
k
no
th
er
ap
y
Im
m
ed
ia
te
33
&
lo
ng
-te
rm
ef
fe
ct
(5
y
po
st
in
te
rv
en
tio
n)
32
80
At
ri
sk
fo
r
CP
Ve
ry
lo
w
bi
rt
h
w
t
34
w
k
GA
<
17
00
g
bi
rt
h
w
t
ND
T Pa
ss
iv
e:
ha
nd
lin
g,
no
rm
al
i
za
tio
n
of
m
ov
em
en
t
Ac
tiv
e:
ni
l
Co
nt
ro
l
No
th
er
ap
y
Gr
iffi
th
s
2
De
ve
lo
pm
en
t
Qu
ot
ie
nt
su
bs
ca
le
s
[g
en
er
al
de
ve
lo
pm
en
t,
in
cl
ud
in
g
m
ot
or
fu
nc
tio
n]
9h
ND
T
[i
nt
en
si
ty
45
m
in
,
fr
eq
ue
nc
y
1/
m
o,
du
ra
tio
n
52
w
k
1
da
ily
ho
m
e
pr
og
ra
m
]
Lo
w
do
se
Hi
gh
dr
op
ou
t
ra
te
Ho
m
e
pr
og
ra
m
do
se
no
t
re
po
rt
ed
Al
te
rn
at
e
no
t
ra
nd
om
as
si
gn
m
en
t
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
im
pr
ov
in
g
de
ve
lo
pm
en
t
on
th
e
Gr
iffi
th
s,
in
cl
ud
in
g
lo
co
m
ot
io
n
fo
r
im
m
ed
ia
te
or
lo
ng
-te
rm
ou
tc
om
es
No
5a
La
ba
f
20
15
54
RC
T 2
gr
ou
ps
1
5
ND
T
2
5
Ho
m
e
pr
og
ra
m
Im
m
ed
ia
te
ef
fe
ct
28
CP
2–
6
y
Se
ve
ri
ty
no
t
lis
te
d
Sp
as
tic
[d
ip
le
gi
a,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
st
re
tc
hi
ng
,
re
du
ct
io
n
of
sp
as
tic
ity
,
fa
ci
lit
at
io
n
Ac
tiv
e:
si
tt
in
g
on
a
ch
ai
r,
w
al
ki
ng
Ho
m
e
Pr
og
ra
m
Pa
ss
iv
e:
st
re
tc
hi
ng
,
pa
ss
iv
e
ra
ng
e
of
m
ot
io
n
Ac
tiv
e:
ac
tiv
e
ra
ng
e
of
m
ot
io
n
GM
FM
-8
8
[g
ro
ss
m
ot
or
fu
nc
tio
n]
36
h [i
nt
en
si
ty
1h
,
fr
eq
ue
nc
y
3/
w
k,
du
ra
tio
n
12
w
k]
M
ul
tip
le
in
de
pe
nd
en
t
t
te
st
s
co
nd
uc
te
d
of
GM
FM
-8
8
do
m
ai
ns
Po
ss
ib
le
re
po
rt
in
g
er
ro
r
on
GM
FM
-8
8
Im
pr
ov
ed
la
yi
ng
,
ro
lli
ng
&
si
tt
in
g
di
m
en
si
on
s
on
GM
FM
fa
vo
ri
ng
ND
T
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
w
al
ki
ng
,
ru
nn
in
g,
ju
m
pi
ng
di
m
en
si
on
s
on
GM
FM
Pa
rt
ia
lly
6a
La
w
19
97
35
RC
T 2
gr
ou
ps
w
ith
cr
os
s
ov
er
1
5
Ca
st
in
g
1
in
te
ns
iv
e
ND
T
2
5
Re
gu
la
r
OT Im
m
ed
ia
te
&
lo
ng
-te
rm
(2
m
o)
ef
fe
ct
50
CP
1.
5–
4
y
M
od
er
at
e
to
se
ve
re
up
pe
r
ex
tr
em
ity
in
vo
lv
em
en
t
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
(w
ith
up
pe
r
lim
b
in
vo
lv
em
en
t)
,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
fa
ci
lit
at
io
n
&
ha
nd
lin
g
Ac
tiv
e:
ni
l
Re
gu
la
r
OT
Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n,
ta
sk
an
al
ys
is
w
as
us
ed
bu
t
Pe
ab
od
y
Fi
ne
M
ot
or
Sc
al
es
[fi
ne
m
ot
or
fu
nc
tio
n]
QU
ES
T
[q
ua
lit
y
of
up
pe
r
ex
tr
em
ity
m
ov
em
en
t]
CO
PM
[p
ar
en
t
pe
rc
ep
tio
n
of
ha
nd
fu
nc
tio
n]
80
h
ND
T
[i
nt
en
si
ty
45
m
in
,
fr
eq
ue
nc
y
2/
w
k,
du
ra
tio
n
16
w
k
1
30
m
in
/d
ho
m
e
pr
og
ra
m
]
12
h
OT
[i
nt
en
si
ty
45
m
in
,
Cr
os
so
ve
r
de
si
gn
lim
its
po
w
er
.
Po
or
de
sc
ri
pt
io
n
of
re
gu
la
r
OT
in
te
rv
en
tio
n
Va
st
do
se
di
ffe
re
nt
ia
l
fa
vo
ri
ng
ND
T
bu
t
no
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
on
an
y
m
ea
su
re
No
PEDIATRICS Volume 149, number 6, Month 2022 71
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by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
th
e
tr
ea
tm
en
t
ap
pr
oa
ch
is
no
t
de
sc
ri
be
d
fr
eq
ue
nc
y
1/
w
k,
du
ra
tio
n
16
w
k]
7b
Pi
pe
r
19
86
57
RC
T 2
gr
ou
ps
1
5
ND
T
2
5
No
th
er
ap
y
Im
m
ed
ia
te
ef
fe
ct
13
4
At
-r
is
k
fo
r
CP
NI
CU
gr
ad
ua
te
s
(<
15
00
g
bi
rt
h
w
t,
as
ph
yx
ia
,
se
iz
ur
es
,C
NS
dy
sf
un
ct
io
n
w
ith
ab
no
rm
al
EE
G)
25
–
41
w
k
GA
ND
T Pa
ss
iv
e:
ha
nd
lin
g,
fa
ci
lit
at
io
n
&
ex
er
ci
se
s
(n
ot
de
fi
ne
d)
1
pa
re
nt
co
ac
hi
ng
in
ha
nd
lin
g
Ac
tiv
e:
ni
l
Co
nt
ro
l
No
th
er
ap
y
W
ol
an
sk
i
Gr
os
s
M
ot
or
Ev
al
ua
tio
n
M
ila
ni
-
Co
m
pa
re
tt
i
M
ot
or
De
ve
lo
pm
en
t
Te
st
[m
ot
or
fu
nc
tio
n]
Gr
iffi
th
s
M
en
ta
l
De
ve
lo
pm
en
t
Sc
al
e
[c
og
ni
tio
n]
W
ils
on
De
ve
lo
pm
en
ta
l
Re
fl
ex
Pr
ofi
le
[r
efl
ex
st
at
us
]
30
h
ND
T
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
1/
w
k,
du
ra
tio
n
12
w
k
1
in
te
ns
ity
1h
,
fr
eq
ue
nc
y
0.
5×
/w
k,
du
ra
tio
n
36
w
k]
Ri
sk
fo
r
CP
no
t
cl
ea
rl
y
de
fi
ne
d
bo
th
gr
ou
ps
,
i.e
.i
nf
an
ts
m
ay
ha
ve
be
en
on
a
tr
aj
ec
to
ry
to
no
rm
al
ou
tc
om
e
an
d
no
t
ne
ed
ed
tr
ea
tm
en
t
Va
st
do
se
di
ffe
re
nt
ia
l
fa
vo
ri
ng
ND
T
bu
t
no
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r:
m
ot
or
fu
nc
tio
n
on
W
ol
an
sk
i
Gr
os
s
M
ot
or
&
M
ila
ni
-
Co
m
pa
re
tt
i
M
ot
or
De
ve
lo
pm
en
t
Te
st
Ov
er
al
l
de
ve
lo
pm
en
t
on
Gr
iffi
th
or
ne
ur
ol
og
ic
st
at
us
on
W
ils
on
De
ve
lo
pm
en
ta
l
Re
fl
ex
Pr
ofi
le
No
8
Ro
th
m
an
19
78
45
RC
T 2
gr
ou
ps
1
5
ND
T
re
sp
ir
at
or
y
ex
er
ci
se
s
2
5
No
th
er
ap
y
Im
m
ed
ia
te
ef
fe
ct
10
CP
5–
8
y
GM
FC
S
I&
II
(a
m
bu
la
nt
w
ith
ou
t
as
si
st
iv
e
de
vi
ce
s)Sp
as
tic
[d
ip
le
gi
a]
ND
T Pa
ss
iv
e:
ni
l
Ac
tiv
e:
di
ap
hr
ag
m
at
ic
br
ea
th
in
g,
ex
pi
ra
to
ry
ac
tiv
ity
w
ith
ta
rg
et
s,
in
sp
ir
at
io
n
&
ex
pa
ns
io
n,
ab
do
m
in
al
st
re
ng
th
en
in
g
ex
er
ci
se
s
Co
nt
ro
l
No
th
er
ap
y
M
ea
n
vi
ta
l
ca
pa
ci
ty
1-
s
fo
rc
ed
ex
pi
ra
to
ry
vo
l
[r
es
pi
ra
to
ry
fu
nc
tio
n]
6h
ND
T
[i
nt
en
si
ty
5–
7
m
in
,
fr
eq
ue
nc
y
7/
w
k,
du
ra
tio
n
8
ks
]
Sm
al
l
sa
m
pl
e
No
te
:a
ll
th
e
ex
er
ci
se
s
in
th
is
ND
T
pr
og
ra
m
w
er
e
ch
ild
ac
tiv
e,
no
pa
ss
iv
e
el
em
en
ts
Im
pr
ov
ed
vi
ta
l
ca
pa
ci
ty
on
sp
ir
om
et
ry
fa
vo
ri
ng
ND
T
Ye
s
9
So
m
m
er
fe
ld
19
81
55
RC
T 3
gr
ou
ps
1
5
ND
T
di
re
ct
2
5
ND
T
su
pe
rv
is
ed
3
5
No
19
CP
In
te
lle
ct
ua
l
di
sa
bi
lit
y
3–
22
y
M
ild
–
Se
ve
re
Sp
as
tic
ND
T
Di
re
ct
Pa
ss
iv
e:
in
hi
bi
tio
n
of
re
fl
ex
es
,
fa
ci
lit
at
io
n,
no
rm
al
iz
at
io
n
W
ils
on De
ve
lo
pm
en
ta
l
Re
fl
ex
Te
st
[r
efl
ex
st
at
us
]
W
ay
ne
Co
un
ty
In
te
rm
ed
ia
te
Un
kn
ow
n
Du
ra
tio
n
no
t
st
at
ed
pr
ec
lu
di
ng
ca
lc
ul
at
io
n
ND
T
di
re
ct
Pr
ob
ab
