Thursday, 10 June 2010

Chewing over the gristle of CE research

Another Scandinavian systematic review

Rony Schenker writes this morning to pass on the following –

Evidence-based perspective on CP rehabilitation
Reviews on physiotherapy, physiotherapy-related
motor-based interventions and orthotic devices
Heidi Antilla
Department of Public Health,
University of Helsinki

A review of reviews

Conductive Education is included in Heidi Antilla's detailed review of published research (more accurately: evaluations). Everyone in Conductive Education should already know the cumulative outcome of such studies. She puts it like this –

The effectiveness of conductive education has been evaluated in four reviews (French & Nommensen 1992; Ludwig et al. 2000; Pedersen 2000; Darrah et al. 2003). One RCT (Reddihough et al. 1998) and 21 observational studies (N=1264) were included in the four reviews, seven of the observational studies being included in more than one review. The overall conclusions of these reviews were concordant: the number of studies was too small and the quality too low to draw conclusions about the effectiveness or ineffectiveness of CE. (p. 80)

What is Conductive Education doing there?

The inclusion/exclusion criteria for Heidi Antilla's review are graciously broad:

There remains some debate as to what interventions to include or exclude in the category of physiotherapy interventions. It is not always clear as to which interventions are strictly physiotherapy and which should be considered to belong to other professions....These borderline interventions include the upper extremity interventions, sensory integration, and conductive education.... the analyses and results in this review comprise various handling, exercise and managing techniques of motor-based physiotherapy or physiotherapy-related interventions rather than all aspects of physiotherapy. (pp. 92-93)

Cough it up, spit it out, don't let it choke you!

She concludes –

...there is a need for original, well-designed, and longterm studies on the effects of many currently used and novel physiotherapy interventions in children with CP, as are also new methods for analysing the effects of comprehensive physiotherapy interventions.

Her words, '...original,well-designed, and longterm... also new methods', may seem unproblematical.

Are they not, however, just a fresh way to state the old mantra 'more research is needed'. Here is the problem of evaluation without research – rather like the perhaps associated problem of training without education. The problem has not been, as she implies, simply that studieshave been unoriginal, ill-designed and short-term, dependent upon old methods (though this is a fair judgement). It is that they have been carried out, as has been argued again and again in Conductive World, according to a paradigm that is inappropriate to the phenomena under investigation.

Without the vital component of critical re-examination of what Conductive Education is, and what questions really need asking of it, then 'Conductive Education research' may simply languish in the intellectual doldrums of more-of-the-same, leading inevitably to more of the same findings, enabling in their turn – no, requiring – yet further comprehensive systematic reviews such as Ms Antilla's, leading to yet more of the same ad infinitum till money and patience are all spent. Cui bono?

Best spit it out and take a bite of something new.

Not Conductive Education alone

The full abstract of this research review is appended below.

Its content does rather suggest that the research paradigm under question here seems to have its limits in investigating other 'interventions' too. It is not enough for Conductive Education to dismiss this as someone else's problem. Better by far to recognise congruities and commonalities of interest, and consider the implications of the whole colossal meta-error of reducing disabilities of any kind to the level of medicine, including the medical-style research paradigm represented above, and open dialogue with those who might potentially march alongside. 

Schenker et al. have demonstrated that dialogue is both possible and potentially fruitful. Peter Rosenbaum has reached up towards a more developmental model of what constitutes disability, from his base in paediatrics. Methodological issues around research (note, not specific methods), within the meta-question of the essentially systemic, developmental nature of human disability, would be a potentially profitable area on which to identify common ground and common actin between interventions.

First, however, Conductive Education really ought to get its own house in order.


Anttila, A. (2008) Evidence-based perspective on CP rehabilitation – reviews on physiotherapy, physiotherapy-related motor-based interventions and orthotic devices, Helsinki, STAKES Research Report 180

Rosenbaum, P. (2009) Cerebral palsy in the 21st century: what's new? In Morris, C., Condie, D. (eds) Recent developments in healthcare in cerebral palsy implications and opportunities for orthotics, Copenhagen, International Society for prosthetics and Orthotics, pp. 25-39

Schenker, R., Capelovitch, S., Sutton, A., Rosenbaum, P. (2010)  Conductive Education and NDT-Bobath: experts' discussion on history, development and current practice, Israeli Journal of Occupational Therapy, vol. 19, no 2, pp. E31-53


Full author's abstract

Heidi Anttila. Evidence-based Perspective on CP Rehabilitation – Reviews on physiotherapy, physiotherapy-related motor-based interventions and orthotic devices. STAKES, Research Report 180. Helsinki 2008. ISBN 978-951-33-2249-6

This thesis utilises an evidence-based approach to critically evaluate and summarize effectiveness research on physiotherapy, physiotherapy-related motor-based interventions and orthotic devices in children and adolescents with cerebral palsy (CP). It aims to assess the methodological challenges of the systematic reviews and trials, to evaluate the effectiveness of interventions in current use, and to make suggestions for future trials
Systematic reviews were searched from computerized bibliographic databases up to August 2007 for physiotherapy and physiotherapy-related interventions, and up to May 2003 for orthotic devices. Two reviewers independently identified, selected, and assessed the quality of the reviews using the Overview Quality Assessment Questionnaire complemented with decision rules.
From a sample of 14 randomized controlled trials (RCT) published between January 1990 and June 2003 we analysed the methods of sampling, recruitment, and comparability of groups; defined the components of a complex intervention; identified outcome measures based on the International Classification of Functioning, Disability and Health (ICF); analysed the clinical interpretation of score changes; and analysed trial reporting using a modified 33-item CONSORT (Consolidated Standards of Reporting Trials) checklist.
The effectiveness of physiotherapy and physiotherapy-related interventions in children with diagnosed CP was evaluated in a systematic review of randomised controlled trials that were searched from computerized databases from January 1990 up to February 2007. Two reviewers independently assessed the methodological quality, extracted the data, classified the outcomes using the ICF, and considered the level of evidence according to van Tulder et al. (2003).
We identified 21 reviews on physiotherapy and physiotherapy-related interventions and five on orthotic devices. These reviews summarized 23 or 