ly
un
de
rp
ow
er
ed
,
no
sa
m
pl
e
si
ze
ca
lc
ul
at
io
ns
M
ot
or
ou
tc
om
e
m
ea
su
re
no
t
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
im
pr
ov
in
g
gr
os
s
m
ot
or
sk
ill
s
on
W
CI
SD
Gr
os
s
M
ot
or
Ev
al
ua
tio
n
No
72 TE VELDE et al
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
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TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
th
er
ap
y
Un
ab
le
to
de
te
rm
in
e
lik
el
y
im
m
ed
ia
te
ef
fe
ct
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
At
he
to
id
[D
ys
ki
ne
tic
]
At
ax
ic
of
to
ne
,r
an
ge
of
m
ot
io
n
an
d
po
si
tio
ni
ng
Ac
tiv
e:
ni
l
ND
T
Su
pe
rv
is
ed
Pa
ss
iv
e:
in
hi
bi
tio
n
of
re
fl
ex
es
,
fa
ci
lit
at
io
n,
no
rm
al
iz
at
io
n
of
to
ne
,r
an
ge
of
m
ot
io
n
&
po
si
tio
ni
ng
Ac
tiv
e:
ni
l
Sc
ho
ol
Di
st
ri
ct
's
(W
CI
SD
)
Gr
os
s
M
ot
or
Ev
al
ua
tio
n
[g
ro
ss
m
ot
or
fu
nc
tio
n]
Ra
ng
e
of
M
ot
io
n
Sc
al
e
[m
us
cl
e
le
ng
th
]
[i
nt
en
si
ty
30
m
in
,
fr
eq
ue
nc
y
2×
/w
k]
ND
T
Su
pe
rv
is
ed
[i
nt
en
si
ty
2
h,
fr
eq
ue
nc
y
5×
/w
k]
re
lia
bl
e
or
st
an
da
rd
iz
ed
fo
r
ND
T
in
ei
th
er
fo
rm
at
co
m
pa
re
d
w
ith
no
th
er
ap
y
10
W
ri
gh
t
19
73
56
RC
T 3
gr
ou
ps
1
5
ND
T
lo
ng
du
ra
tio
n
2
5
ND
T
sh
or
t
du
ra
tio
n
3
5
No
th
er
ap
y
Im
m
ed
ia
te
ef
fe
ct
47
CP
1–
6
y
Se
ve
ri
ty
di
ffi
cu
lt
to
de
te
rm
in
e
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
no
rm
al
iz
ed
to
ne
,
no
rm
al
iz
ed
m
ov
em
en
t
Ac
tiv
e:
ni
l
M
ot
or
fu
nc
tio
n
as
se
ss
m
en
t8
3
In
cl
ud
ed
(a
)
fu
nc
tio
n,
(b
)
ra
ng
e
of
m
ov
em
en
t
an
d
(c
)
th
e
pr
es
en
ce
or
ab
se
nc
e
of
th
e
pr
im
ar
y
au
to
m
at
ic
re
fl
ex
es
[m
ot
or
fu
nc
tio
n]
Pa
ss
iv
e
ra
ng
e
of
m
ot
io
n
[m
us
cl
e
le
ng
th
]
Do
se
un
ab
le
to
be ca
lc
ul
at
ed
Lo
ng
du
ra
tio
n
12
m
o
Sh
or
t
du
ra
tio
n
6
m
o
Ra
tio
of
th
er
ap
y
by
gr
ou
ps
2:
1:
0
fa
vo
ri
ng
ND
T
Hi
gh
dr
op
ou
t
ra
te
Sm
al
l
sa
m
pl
e
si
ze
M
ot
or
ou
tc
om
e
m
ea
su
re
no
t
re
lia
bl
e
or
st
an
da
rd
iz
ed
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
m
ot
or
fu
nc
tio
n
be
tw
ee
n
ND
T
lo
ng
an
d
sh
or
t
du
ra
tio
n
an
d
no
th
er
ap
y
gr
ou
ps
No
ch
an
ge
in
pa
ss
iv
e
ra
ng
e
of
m
ov
em
en
t
be
tw
ee
n
ND
T
lo
ng
an
d
sh
or
t
du
ra
tio
n
an
d
no
th
er
ap
y
gr
ou
ps
No
ND
T
vs
Ac
tiv
ity
-B
as
ed
Ap
pr
oa
ch
es
11
a
Al
-O
ra
ib
i
20
11
37
RC
T 2
gr
ou
ps
1
5
CI
M
T
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
20
CP
3–
5
y
Se
ve
ri
ty
no
t
lis
te
d
Sp
as
tic
[h
em
ip
le
gi
a]
CI
M
T Pa
ss
iv
e:
ni
l
Ac
tiv
e:
m
an
ip
ul
at
io
n
ta
sk
-s
pe
ci
fi
c
pr
ac
tic
e,
w
ith
in
cr
em
en
te
d
ch
al
le
ng
e.
Pa
re
nt
ed
uc
at
io
n
fo
r
ho
m
e
pr
ac
tic
e
at
ho
m
e
w
hi
le
w
ea
ri
ng
co
ns
tr
ai
nt
AH
A
[h
an
d
fu
nc
tio
n]
11
2
h
CI
M
T
[i
nt
en
si
ty
2
h,
fr
eq
ue
nc
y
7×
/w
k,
du
ra
tio
n
8
w
k]
16
h
ND
T
[i
nt
en
si
ty
2
h,
fr
eq
ue
nc
y
1×
/w
k,
du
ra
tio
n
8
w
k]
In
te
rv
en
tio
ns
no
t
do
se
m
at
ch
ed
Hi
gh
dr
op
ou
ts
(r
ea
so
ns
ac
co
un
te
d
fo
r)
CI
M
T
gr
ou
p
sl
ig
ht
ly
yo
un
ge
r
Di
ffe
re
nc
e
in
ba
se
lin
e
AH
A
sc
or
es
Gr
ou
p
ef
fe
ct
fo
r
im
pr
ov
in
g
ha
nd
fu
nc
tio
n
on
AH
A
fa
vo
ri
ng
CI
M
T
No
PEDIATRICS Volume 149, number 6, Month 2022 73
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
ND
T
Pa
ss
iv
e:
w
ei
gh
tb
ea
ri
ng
an
d
fa
ci
lit
at
io
n
of
ar
m
m
ov
em
en
t.
Ac
tiv
e:
ni
l
12
a
Ba
r-
Ha
im
20
10
38
RC
T 2
gr
ou
ps
1
5
M
ot
or
le
ar
ni
ng
co
ac
hi
ng
2
5
ND
T
Im
m
ed
ia
te
&
lo
ng
-te
rm
ef
fe
ct
78
CP
6–
12
y
GM
FC
S
II-
III
Sp
as
tic
[d
ip
le
gi
a,
qu
ad
ri
pl
eg
ia
]
M
ix
ed
ty
pe
M
ot
or
Le
ar
ni
ng
Pa
ss
iv
e:
ni
l
Ac
tiv
e:
ch
ild
-s
et
go
al
s,
pr
ac
tic
e
of
re
al
-li
fe
go
al
ta
sk
s,
fe
ed
ba
ck
on pe
rf
or
m
an
ce
,
va
ri
ab
ili
ty
ND
T
Pa
ss
iv
e:
st
re
tc
hi
ng
,
no
rm
al
iz
in
g
to
ne
,
fa
ci
lit
at
io
n
of
m
ov
em
en
t
Ac
tiv
e:
w
al
ki
ng
,
si
t-t
o-
st
an
d
GM
FM
-6
6
[g
ro
ss
m
ot
or
fu
nc
tio
n]
M
ec
ha
ni
ca
l
ef
fi
ci
en
cy
du
ri
ng
st
ai
r
cl
im
bi
ng
Qu
an
tit
at
iv
e
ph
ys
io
lo
gi
c
m
ea
su
re
of
co
or
di
na
tio
n
[c
oo
rd
in
at
io
n]
36
h [i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
3×
/w
k,
du
ra
tio
n
12
w
k]
Lo
w
do
se
Sm
al
l
sa
m
pl
e
si
ze
La
ck
of
co
nc
ea
le
d
al
lo
ca
tio
n
Im
pr
ov
ed
gr
os
s
m
ot
or
fu
nc
tio
n
on
th
e
GM
FM
-6
6
fa
vo
ri
ng
th
e
m
ot
or
le
ar
ni
ng
gr
ou
p
No
13
a
Bl
ey
en
he
uf
t
20
15
39
RC
T 2
gr
ou
ps
1
5
HA
BI
T-
IL
E
2
5
ND
T
(d
el
ay
ed
HA
BI
T-
IL
E)
Im
m
ed
ia
te
ef
fe
ct
24
CP
6–
13
y
GM
FC
S
I-I
I,
M
in
iM
AC
S
I-I
II
Sp
as
tic
[h
em
ip
le
gi
a]
HA
BI
T-
IL
E
Pa
ss
iv
e:
ni
l
Ac
tiv
e:
gr
ad
ed
bi
m
an
ua
l
an
d
gr
os
s
m
ot
or
fu
nc
tio
na
l
ta
sk
tr
ai
ni
ng
,a
ct
iv
e
tr
ai
ni
ng
of
po
st
ur
e
co
nt
ro
l
in
si
tt
in
g
an
d
st
an
di
ng
,c
hi
ld
an
d
pa
re
nt
se
t
go
al
s,
ch
ild
pr
ob
le
m
so
lv
in
g,
re
pe
tit
iv
e
up
pe
r
lim
b
Pr
im
ar
y
AH
A
[h
an
d
fu
nc
tio
n]
6M
W
T
[w
al
ki
ng
ca
pa
ci
ty
]
M
ul
tip
le
se
co
nd
ar
y
ou
tc
om
e
m
ea
su
re
s
90
h [i
nt
en
si
ty
9
h,
fr
eq
ue
nc
y
da
ily
,
du
ra
tio
n
10
d]
80
h
(a
ve
ra
ge
)
co
nv
en
tio
na
l
th
er
ap
y
[i
nt
en
si
ty
1–
5
h/
w
k,
fr
eq
ue
nc
y
un
ab
le
to
de
te
rm
in
e,
du
ra
tio
n
20
w
k]
Di
ffe
re
nc
e
in
do
se
fa
vo
ri
ng
HA
BI
T-
IL
E
(8
0h
v
90
h
av
er
ag
e)
,b
ut
re
as
on
s
fo
r
lo
w
er
do
se
ac
co
un
te
d
fo
r
Be
tw
ee
n
gr
ou
p
di
ffe
re
nc
e
fo
r
ha
nd
fu
nc
tio
n
(A
HA
)
an
d
w
al
ki
ng
(6
M
W
D)
fa
vo
ri
ng
HA
BI
T-
IL
E.
No
74 TE VELDE et al
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
red]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
m
ov
em
en
ts
ND
T
Pa
ss
iv
e:
re
m
ed
ia
tio
n
of
im
pa
ir
m
en
ts
,
co
rr
ec
tin
g
m
ov
em
en
t
pa
tt
er
ns
.
Ac
tiv
e:
fu
nc
tio
na
l
tr
ai
ni
ng
us
in
g
no
nm
ot
or
tr
ai
ni
ng
pr
in
ci
pl
es
14
a
Ch
oi
20
11
48
RC
T 2
gr
ou
ps
1
5
Ta
sk
-
or
ie
nt
ed
si
tt
in
g
ba
la
nc
e
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
10
CP
2–
9
y
Se
ve
ri
ty
no
t
lis
te
d
Sp
as
tic
[d
ip
le
gi
a]
Ta
sk
-O
ri
en
te
d
Tr
ai
ni
ng
Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n:
st
re
tc
hi
ng
of
pe
lv
is
,
in
hi
bi
tio
n
of
hi
gh
to
ne
,
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
lis
te
d
as
m
ot
or
tr
ai
ni
ng
ap
pr
oa
ch
:
st
re
ng
th
tr
ai
ni
ng
tr
un
k
an
d
lo
w
er
lim
b,
ta
sk
pr
ac
tic
e
si
tt
in
g,
st
an
di
ng
,a
ct
iv
e
ba
la
nc
e
on
a
ba
ll.
ND
T
Pa
ss
iv
e:
no
de
sc
ri
pt
io
n
GM
FM
si
tt
in
g
di
m
en
si
on
[s
itt
in
g
fu
nc
tio
n]
El
ec
tr
o
m
yo
gr
ap
hy
(E
M
G)
[r
ec
tu
s
ab
do
m
in
us
an
d
er
ec
to
r
sp
in
ae
m
us
cl
e
ac
tiv
ity
]
15
h Ta
sk
-o
ri
en
te
d
ap
pr
oa
ch
[in
te
ns
ity
30
m
,
fre
qu
en
cy
5/
w
k,
du
ra
tio
n
6
w
k]
ND
T:
no
do
se
de
sc
rip
tio
n
Un
cl
ea
r
de
sc
ri
pt
io
n
bo
th
in
te
rv
en
tio
ns
.
No
ca
lc
ul
at
io
n
to
ju
st
ify
sm
al
l
sa
m
pl
e
si
ze
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
im
pr
ov
in
g
GM
FM
si
tt
in
g
su
b
sc
al
e
or
m
us
cl
e
ac
tiv
ity
on
EM
G.
No
PEDIATRICS Volume 149, number 6, Month 2022 75
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by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
Ac
tiv
e:
no
de
sc
ri
pt
io
n
15
a
Ke
te
la
ar
20
01
14
RC
T 2
gr
ou
ps
1
5
Fu
nc
tio
na
l
tr
ai
ni
ng
2
5
ND
T
&
Vo
jta
Im
m
ed
ia
te
&
lo
ng
-te
rm
(6
&
12
m
o)
ef
fe
ct
55
CP
2–
7
y
M
ild
–
M
od
er
at
e
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
Fu
nc
tio
na
l
Tr
ai
ni
ng
Pa
ss
iv
e:
ni
l
Ac
tiv
e:
ch
ild
ge
ne
ra
te
d
m
ov
em
en
t
so
lu
tio
ns
to
re
ac
h
go
al
s,
re
pe
tit
iv
e
ta
sk
-
sp
ec
ifi
c
pr
ac
tic
e
ND
T
Pa
ss
iv
e:
no
rm
al
iz
ed
m
ov
em
en
t,
fa
ci
lit
at
io
n,
in
hi
bi
tio
n
ab
no
rm
al
m
ov
em
en
t
Ac
tiv
e:
ni
l
GM
FM
-8
8
st
an
di
ng
&
w
al
ki
ng
ru
nn
in
g
&
ju
m
pi
ng
di
m
en
si
on
s
[m
ob
ili
ty
fu
nc
tio
n]
PE
DI
[m
ot
or
fu
nc
tio
n]
26
h
bo
th
gr
ou
ps
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
1/
w
k,
du
ra
tio
n
26
w
k]
M
ea
su
re
s
co
m
pl
et
ed
po
st
ra
nd
om
iz
at
io
n
Im
pr
ov
ed
fu
nc
tio
na
l
sk
ill
s
on
th
e
PE
DI
fa
vo
ri
ng
Fu
nc
tio
na
l
Tr
ai
ni
ng
gr
ou
p
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
gr
os
s
m
ot
or
sk
ill
s
on
GM
FM
di
m
en
si
on
s
No
16
a
Ko
20
20
49
RC
T 2
gr
ou
ps
1
5
Gr
ou
p-
ba
se
d
ta
sk
-o
ri
en
te
d
tr
ai
ni
ng
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
18
CP
4–
7.
5
y
GM
FC
S
I-I
II
Sp
as
tic
[u
ni
la
te
ra
l
&
bi
la
te
ra
l]
Gr
ou
p
Ta
sk
-
Or
ie
nt
ed
Tr
ai
ni
ng
Pa
ss
iv
e:
ni
l
Ac
tiv
e:
fu
nc
tio
na
l
ch
ild
go
al
-d
ir
ec
te
d,
ac
tiv
ity
in
te
rv
en
tio
ns
ba
se
d
on
m
ot
or
le
ar
ni
ng
,
fe
ed
ba
ck
on
pe
rf
or
m
an
ce
.
ND
T
Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n:
no
rm
al
iz
at
io
n
of
qu
al
ity
of
m
ov
em
en
t,
in
lin
e
w
ith
ND
T
Ac
tiv
e:
un
cl
ea
r
GM
FM
-8
8
[g
ro
ss
m
ot
or
fu
nc
tio
n]
BO
T-
2
m
an
ua
l
de
xt
er
ity
su
bs
ca
le
[fi
ne
m
ot
or
fu
nc
tio
n]
PE
DI
[s
el
f-c
ar
e,
m
ob
ili
ty
]
16
h
bo
th
gr
ou
ps
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
2/
w
k,
du
ra
tio
n
8
w
k]
La
ck
of
co
nc
ea
le
d
gr
ou
p
al
lo
ca
tio
n
Co
nt
ro
l
of
ot
he
r
sc
ho
ol
an
d
co
m
m
un
ity
ac
tiv
iti
es
no
t
fa
ct
or
ed
in
to
in
te
ns
ity
Be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
un
ab
le
to
be
m
ea
su
re
d
lo
ng
-
te
rm
as
no
fo
llo
w
up
of
co
m
pa
ra
to
r
gr
ou
p
Si
gn
ifi
ca
nt
im
pr
ov
em
en
t
in
GM
FM
-8
8
(s
ta
nd
in
g
an
d
w
al
ki
ng
/
ru
nn
in
g/
ju
m
pi
ng
di
m
en
si
on
)
Im
pr
ov
ed
m
an
ua
l
de
xt
er
ity
on
BO
T-
2
an
d
so
ci
al
fu
nc
tio
n
on
PE
DI
fa
vo
ri
ng
ta
sk
-o
ri
en
te
d
tr
ai
ni
ng
gr
ou
p
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
on
an
y
ou
tc
om
e
m
ea
su
re
No
76 TE VELDE et al
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
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on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
de
sc
ri
pt
io
n,
no
ac
tiv
e
co
m
po
ne
nt
s
de
sc
ri
be
d
17
a,
b
Pa
lm
er
19
88
41
RC
T 2
gr
ou
ps
1
5
In
fa
nt
st
im
ul
at
io
n
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
48
CP
12
–
19
m
o
M
ild
–
Se
ve
re
Sp
as
tic
[d
ip
le
gi
a]
In
fa
nt
St
im
ul
at
io
n
Pa
ss
iv
e:
ni
l
Ac
tiv
e:
ac
tiv
e
pr
ac
tic
e
of
m
ot
or
,
co
gn
iti
ve
an
d
la
ng
ua
ge
ta
sk
s
us
in
g
th
e
Le
ar
ni
ng
Ga
m
es
cu
rr
ic
ul
um
ND
T
Pa
ss
iv
e:
im
pr
ov
em
en
t
of
ri
gh
tin
g
&
eq
ui
lib
ri
um
re
ac
tio
ns
Ac
tiv
e:
ni
l
BM
S
[m
ot
or
fu
nc
tio
n]
Ba
yl
ey
Sc
al
es
M
en
ta
l
qu
ot
ie
nt
[c
og
ni
tio
n]
Vi
ne
la
nd
So
ci
al
M
at
ur
ity
Sc
al
e
[s
oc
ia
l
de
ve
lo
pm
en
t]
12
h
in
fa
nt
st
im
ul
at
io
n
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
0.
5/
w
k,
du
ra
tio
n
26
w
k]
20
h
ND
T
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
5/
w
k,
du
ra
tio
n
un
til
si
tt
in
g
ac
hi
ev
ed
]
ND
T
no
t
w
el
l
de
sc
ri
be
d
Hi
gh
er
do
se
fa
vo
ri
ng
ND
T
Im
pr
ov
ed
m
ot
or
sk
ill
s,
w
al
ki
ng
an
d
co
gn
iti
ve
de
ve
lo
pm
en
t
fa
vo
ri
ng
in
fa
nt
st
im
ul
at
io
n,
de
sp
ite
ND
T
be
in
g
of
fe
re
d
at
a
hi
gh
er
do
se
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
e
fo
r
so
ci
al
de
ve
lo
pm
en
t
No
18
Sa
h
20
19
61
RC
T 2
gr
ou
ps
1
5
Ta
sk
or
ie
nt
ed
ND
T
(T
OA
-N
DT
)
2
5
co
nv
en
tio
na
l
ph
ys
io
th
er
ap
y
Im
m
ed
ia
te
ef
fe
ct
44
CP
7–
15
y
GM
FC
S
II-
III
Sp
as
tic
[d
ip
le
gi
a]
Ta
sk
-O
ri
en
te
d
Ac
tiv
iti
es
Ba
se
d
on
ND
T
(T
OA
-
ND
T)
Pa
ss
iv
e:
fa
ci
lit
at
io
n
fo
r
op
tim
al
tr
un
k
al
ig
nm
en
t
Ac
tiv
e:
tr
un
k
ac
tiv
at
io
n
in
m
ul
tip
le
pl
an
es
in
si
tt
in
g
an
d
st
an
di
ng
us
in
g
ha
nd
s-
on
fa
ci
lit
at
io
n.
Re
ac
hi
ng
du
ri
ng
ac
tiv
ity
(p
op
pi
ng
bu
bb
le
s,
re
ac
h
fo
r
ba
lls
,
GM
FM
-8
8
[g
ro
ss
m
ot
or
fu
nc
tio
n]
Po
st
ur
al
As
se
ss
m
en
t
Sc
al
e
[p
os
tu
ra
l
co
nt
ro
l]
Pe
di
at
ri
c
Ba
la
nc
e
Sc
al
e
[d
yn
am
ic
ba
la
nc
e
ab
ili
ty
]
Tr
un
k
Im
pa
ir
m
en
t
Sc
al
e
[s
itt
in
g
ba
la
nc
e
fu
nc
tio
n]
36
h
TO
A-
ND
T
[i
nt
en
si
ty
1h
,
fr
eq
ue
nc
y
6/
w
k,
du
ra
tio
n
6
w
k]
36
h
Co
nv
en
tio
na
l
Ph
ys
io
th
er
ap
y
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
6/
w
k,
du
ra
tio
n
6
w
k]
No
nb
lin
de
d
as
se
ss
m
en
t
of
ou
tc
om
es
Im
pr
ov
em
en
t
in
gr
os
s
m
ot
or
fu
nc
tio
n
an
d
dy
na
m
ic
ba
la
nc
e
sk
ill
s
fa
vo
ri
ng
TO
A-
ND
T
gr
ou
p
ov
er
pa
ss
iv
e
st
re
tc
h
gr
ou
p
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
po
st
ur
al
co
nt
ro
l
an
d
dy
na
m
ic
si
tt
in
g
ba
la
nc
e
Ye
s
PEDIATRICS Volume 149, number 6, Month 2022 77
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by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
res
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
tr
an
sf
er
ri
ng
)
Co
nv
en
tio
na
l
Ph
ys
io
th
er
ap
y
Pa
ss
iv
e:
pa
ss
iv
e
st
re
tc
h
an
d
ra
ng
e
of
m
ov
em
en
t
of
lo
w
er
lim
bs
Ac
tiv
e:
pe
gb
oa
rd
re
ac
hi
ng
ta
sk
,
st
an
di
ng
on
ba
la
nc
e
bo
ar
d,
ba
ll
th
ro
w
in
g
19
a
Sa
le
m
20
09
40
RC
T 2
gr
ou
ps
1
5
Ta
sk
-
or
ie
nt
at
ed
tr
ai
ni
ng
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
10
CP
4–
12
y
GM
FC
S
I-I
II
Sp
as
tic
[d
ip
le
gi
a,
qu
ad
ri
pl
eg
ia
]
Ta
sk
-O
ri
en
te
d
Tr
ai
ni
ng
Pa
ss
iv
e:
ni
l
Ac
tiv
e:
ta
sk
-
or
ie
nt
at
ed
st
re
ng
th
tr
ai
ni
ng
,
pr
ac
tic
e
of
fu
nc
tio
na
l
ta
sk
s
ND
T
Pa
ss
iv
e:
fa
ci
lit
at
io
n,
no
rm
al
iz
at
io
n
of
m
ov
em
en
t
Ac
tiv
e:
ni
l
GM
FM
-8
8
st
an
di
ng
an
d
w
al
ki
ng
di
m
en
si
on
s
[m
ob
ili
ty
]
TU
G
[m
ob
ili
ty
]
10
h [i
nt
en
si
ty
1h
,
fr
eq
ue
nc
y
2/
w
k,
du
ra
tio
n
5
w
k]
No
ca
lc
ul
at
io
n
to
ju
st
ify
sm
al
l
sa
m
pl
e
si
ze
Im
pr
ov
ed
gr
os
s
m
ot
or
sk
ill
s
in
st
an
di
ng
an
d
w
al
ki
ng
on
th
e
GM
FM
fa
vo
ri
ng
th
e
ta
sk
-
or
ie
nt
at
ed
tr
ai
ni
ng
Im
pr
ov
ed
m
ob
ili
ty
sp
ee
d
on
TU
G
fa
vo
ri
ng
th
e
ta
sk
-
or
ie
nt
at
ed
tr
ai
ni
ng
gr
ou
p
No
ND
T
vs
Bo
dy
Fu
nc
tio
n
&
St
ru
ct
ur
es
-B
as
ed
Ap
pr
oa
ch
es
20
a
Av
ci
l
20
20
46
RC
T 2
gr
ou
ps
1
5
Vi
de
o
ga
m
e-
ba
se
d
th
er
ap
y
(V
GB
T)
2
5
ND
T
im
m
ed
ia
te
ef
fe
ct
30
CP
10
y
(m
ea
n
ag
e)
GM
FC
S
I-I
V
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
]
Dy
sk
in
es
ia
VG
BT Pa
ss
iv
e:
to
ne
re
gu
la
tio
n,
se
ns
or
y
su
pp
or
t
Ac
tiv
e:
si
m
ul
at
ed
sp
or
ts
(t
en
ni
s
an
d
bo
xi
ng
),
pr
og
re
ss
iv
e
re
pe
tit
iv
e
w
ri
st
M
in
ne
so
ta
M
an
ua
l
De
xt
er
ity
Te
st
(M
M
DT
)
[m
an
ua
l
de
xt
er
ity
]
Ch
ild
ho
od
He
al
th
As
se
ss
m
en
t
Qu
es
tio
nn
ai
re
[f
un
ct
io
na
l
ab
ili
ty
]
Du
ru
oz
Ha
nd
In
de
x
[fi
ne
24
h
bo
th
gr
ou
ps
[i
nt
en
si
ty
1
hr
,
fr
eq
ue
nc
y
3/
w
k,
du
ra
tio
n
8
w
k]
M
ot
or
se
ve
ri
ty
di
ffe
re
nt
be
tw
ee
n
gr
ou
ps
at
ba
se
lin
e
Un
ab
le
to
as
se
ss
to
ne
ou
tc
om
es
as
lo
w
nu
m
be
rs
of
in
fa
nt
s
Im
pr
ov
ed
m
an
ua
l
de
xt
er
ity
fa
vo
ri
ng
VG
BT
gr
ou
p
fo
r
he
m
ip
le
gi
a,
im
pr
ov
ed
gr
ip
st
re
ng
th
in
bo
th
gr
ou
ps
No
78 TE VELDE et al
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TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
an
d
ha
nd
ga
m
es
,g
ri
p
de
ve
lo
pm
en
t
ga
m
es
,
fe
ed
ba
ck
vi
a
vi
de
o
ha
nd
co
nt
ro
lle
r
ND
T
Pa
ss
iv
e:
to
ne
re
gu
la
tio
n,
se
ns
or
y
su
pp
or
t,
fa
ci
lit
at
io
n
fo
r
no
rm
al
iz
ed
m
ov
em
en
t
Ac
tiv
e:
dr
es
si
ng
,
ea
tin
g,
in
cr
ea
se
d
co
m
pl
ex
ity
of
ac
tiv
iti
es
m
ot
or
fu
nc
tio
n]
Dy
na
m
om
et
ry
[g
ri
p
an
d
pi
nc
h
st
re
ng
th
]
di
sp
la
ye
d
sp
as
tic
ity
21
a
Ba
r-
Ha
im
20
06
36
RC
T 2
gr
ou
ps
1
5
Ad
el
i
Su
it
2
5
ND
T
Im
m
ed
ia
te
&
lo
ng
-te
rm
(9
m
o)
ef
fe
ct
24
CP
5–
12
y
GM
FC
S
II-
IV
Sp
as
tic
[d
ip
le
gi
a,
tr
ip
le
gi
a,
qu
ad
ri
pl
eg
ia
]
At
ax
ic
M
ix
ed
Ad
el
i
Su
it
Pa
ss
iv
e:
m
as
sa
ge
,
st
re
tc
hi
ng
,s
ui
t
w
ea
ri
ng
Ac
tiv
e:
w
al
ki
ng
on
va
ri
ed
te
rr
ai
ns
,s
it-
to
-
st
an
d,
ba
ll
pl
ay
,
tr
am
po
lin
e
ju
m
pi
ng
,s
ta
ir
-
cl
im
bi
ng
,
la
dd
er
-c
lim
bi
ng
ND
T
Pa
ss
iv
e:
st
re
tc
hi
ng
,
no
rm
al
iz
in
g
to
ne
,
GM
FM
-6
6
[g
ro
ss
m
ot
or
fu
nc
tio
n]
M
ec
ha
ni
ca
l
ef
fi
ci
en
cy
du
ri
ng
st
ai
r
cl
im
bi
ng
40
h
bo
th
gr
ou
ps
[i
nt
en
si
ty
2
h,
fr
eq
ue
nc
y
5×
/w
k,
du
ra
tio
n
4
w
k]
Sh
or
t
du
ra
tio
n
in
te
rv
en
tio
n
Im
pr
ov
ed
m
ec
ha
ni
ca
l
ef
fi
ci
en
cy
du
ri
ng
st
ai
r
cl
im
bi
ng
fa
vo
ri
ng
th
e
su
it
gr
ou
p
No
di
ffe
re
nc
e
be
tw
ee
n
gr
ou
ps
fo
r
gr
os
s
m
ot
or
fu
nc
tio
n
No
PEDIATRICS Volume 149, number 6, Month 2022 79
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
fa
ci
lit
at
io
n
of
m
ov
em
en
t
Ac
tiv
e:
w
al
ki
ng
,
si
t-t
o-
st
an
d
22
a
Ba
tr
a
20
15
59
RC
T 2
gr
ou
ps
1
5
Ne
ur
o-
fa
ci
lit
at
io
n
of
De
ve
lo
pm
en
ta
l
Re
ac
tio
n
(N
FD
R)
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
30
CP
IQ
$
55
4–
7
y
M
ild
–
M
od
er
at
e
Sp
as
tic
[t
op
og
ra
ph
y
un
cl
ea
r]
NF
DR Pa
ss
iv
e:
pr
ep
ar
at
io
n
fo
r
m
ov
em
en
t,
fa
ci
lit
at
io
n,
ve
st
ib
ul
ar
in
pu
t,
no
rm
al
iz
at
io
n
of
to
ne
an
d
re
fl
ex
es
Ac
tiv
e:
pe
rt
ur
ba
tio
n
to
el
ic
it
ad
ap
tiv
e
po
st
ur
al
re
ac
tio
ns
,
tr
ai
ni
ng
m
ot
or
co
nt
ro
l
ND
T
Pa
ss
iv
e:
po
si
tio
ni
ng
,
ha
nd
lin
g,
st
re
tc
hi
ng
,
in
hi
bi
tio
n
an
d
fa
ci
lit
at
io
n
te
ch
ni
qu
es
,
w
ei
gh
t-b
ea
ri
ng
Ac
tiv
e:
ni
l
GM
FM
-8
8[
gr
os
s
m
ot
or
fu
nc
tio
n]
M
od
ifi
ed
As
hw
or
th
Sc
al
e
[m
us
cl
e
to
ne
,
sp
as
tic
ity
]
Pr
im
iti
ve
Re
fl
ex
In
te
ns
ity
Gr
ad
in
g
Sc
or
e
[r
efl
ex
st
at
us
]
24
h
bo
th
gr
ou
ps
[i
nt
en
si
ty
40
m
in
,
fr
eq
ue
nc
y
3×
/w
k,
du
ra
tio
n
12
w
k]
In
te
rv
en
tio
ns
ha
ve
si
m
ila
r
ch
ar
ac
te
ri
st
ic
s
No
ca
lc
ul
at
io
n
to
ju
st
ify
sm
al
l
sa
m
pl
e
si
ze
Re
po
rt
on
ch
an
ge
in
GM
FC
S
le
ve
ls
fa
vo
ri
ng
NF
DR
w
hi
ch
se
em
s
un
fe
as
ib
le
Re
du
ce
d
sp
as
tic
ity
in
se
le
ct
m
us
cl
e
gr
ou
ps
an
d
im
pr
ov
ed
gr
os
s
m
ot
or
fu
nc
tio
n
an
d
GM
FC
S
le
ve
ls
fa
vo
ri
ng
NF
DR
No
ch
an
ge
in
re
fl
ex
st
at
us
be
tw
ee
n
gr
ou
ps
No
23
a,
b
Ba
tr
a
20
12
58
RC
T 2
gr
ou
ps
1
5
NF
DR
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
30
CP
0.
5–
2
y
M
ild
–
M
od
er
at
e
Sp
as
tic
[t
op
og
ra
ph
y
un
cl
ea
r]
NF
DR Pa
ss
iv
e:
pr
ep
ar
at
io
n
fo
r
m
ov
em
en
t,
fa
ci
lit
at
io
n,
ve
st
ib
ul
ar
in
pu
t
Ac
tiv
e:
pe
rt
ur
ba
tio
n
to
el
ic
it
po
st
ur
al
re
ac
tio
ns
ND
T
Pa
ss
iv
e:
GM
FM
-8
8[
gr
os
s
m
ot
or
fu
nc
tio
n]
M
od
ifi
ed
As
hw
or
th
Sc
al
e
[m
us
cl
e
to
ne
,
sp
as
tic
ity
]
Pr
im
iti
ve
Re
fl
ex
In
te
ns
ity
Gr
ad
in
g
Sc
or
e
[r
efl
ex
st
at
us
]
24
h
bo
th
gr
ou
ps
[i
nt
en
si
ty
40
m
in
,
fr
eq
ue
nc
y
3×
/w
k,
du
ra
tio
n
12
w
k]
Sm
al
l
sa
m
pl
e
si
ze
In
te
rv
en
tio
ns
ar
e
si
m
ila
r
in
m
an
y
el
em
en
ts
Re
du
ce
d
sp
as
tic
ity
in
se
le
ct
m
us
cl
e
gr
ou
ps
an
d
im
pr
ov
ed
gr
os
s
m
ot
or
fu
nc
tio
n
fa
vo
ri
ng
NF
DR
No
80 TE VELDE et al
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
po
si
tio
ni
ng
,
ha
nd
lin
g,
st
re
tc
hi
ng
,
w
ei
gh
t-b
ea
ri
ng
Ac
tiv
e:
ni
l
24
a
Na
m
20
17
47
RC
T 2
gr
ou
ps
1
5
Dy
na
m
ic
ba
la
nc
e
tr
ai
ni
ng
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
15
CP
14
y
(m
ea
n
ag
e)
GM
FC
S
I-I
II
Sp
as
tic
[d
ip
le
gi
a]
Dy
na
m
ic
Ba
la
nc
e
Pa
ss
iv
e:
ni
l
Ac
tiv
e:
ac
tiv
e
ba
la
nc
e
on
a
ba
la
nc
e
tr
ai
ne
r
de
vi
ce
,w
he
re
th
e
ch
ild
’s
load
fo
rc
es
to
ac
tiv
el
y
m
ai
nt
ai
n
ba
la
nc
e
w
er
e
re
co
rd
ed
ND
T
Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
M
us
cl
e
th
ic
kn
es
s
(o
n
ul
tr
as
ou
nd
)
[p
ro
xy
fo
r
m
us
cl
e
st
re
ng
th
]
9
h [i
nt
en
si
ty
30
m
in
,
fr
eq
ue
nc
y
3×
/w
k,
du
ra
tio
n
6
w
k]
No
m
ea
su
re
m
en
t
of
th
e
fu
nc
tio
na
l
im
pl
ic
at
io
ns
of
th
is
tr
ea
tm
en
t
Be
tw
ee
n
gr
ou
p
di
ffe
re
nc
e
of
m
us
cl
e
th
ic
kn
es
s
fa
vo
ri
ng
dy
na
m
ic
ba
la
nc
e
tr
ai
ni
ng
No
25
b
Sc
he
rz
er
19
76
60
RC
T 2
gr
ou
ps
1
5
Pa
ss
iv
e
st
re
tc
hi
ng
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
24
CP
,h
ig
h
ri
sk
CP
<
18
m
o
M
ild
–
Se
ve
re
Sp
as
tic
At
he
to
id
[d
ys
ki
ne
tic
]
At
ax
ic
M
ix
ed
Pa
ss
iv
e
St
re
tc
h
Pa
ss
iv
e:
pa
ss
iv
e
ra
ng
e
of
m
ot
io
n
Ac
tiv
e:
ni
l
ND
T
Pa
ss
iv
e:
po
si
tio
ni
ng
to
in
hi
bi
t
ab
no
rm
al
re
fl
ex
es
,
fa
ci
lit
at
io
n,
pa
re
nt
s
tr
ai
ne
d
in
te
ch
ni
qu
es
Ac
tiv
e:
m
ov
em
en
t
to
M
ot
or
De
ve
lo
pm
en
t
Ev
al
ua
tio
n
Fo
rm
[m
ot
or
fu
nc
tio
n]
So
ci
al
M
at
ur
at
io
n
qu
es
tio
nn
ai
re
[s
oc
ia
l
de
ve
lo
pm
en
t]
Ho
m
e
m
an
ag
em
en
t
qu
es
tio
nn
ai
re
[s
el
f-c
ar
e]
Un
ab
le
to
ca
lc
ul
at
e
do
se
[i
nt
en
si
ty
:
no
t
lis
te
d,
fr
eq
ue
nc
y
2×
/w
k,
du
ra
tio
n:
m
ea
n
12
.5
m
o]
Un
de
rp
ow
er
ed
sa
m
pl
e
si
ze
No
n
st
an
da
rd
iz
ed
ou
tc
om
e
m
ea
su
re
s
Be
tw
ee
n
gr
ou
p
di
ffe
re
nc
e
no
t
m
ea
su
re
d
Im
pr
ov
em
en
t
in
m
ot
or
st
at
us
an
d
so
ci
al
m
at
ur
at
io
n
af
te
r
ND
T
Ye
s
PEDIATRICS Volume 149, number 6, Month 2022 81
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
in
hi
bi
t
ab
no
rm
al
re
fl
ex
es
,
st
im
ul
at
io
n
of
m
ov
em
en
t
26
a
Sh
am
so
dd
in
i
20
10
65
RC
T 2
gr
ou
ps
1
5
Se
ns
or
y
in
te
gr
at
io
n
(S
I)
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
22
CP
2–
6
y
Se
ve
ri
ty
no
t
lis
te
d
Sp
as
tic
[d
ip
le
gi
a,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
st
re
tc
hi
ng
,
re
du
ci
ng
sp
as
tic
ity
,
fa
ci
lit
at
io
n,
no
rm
al
iz
ed
m
ov
em
en
t
Ac
tiv
e:
ni
l
SI Pa
ss
iv
e:
st
re
tc
hi
ng
,
re
du
ci
ng
sp
as
tic
ity
,
fa
ci
lit
at
io
n,
no
rm
al
iz
ed
m
ov
em
en
t
Ac
tiv
e:
vi
su
al
m
ot
or
co
or
di
na
tio
n,
oc
ul
ar
pu
rs
ui
t
ac
tiv
iti
es
,
pe
gb
oa
rd
ac
tiv
iti
es
,
tu
rn
in
g
le
ft
&
ri
gh
t
GM
FM
-8
8
[g
ro
ss
m
ot
or
fu
nc
tio
n]
36
–
54
h
[i
nt
en
si
ty
1–
1.
5
h,
fr
eq
ue
nc
y
3×
/w
k,
du
ra
tio
n
12
w
k]
Po
ss
ib
le
re
po
rt
in
g
er
ro
r
No
ca
lc
ul
at
io
n
to
ju
st
ify
sm
al
l
sa
m
pl
e
si
ze
Im
pr
ov
ed
ly
in
g,
si
tt
in
g,
cr
aw
lin
g
m
ot
or
sk
ill
s
on
GM
FM
-8
8
fa
vo
ri
ng
SI
No
ND
T
vs
En
vi
ro
nm
en
ta
l-B
as
ed
Ap
pr
oa
ch
es
27
b
Ha
nz
lik
19
89
62
RC
T 2
gr
ou
ps
1
5
Pa
re
nt
co
ac
hi
ng
2
5
ND
T
Im
m
ed
ia
te
ef
fe
ct
20
CP
& de
ve
lo
pm
en
ta
l
de
la
y
1–
2
y
M
ild
–
Se
ve
re
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
Pa
re
nt
Co
ac
hi
ng
Pa
ss
iv
e:
ad
ap
tiv
e
se
at
in
g
fo
r
in
fa
nt
Ac
tiv
e:
co
ac
hi
ng
in
pl
ay
re
sp
on
si
vi
ty
,
re
du
ce
d
M
od
ifi
ed
M
ila
ni
-
Co
m
pa
re
tt
i
an
d
Gi
do
ni
Sc
al
e
of
Gr
os
s
M
ot
or
De
ve
lo
pm
en
t
[g
ro
ss
m
ot
or
fu
nc
tio
n]
Ba
yl
ey
Sc
al
es
of
M
en
ta
l
De
ve
lo
pm
en
t
1
h [i
nt
en
si
ty
:
1
h
co
ac
hi
ng
or
ND
T
1
ho
m
e
pr
ac
tic
e
do
se
un
sp
ec
ifi
ed
]
Br
ie
f
de
sc
ri
pt
io
ns
of
th
e
in
te
rv
en
tio
n
Lo
w
do
se
bo
th
gr
ou
ps
Im
pr
ov
ed
in
fa
nt
re
sp
on
si
ve
ne
ss
fa
vo
ri
ng
pa
re
nt
co
ac
hi
ng
gr
ou
p
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
in
de
pe
nd
en
t
pl
ay
No
82 TE VELDE et al
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on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
ph
ys
ic
al
co
nt
ac
t
w
hi
ch
w
as
co
nv
er
te
d
to
fa
ce
-to
-fa
ce
co
nt
ac
t
1
co
m
m
un
ic
at
io
n
ND
T
Pa
ss
iv
e:
fa
ci
lit
at
io
n,
no
rm
al
iz
ed
to
ne
,
no
rm
al
iz
ed
m
ov
em
en
t
Ac
tiv
e:
ni
l
[c
og
ni
tio
n]
M
at
er
na
l
Ob
se
rv
at
io
n
In
te
rv
ie
w
[b
eh
av
io
ra
l
st
yl
es
]
Ho
lli
ng
sh
ea
d
Fo
ur
-F
ac
to
r
In
de
x
of
So
ci
al
Po
si
tio
n
[s
oc
io
ec
on
om
ic
st
at
us
]
28
b
Gi
ro
la
m
i
19
94
63
RC
T 3
gr
ou
ps
1
5
ND
T
2
5
No
ns
pe
ci
fi
c
ha
nd
lin
g
3
5
Te
rm
co
nt
ro
ls
(n
o
th
er
ap
y)
Im
m
ed
ia
te
ef
fe
ct
27
Pr
et
er
m
in
fa
nt
s
at
ri
sk
fo
r
CP
,3
4
w
k
GA
0–
1
y
Te
rm
-b
or
n
co
nt
ro
ls
Se
ve
ri
ty
&
to
po
gr
ap
hy
no
t
cl
ea
r
No
ns
pe
ci
fi
c
Ha
nd
lin
g
Pa
ss
iv
e:
po
si
tio
ni
ng
w
ith
ou
t
ND
T
ha
nd
lin
g
Ac
tiv
e:
ni
l
ND
T
Pa
ss
iv
e:
ha
nd
lin
g,
fa
ci
lit
at
io
n
Ac
tiv
e:
ac
tiv
e
po
st
ur
es
du
ri
ng
ha
nd
lin
g
Ne
on
at
al
Be
ha
vi
or
al
As
se
ss
m
en
t
Sc
al
e
(N
BA
S)
m
ot
or
cl
us
te
r
[m
ot
or
fu
nc
tio
n]
Su
pp
le
m
en
ta
l
M
ot
or
Te
st
[m
ot
or
co
nt
ro
l]
5
h [i
nt
en
si
ty
15
m
in
,
fr
eq
ue
nc
y
14
/w
k,
du
ra
tio
n
1–
2
w
k]
Hi
gh
at
tr
iti
on
ra
te
s
Sm
al
l
sa
m
pl
e
si
ze
Ri
sk
fo
r
CP
no
t
cl
ea
rl
y
de
fi
ne
d,
i.e
.t
he
se
pr
et
er
m
in
fa
nt
s
m
ay
ha
ve
be
en
on
a
tr
aj
ec
to
ry
to
a
no
rm
al
ou
tc
om
e
an
d
th
us
no
t
ne
ed
ed
tr
ea
tm
en
t
Im
pr
ov
ed
m
ot
or
pe
rf
or
m
an
ce
on
th
e
NB
AS
fa
vo
ri
ng
ND
T
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
e
fo
r
to
ne
,
be
ha
vi
or
al
st
at
e,
re
fl
ex
es
&
re
gu
la
tio
n
Pa
rt
ia
lly
ND
T
Hi
gh
er
Do
se
vs
ND
T
Lo
w
er
Do
se
29
Bo
w
er
19
96
42
RC
T 4
gr
ou
ps
1
5
Lo
w
er
do
se
ND
T
1
ai
m
s
2
5
Hi
gh
er
do
se
ND
T
1
ai
m
s
3
5
Lo
w
er
44
CP
3–
11
y
M
od
er
at
e–
Se
ve
re
Sp
as
tic
[q
ua
dr
ip
le
gi
a]
ND
T Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
GM
FM
-8
8
[g
ro
ss
m
ot
or
fu
nc
tio
n]
2
h
m
ea
n
lo
w
er
do
se
(a
im
s
1
go
al
s
gr
ou
p)
[d
ur
at
io
n
2
w
k]
9
h
m
ea
n
hi
gh
er
do
se
(a
im
s
1
Lo
w
do
se
in
bo
th
gr
ou
ps
w
ith
in
th
e
co
nt
ex
t
of
ne
ur
op
la
st
ic
ity
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
lo
w
er
ve
rs
us
hi
gh
er
do
se
gr
ou
p
fo
r
gr
os
s
m
ot
or
fu
nc
tio
n
Im
pr
ov
ed
gr
os
s
m
ot
or
sk
ill
s
on
th
e
GM
FM
No
PEDIATRICS Volume 149, number 6, Month 2022 83
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
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on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
do
se
ND
T
1
go
al
s
4
5
Hi
gh
er
do
se
ND
T
1
go
al
s
Im
m
ed
ia
te
ef
fe
ct
go
al
s
gr
ou
p)
[d
ur
at
io
n
2
w
k]
fa
vo
ri
ng
go
al
s
ov
er
ai
m
s
30
Bo
w
er
20
01
43
RC
T 4
gr
ou
ps
1
5
Lo
w
er
do
se
ND
T
1
ai
m
s
2
5
Hi
gh
er
do
se
ND
T
1
ai
m
s
3
5
Lo
w
er
do
se
ND
T
1
go
al
s
4
5
Hi
gh
er
do
se
ND
T
1
go
al
s
Im
m
ed
ia
te
ef
fe
ct
56
CP
3–
12
y
GM
FC
S
III
-V
Sp
as
tic
[b
ila
te
ra
l]
ND
T Pa
ss
iv
e:
st
re
tc
hi
ng
,
ha
nd
lin
g,
po
si
tioni
ng
,
eq
ui
pm
en
t,
or
th
os
es
,
ca
st
in
g
Ac
tiv
e:
m
us
cl
e
st
re
ng
th
en
in
g,
ac
tiv
e
m
ov
em
en
t,
gr
os
s
m
ot
or
sk
ill
s
tr
ai
ni
ng
GM
FM
-8
8
[g
ro
ss
m
ot
or
fu
nc
tio
n]
Gr
os
s
M
ot
or
Pe
rf
or
m
an
ce
M
ea
su
re
(G
M
PM
)
[g
ro
ss
m
ot
or
pe
rf
or
m
an
ce
]
M
PO
C-
20
[p
ar
en
t
pe
rc
ep
tio
n
of
ca
re
gi
vi
ng
]
36
h
m
ed
ia
n
lo
w
er
do
se
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
0.
5/
w
k,
du
ra
tio
n
72
w
k]
11
2
h
m
ed
ia
n
hi
gh
er
do
se
[i
nt
en
si
ty
5
h,
fr
eq
ue
nc
y
1/
w
k,
du
ra
tio
n
26
w
k
1
in
te
ns
ity
1
h,
fr
eq
ue
nc
y
0.
5×
/w
k,
du
ra
tio
n
46
w
k]
Th
es
e
do
se
s
w
ou
ld
be
co
ns
id
er
ed
to
be
in
th
e
th
er
ap
eu
tic
ra
ng
e
bu
t
ar
e
ov
er
a
lo
ng
du
ra
tio
n
(1
8
m
o)
M
ul
tip
le
tr
ea
tin
g
th
er
ap
is
ts
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
es
fo
r
ai
m
s
ve
rs
us
go
al
s
or
lo
w
er
do
se
v
hi
gh
er
do
se
fo
r
gr
os
s
m
ot
or
sk
ill
s
on
GM
FM
or
GM
PM
No
31
a
La
w
19
91
44
RC
T 4
gr
ou
ps
,2
gr
ou
ps
re
le
va
nt
to
do
se
qu
es
tio
n
1
5
Lo
w
er
do
se
(r
eg
ul
ar
ND
T)
2
5
Hi
gh
er
do
se
(i
nt
en
si
ve
ND
T)
Im
m
ed
ia
te
&
lo
ng
te
rm
(3
m
o)
ef
fe
ct
36
CP
1.
5–
8
y
Se
ve
ri
ty
no
t
lis
te
d
Sp
as
tic
[h
em
ip
le
gi
a,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
w
ei
gh
t-
be
ar
in
g,
fa
ci
lit
at
io
n
Ac
tiv
e:
re
ac
hi
ng
&
gr
as
pi
ng
,
bi
la
te
ra
l
co
-
or
di
na
tio
n
Pe
ab
od
y
fi
ne
m
ot
or
sc
al
es
[fi
ne
m
ot
or
fu
nc
tio
n]
QU
ES
T
[q
ua
lit
y
of
up
pe
r
ex
tr
em
ity
m
ov
em
en
t]
39
h
lo
w
er
do
se
ND
T
[i
nt
en
si
ty
45
m
in
,
fr
eq
ue
nc
y
1/
w
k
1
ho
m
e
pr
og
ra
m
30
m
in
3×
/w
k,
du
ra
tio
n
26
w
k]
13
0
h
hi
gh
er
do
se
ND
T
[In
te
ns
ity
Sm
al
l
sa
m
pl
e
si
ze
le
ad
in
g
to
un
de
rp
ow
er
ed
st
ud
y
Va
ri
at
io
n
in
do
se
w
ith
in
gr
ou
ps
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
e
fo
r
fi
ne
m
ot
or
fu
nc
tio
n
on
PD
M
S
or
qu
al
ity
of
m
ov
em
en
t
on
QU
ES
T
No
84 TE VELDE et al
Downloaded from http://publications.aap.org/pediatrics/article-pdf/149/6/e2021055061/1554282/peds_2021055061.pdf
by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
45
m
in
Fr
eq
ue
nc
y
2/
w
k
1
ho
m
e
pr
og
ra
m
30
m
in
7×
/w
k
Du
ra
tio
n
26
w
k]
32
b
M
ay
o
19
91
64
RC
T 2
gr
ou
ps
1
5
Lo
w
er
do
se
ND
T
2
5
Hi
gh
er
do
se
ND
T
Im
m
ed
ia
te
ef
fe
ct
29
CP
0–
1.
5
y
M
od
er
at
e–
Se
ve
re
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ag
gr
eg
at
e
of
7
in
st
ru
m
en
ts
:
(r
efl
ex
ac
tiv
ity
,
po
st
ur
al
re
ac
tio
ns
,
W
ol
an
sk
i
Gr
os
s
M
ot
or
Ev
al
ua
tio
n,
[g
ro
ss
m
ot
or
fu
nc
tio
n]
,fi
ne
m
ot
or
,B
ay
le
y
m
en
ta
l
sc
al
e,
Ab
no
rm
al
m
ov
em
en
t
sc
al
e,
ac
tiv
iti
es
of
da
ily
liv
in
g)
6
h
m
ed
ia
n
lo
w
er
do
se
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
1/
m
o,
du
ra
tio
n
26
w
k
1
un
sp
ec
ifi
ed
in
te
ns
ity
fo
r
ho
m
e
pr
og
ra
m
]
26
h
m
ed
ia
n
hi
gh
er
do
se
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
1/
w
k,
du
ra
tio
n
26
w
k
1
un
sp
ec
ifi
ed
in
te
ns
ity
fo
r
ho
m
e
pr
og
ra
m
]
Lo
w
do
se
in
bo
th
gr
ou
ps
w
ith
in
th
e
co
nt
ex
t
of
ne
ur
op
la
st
ic
ity
Hi
gh
ra
te
of
no
CP
by
en
d
of
st
ud
y
(3
1%
)
Re
po
rt
ed
ag
gr
eg
at
e
sc
or
e
w
ith
7
in
st
ru
m
en
ts
m
ea
ni
ng
sc
or
e
co
ul
d
ar
tifi
ci
al
ly
ri
se
if
th
e
ch
ild
m
ad
e
im
pr
ov
em
en
ts
on
a
te
st
in
w
hi
ch
th
ey
ha
d
no im
pa
ir
m
en
ts
Im
pr
ov
ed
sk
ill
s
on
ag
gr
eg
at
e
of
7
in
st
ru
m
en
ts
fa
vo
ri
ng
hi
gh
er
do
se
ND
T
Ye
s
33
a
Ts
or
la
ki
s
20
04
4
RC
T 2
gr
ou
ps
1
5
Lo
w
er
do
se
ND
T
2
5
Hi
gh
er
do
se
ND
T
Im
m
ed
ia
te
ef
fe
ct
34
CP
3–
14
y
GM
FC
S
I-I
II
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ac
tiv
e:
un
cl
ea
r
de
sc
ri
pt
io
n
Ba
se
d
on
Bo
ba
th
pr
in
ci
pl
es
GM
FM
-6
6
[g
ro
ss
m
ot
or
fu
nc
tio
n]
32
h
m
ed
ia
n
lo
w
er
do
se
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
2/
m
o,
du
ra
tio
n
16
w
k]
80
h
m
ed
ia
n
Un
cl
ea
r
de
sc
ri
pt
io
n
of
in
te
rv
en
tio
n
Un
de
rp
ow
er
ed
st
ud
y
(d
id
no
t
m
ee
t
ca
lc
ul
at
ed
sa
m
pl
e
si
ze
)
Im
pr
ov
ed
gr
os
s
m
ot
or
sk
ill
s
on
th
e
GM
FM
fa
vo
ri
ng
hi
gh
er
do
se
ND
T.
Re
su
lts
w
er
e
la
rg
er
in
yo
un
ge
r
ch
ild
re
n
Ye
s
PEDIATRICS Volume 149, number 6, Month 2022 85
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by Universidade Federal da Bahia user
on 08 April 2024
TA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
19
94
–
20
01
er
a,
su
gg
es
tin
g
it
pr
ob
ab
ly
in
cl
ud
ed
:
ha
nd
lin
g,
fa
ci
lit
at
io
n,
no
rm
al
iz
at
io
n
of
m
ov
em
en
t
hi
gh
er
do
se
[i
nt
en
si
ty
1
h,
fr
eq
ue
nc
y
5/
w
k,
du
ra
tio
n
16
w
k]
34
b
W
ei
nd
lin
g
19
96
50
RC
T 2
gr
ou
ps
1
5
Lo
w
er
do
se
ND
T
(d
el
ay
ed
ph
ys
io
th
er
ap
y)
1
5
Hi
gh
er
do
se
ND
T
(e
ar
ly
ph
ys
io
th
er
ap
y)
Im
m
ed
ia
te
&
lo
ng
-te
rm
(a
t
ag
e
30
m
o)
ef
fe
ct
11
0
In
fa
nt
s
at
ri
sk
fo
r
CP
on
ne
ur
oi
m
ag
in
g,
in
cl
ud
ed
pr
et
er
m
an
d
te
rm
bo
rn
in
fa
nt
s
CP
(n
5
45
)
0–
1
y
Se
ve
ri
ty
no
t
cl
ea
r
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
ha
nd
lin
g,
po
si
tio
ni
ng
,
pa
ss
iv
e
lim
b
m
ov
em
en
t
Ac
tiv
e:
ho
ld
in
g
fe
ed
er
cu
p
Gr
iffi
th
s
De
ve
lo
pm
en
ta
l
Qu
ot
ie
nt
[g
en
er
al
de
ve
lo
pm
en
t]
in
cl
ud
ed
an
al
ys
is
of
su
b
sc
al
es
:
Lo
co
m
ot
or
Pe
rs
on
al
So
ci
al
Pe
rf
or
m
an
ce
He
ar
in
g–
Sp
ee
ch
Ey
e–
Ha
nd
M
en
ta
l
Ra
ng
e
16
h
lo
w
er
do
se
[i
nt
en
si
ty
no
t
lis
te
d,
fr
eq
ue
nc
y
1/
w
k,
du
ra
tio
n
16
w
k]
35
–
52
h
hi
gh
er
do
se
[i
nt
en
si
ty
:
no
t
lis
te
d,
fr
eq
ue
nc
y
1/
w
k,
du
ra
tio
n
35
–
52
w
k]
Do
se
s
es
tim
at
ed
on
1
h/
se
ss
io
n
Do
se
di
ffi
cu
lt
to
ca
lc
ul
at
e
as
in
te
ns
ity
no
t
lis
te
d
No
st
ra
tifi
ca
tio
n
fo
r
m
ot
or
se
ve
ri
ty
,
le
ad
in
g
to
no
nb
as
el
in
e
eq
ui
va
le
nc
e
fo
r
se
ve
ri
ty
fa
vo
ri
ng
hi
gh
er
do
se
gr
ou
p
Gr
iffi
th
s
lo
co
m
ot
or
sc
al
e
no
t
va
lid
fo
r
se
ve
re
m
ot
or
im
pa
ir
m
en
t
On
ly
50
%
of
in
fa
nt
s
ha
d
CP
ou
tc
om
e
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
e
at
12
or
30
m
o
fo
r
m
ot
or
de
ve
lo
pm
en
t
or
to
ta
l
de
ve
lo
pm
en
ta
l
qu
ot
ie
nt
on
Gr
iffi
th
s
No
35
a,
b
W
ei
nd
lin
g
20
07
51
RC
T 2
gr
ou
ps
1
5
Lo
w
er
do
se
ND
T
(s
ta
nd
ar
d
ca
re
ph
ys
io
th
er
ap
y)
2
5
Hi
gh
er
do
se
ND
T
(N
DT
1
ND
T
th
er
ap
y
gi
ve
n
by ph
ys
io
th
er
ap
y
as
si
st
an
t
76
CP
<
4
y
Se
ve
ri
ty
no
t
lis
te
d
Sp
as
tic
[h
em
ip
le
gi
a,
di
pl
eg
ia
,
qu
ad
ri
pl
eg
ia
]
ND
T Pa
ss
iv
e:
no
rm
al
iz
at
io
n
of
po
st
ur
e
an
d
m
ov
em
en
ts
,
m
ov
em
en
t
fa
ci
lit
at
io
n.
Ac
tiv
e:
ni
l
GM
FM
[g
ro
ss
m
ot
or
fu
nc
tio
n]
Gr
iffi
th
s
[g
en
er
al
de
ve
lo
pm
en
t]
Vi
ne
la
nd
[a
da
pt
iv
e
fu
nc
tio
ni
ng
]
Va
ri
ou
s
pa
re
nt
,
ho
m
e
ec
ol
og
y
m
ea
su
re
s
32
h
lo
w
er
do
se
(e
st
im
at
e)
[i
nt
en
si
ty
&
fr
eq
ue
nc
y
no
t
st
an
da
r-
di
ze
d]
60
h
hi
gh
er
do
se
5
34
h
st
an
da
rd
ND
T
ph
ys
io
[in
te
ns
ity
&
fr
eq
ue
nc
y
Do
se
no
t
ab
le
to
be
es
tim
at
ed
(e
stim
at
e
fr
om
nu
m
be
r
of
co
nt
ac
ts
)
No
be
tw
ee
n
gr
ou
p
di
ffe
re
nc
e
be
tw
ee
n
hi
gh
er
an
d
lo
w
er
in
te
ns
ity
ND
T
No
86 TE VELDE et al
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by Universidade Federal da Bahia user
on 08 April 2024
extractable (n 5 2 studies)43,50 and
(2) dose <30 hours threshold
(n 5 2).42,64 No difference between
higher and lower dose NDT on
motor function was found with an
effect size of 0.32 (�0.11 to 0.75),
I2 5 30% (Fig 2D). Interpretation of
all meta-analyses did not change
using a fixed effects model.
NDT in Infants
Across all included studies, we
identified 1133,34,41,50,51,57,58,60,62–64
publications that enrolled infant
participants <2 years, including 2
articles,34 written about the same
cohort. These infant studies
comprised 578 infants, of which 259
(44.8%) had confirmed CP. Studies
were spread across all comparators
including NDT versus control
(n 5 3),33,34,57 NDT versus activity-
based approaches (n 5 1),41 NDT
versus body function and structures-
based approaches (n 5 2),58,60 NDT
versus environment-based
approaches (n 5 2),62,63 and NDT
lower versus higher dose
(n 5 3).50,51,64 In total,
8 studies33,34,41,51,58,62–64 had
extractable standardized mean
difference data; however, no
2 studies were sufficiently
homogenous in terms of
participants, interventions,
outcomes, or outcome measures to
conduct a meaningful meta-analysis.
Of 11 infant studies, 2 of 11 (18%)
favored NDT, 1 of 11 (9%) partially
favored NDT, and 7 of 11 (64%) did
not favor NDT (Table 1). When
studies with some concerns or a
high risk of bias were excluded, only
1 study remained41 that revealed
infant stimulation, and an activity-
based approach improved motor
skills over NDT with a large effect
size (2.62 [1.83 to 3.41]) (Fig 2B).
Reporting Biases
On RoB-2 only 5 of 35
publications52,53,57,62,63 had high
risk and 5 of 3514,45,48,49,60 had
some concerns of reporting biasTA
BL
E
1
Co
nt
in
ue
d
St
ud
y
Nu
m
be
r
Ci
ta
tio
n
De
si
gn
N
Po
pu
la
tio
n:
Di
ag
no
si
s,
Ag
e,
M
ot
or
Se
ve
ri
ty
&
Ty
pe
of
CP
In
te
rv
en
tio
n
El
em
en
ts
Ou
tc
om
e
M
ea
su
re
s
[D
om
ai
n
M
ea
su
re
d]
To
ta
l
Do
se
Li
m
ita
tio
ns
Re
su
lts
Fa
vo
rs
ND
T
Im
m
ed
ia
te
&
lo
ng
-te
rm
(6
&
12
m
o
po
st
in
te
rv
en
tio
n)
ef
fe
ct
no
t
st
an
da
r-
di
ze
d]
1
26
h
ph
ys
io
as
si
st
an
t
[in
te
ns
ity
1
h,
in
te
ns
ity
1/
w
k,
du
ra
tio
n
6
m
o]
AH
A,
As
si
st
in
g
Ha
nd
As
se
ss
m
en
t;
BO
T-
2,
Br
ui
ni
nk
s-
Os
er
et
sk
y
Te
st
of
M
ot
or
Pr
ofi
ci
en
cy
se
co
nd
Ed
iti
on
;
CN
S,
ce
nt
ra
l
ne
rv
ou
s
sy
st
em
;C
OP
M
,C
an
ad
ia
n
Oc
cu
pa
tio
na
l
Pe
rf
or
m
an
ce
M
ea
su
re
;C
P,
ce
re
br
al
pa
ls
y;
BM
S,
Ba
yl
ey
M
ot
or
De
ve
lo
pm
en
t
Sc
al
e;
CI
M
T,
co
ns
tr
ai
nt
-in
du
ce
d
m
ov
em
en
t
th
er
ap
y;
DD
ST
,D
en
ve
r
De
ve
lo
pm
en
ta
l
Sc
re
en
in
g
Te
st
;E
EG
,E
EG
;E
M
G,
El
ec
tr
om
yo
gr
ap
hy
;H
AB
IT
-IL
E,
Ha
nd
an
d
Ar
m
Bi
m
an
ua
l
In
te
ns
iv
e
Th
er
ap
y
In
cl
ud
in
g
Lo
w
er
Ex
tr
em
ity
;G
A,
ge
st
at
io
na
l
ag
e;
GM
FC
S,
Gr
os
s
M
ot
or
Fu
nc
tio
n
Cl
as
si
fi
ca
tio
n
Sy
st
em
;
GM
FM
,
Gr
os
s
M
ot
or
Fu
nc
tio
n
M
ea
su
re
;
GM
PM
,
Gr
os
s
M
ot
or
Pe
rf
or
m
an
ce
M
ea
su
re
;
IQ
,
IQ
;
M
in
iM
AC
S,
M
in
i
M
an
ua
l
Ab
ili
ty
Cl
as
si
fi
ca
tio
n
Sy
st
em
;
M
PO
C-
20
,
M
ea
su
re
of
Pr
oc
es
se
s
of
Ca
re
;
M
M
DT
,
M
in
ne
so
ta
M
an
ua
l
De
xt
er
ity
Te
st
;
NB
AS
,
Ne
on
at
al
Be
ha
vi
or
al
As
se
ss
m
en
t
Sc
al
e;
NI
CU
,
NI
CU
;
ND
T,
ne
ur
od
ev
el
op
m
en
ta
l
th
er
ap
y;
ND
S,
ne
ur
od
ev
el
op
m
en
ta
l
sc
or
e;
NF
DR
,
Ne
ur
of
ac
ili
ta
tio
n
of
De
ve
lo
pm
en
ta
l
Re
ac
tio
n;
OT
,
oc
cu
pa
tio
na
l
th
er
ap
y;
PD
M
S,
Pe
ab
od
y
De
ve
lo
pm
en
ta
l
M
ot
or
Sc
al
es
;
PE
DI
,
Pe
di
at
ri
c
Ev
al
ua
tio
n
of
Di
sa
bi
lit
y
In
ve
nt
or
y;
QU
ES
T,
Qu
al
ity
of
Up
pe
r
Ex
tr
em
ity
Sk
ill
s
Te
st
;
RC
T,
ra
nd
om
iz
ed
co
nt
ro
lle
d
tr
ia
l;
SI
,
se
ns
or
y
in
te
gr
at
io
n;
TO
A-
ND
T
Ta
sk
or
ie
nt
ed
ND
T;
TU
G,
Ti
m
ed
Up
an
d
Go
;V
GB
T,
vi
de
o
ga
m
e-
ba
se
d
th
er
ap
y;
W
CI
SD
,W
ay
ne
Co
un
ty
In
te
rm
ed
ia
te
Sc
ho
ol
Di
st
ri
ct
’s
Gr
os
s
M
ot
or
Ev
al
ua
tio
n.
a
M
et
in
cl
us
io
n
cr
ite
ri
a
fo
r
m
et
a-
an
al
ys
is
.
b
Co
ns
id
er
ed
in
fa
nt
po
pu
la
tio
n.
c
Ro
th
be
rg
19
91
33
fo
llo
w
-u
p
ou
tc
om
es
of
sa
m
e
co
ho
rt
re
po
rt
ed
in
Go
od
m
an
19
85
34
co
ho
rt
.
PEDIATRICS Volume 149, number 6, Month 2022 87
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by Universidade Federal da Bahia user
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(assessed on Domain 5 of RoB-2),
meaning that, overall, there was a
low risk of reporting bias among the
included studies. A funnel plot of
each meta-analysis was visually
inspected, with no asymmetry
detected for any comparator,
indicating a low risk for reporting
bias.
Certainty of Evidence
Overall, based on GRADE
methodology, the body of evidence
was rated as moderate-quality.
Recommendations for the use of
NDT for children and infants with
CP are (1) strong recommendation
for the use of activity-based
approaches in preference to NDT for
improving motor function (with
decisions informed by evidence
certainty, benefits versus lost
opportunity, family and clinician
preferences, cost-effectiveness) and
(2) strong recommendation against
the use of NDT at any dose for
improving motor function (with
decisions informed by evidence
certainty, benefit versus lost
opportunity, cost-effectiveness,
parent preference, feasibility, and
family burden). Evidence and
reasoning for the strength of
recommendations are detailed in the
Supplemental Material 1. The effect
size and comparative effectiveness
of each meta-analysis are depicted
in a bubble chart traffic map using
GRADE32 recommendations and the
Evidence Alert System22 (Fig 3).
DISCUSSION
Our primary objective was to
determine the efficacy of NDT on
any outcome in children and infants
with CP or high risk for CP. We
found 35 RCTs evaluating NDT
efficacy, which is a larger body of
evidence than for most topics in CP
rehabilitation. Despite the moderate
quality of the evidence, the claim
that insufficient evidence exists to
judge the efficacy of NDT can be
seriously challenged. We found no
difference in effect between NDT
and control or between different
doses of NDT. In addition, activity-
based and body function and
structures-based approaches
improved motor function over NDT
with a moderate effect. Findings
reveal top-down interventions are
superior for improving motor
function compared with bottom-up
interventions.
We have made strong
recommendations for the use of
activity-based interventions in
preference to NDT and against
the use of NDT at any dose to
improve motor outcomes in
infants and children with CP. The
certainty of evidence (moderate
quality) in combination with the
effect size of interventions, the
value people place on effective
motor interventions, costs,
impact on health equity,
acceptability, and feasibility of
NDT versus alternative effective
interventions using the GRADE
methodological approach32 were
all considered.
Large Effect
Large Effect
Moderate Effect
Moderate Effect
Small Effect
Small Effect
1 SD Be�er Off
1 SD Be�er Off
1–3 RCTs
Small Effect
Moderate Effect
Large Effect
1 SD Worse Off
Small Effect
Moderate Effect
EF
FE
CT
SI
ZE
EFFECTIVE
INEFFECTIVE
S+
W
+
S
-
DO
IT
TI
OD
YLBABORP
TI
O D
T’NOD
W
-
TI
OD
T’NOD
YLBABORP
15+ RCTs
4–15 RCTs
WORTH IT LINE
0.5
0.8
1.0
0.5
0.8
1.0
0.2
0.2
0.2
0.5
0.8
1.0
0.2
0.5
0.8
1.0
Ac�vity
Based v
NDT
NDT vs
No
therapyNDT high
vs low
dose
Observational Studies ONLY
MOTOR FUNCTION
INFANTS& CHILDREN
Body
Func�on
&
Structure
v NDT
FIGURE 3
Recommendations using GRADE32 based on evidence alert system.22 Green indicates strong recom-
mendation for, yellow a conditional recommendation,and red strong recommendation against use of an
intervention. Y-axis indicates effect size and comparative effectiveness using standardized mean difference.
88 TE VELDE et al
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It is worth discussing the exclusion
of the outlier study61 from the NDT
versus activity-based meta-analysis.
In this study, the NDT intervention
consisted of facilitation handling in
combination with a range of
activity-based elements, including
trunk activation, reaching during
standing or sitting activities. The
comparison intervention consisted
primarily of passive stretching with
some active tasks therefore, not
truly an activity-based approach
that could be pooled with other
studies. Results from the outlier
study61 suggest a child-active
approach is the effective element in
neurorehabilitation.
Overall body functions interventions
improved motor function over NDT,
but the effect size was influenced by
the studies with a high risk of bias,
meaning this result should be
interpreted with caution. Studies
that compared NDT with other body
function and structures-based
approaches for muscle strength46,47
used strength measures taken from
single muscle groups; therefore
results are unlikely to have
functional implications. The 2
studies that compared NDT with
body function and structures-based
approaches for muscle tone
outcomes58,59 tested NDT versus the
NFDR approach. Both studies had a
high risk of bias based on invalid
use of the Modified Ashworth
Scale;66 therefore the result that
NFDR is superior to NDT for
improving muscle tone should be
interpreted with caution. The same
2 studies58,59 revealed no difference
between NDT and NFDR on
primitive reflex status. This is not
surprising given it is scientifically
unlikely that distal manual
interventions will impact central
nervous system reflexes.
We only found 2 studies62,63 that
tested NDT versus environmental
approaches. The low methodological
quality of these studies meant no
meaningful results could be
extrapolated in this review.23,62,63
However, another systematic review
revealed environmental enrichment
improves motor function in infants
with CP with a small effect size
(0.39 [0.05 to 0.72]).67 Other
effective interventions (ie,
constraint-induced movement
therapy)68 also use enriched
environments to induce repetition,
practice, and learning. Because
home environments are typically
more enriching, we recommend
practice in a child’s real-life
environment.69
A previous systematic review from
200119 found NDT is not more
effective in a higher than lower dose
and our review support these
results. One study,4 with a low risk
of bias, is highly cited when
advocating the effectiveness of NDT
for improving motor function.
However, on close examination, the
CIs for the effect size (0.25 [�0.42
to 0.93]) cross the line of no effect
suggesting no genuine statistical
difference between doses.
Studies including infants <2 years
revealed a range of outcomes and
interventions across all
comparators. Most infant studies did
not favor NDT. Palmer and
colleagues’ publication41 was the
only infant study assessed as low
risk of bias to reveal a clear effect
that infant stimulation, an
activity-based approach, improved
motor outcomes over NDT. The
Palmer study reflects an emerging
trend in CP early interventions in
which early, activity-based, top-
down approaches are more effective
than bottom-up approaches in
improving motor function.23,70,71
In addition, findings are consistent
with results in older children with
CP outlined in this systematic
review. Intervention efficacy for
infants is a well-known gap in the
CP literature. Until recently, early
detection of CP was not routine,
leading to a lack of infant
intervention trials. Now, with
guidelines for accurately identifying
infants with CP,24 more studies
testing interventions in infants with
CP are underway.
Historically, it was argued that the
evidence quality was too poor and
evidence volume too small to
adequately test NDT. The quality of
studies varied in this review; 11 of
35 studies had a low risk of bias,
and the overall body of evidence
was rated moderate-quality by using
GRADE.32 However, we did find 35
RCTs with 1332 participants with
outcomes principally pointing in the
same direction. In addition, results
in this review mirror
recommendations for children72 and
adults73 after stroke, which,
although a different population,
have similar mechanisms of action
for neurorehabilitation.
In this review, ineffective
interventions for motor function had
the following common features:
facilitation, handling and positioning
to normalize or minimize atypical
motor behavior (movement), tone
and reflexes/reactions, passive
stretching, sensory support, and
vestibular input. In contrast,
effective interventions had the
following common features: learning
through active self-generated
movement, progressive, repetitive,
and varied specific task practice,
performance feedback, real-life
meaningful goals, and child
problem-solving, all of which are
based on neuroplasticity
principles.74,75
Limitations
Most studies were published before
Consolidated Standards of Reporting
Trials-compliant RCT76 reporting.
The NDT versus control comparator
included studies primarily from the
1970s and 1980s. It is no longer
ethical to provide no therapy or
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passive comparison interventions.
Studies were screened for “Bobath,”
“NDT,” and “Neurodevelopmental
therapy” or “treatment” search
terms in titles and abstracts. It is
likely studies that used NDT but
described it as “physiotherapy,”
“occupational therapy,” or
“traditional therapy” in the full text
may have been missed. However,
given the volume of literature found
and the use of hand searching, this
is unlikely to have influenced our
findings. Heterogeneity of the NDT
versus activity-based approaches
meta-analysis was considerable but
accounted for by diverse outcome
measures on subanalysis.
Heterogeneity of infant studies is a
limitation of the evidence; however,
with likely effective interventions in
this population,71,77 a strong
recommendation against the use of
NDT in infants was made. Despite
some studies with small sample
sizes and dated methods being a
limitation, it is still striking that
most studies did not favor NDT.
Lastly, excluding studies with
<30 hours dose for the dosage
comparator could be a limitation
because there are some effective
interventions with <30 hours dosage.
Implications for Practice, Policy, and
Future Research
Results from this review support the
deimplementation of NDT in clinical
practice. Deimplementation requires
evidence-based, multifaceted, and
context-specific strategies,78 which
include policy changes, restructuring
funding, and financing training for
effective alternatives to NDT.79
Multiple alternatives for NDT
exist;23 for example, task-specific
training,80 goal-directed training,80
treadmill training,81 constraint-
induced movement therapy,82 action
observation,30 and bimanual
therapy.82,84–86 Clinical education in
these effective alternatives is
required because Bobath or NDT
training is considered the best
rehabilitation training in some
countries.
CONCLUSIONS
We found activity-based
interventions are more effective
than NDT and no difference between
higher and lower dose NDT, nor
between NDT and control for
improving motor function in CP. We
give strong recommendations for
the use of activity-based
interventions in preference to NDT
and against the use of NDT at any
dose to improve motor function in
CP. Deimplementation of NDT in
clinical practice iswarranted and
will provide the best outcomes for
children with CP.
ACKNOWLEDGMENTS
We acknowledge Callum McEwan for
his contribution to data extraction.
ABBREVIATIONS
CI: confidence interval
CP: cerebral palsy
GRADE: Grading of
Recommendations
Assessment,
Development and
Evaluation
NDT: neurodevelopmental
therapy
NFDR: neurofacilitation of
developmental reaction
RCT: randomized controlled trial
RoB-2: Cochrane Risk of Bias-2
tool
Address correspondence to Anna te Velde, Cerebral Palsy Alliance Research Institute, PO Box 6427, Frenchs Forest, NSW, 2086, Australia. E-mail: atevelde@
cerebralpalsy.org.au
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright© 2022 by the American Academy of Pediatrics
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
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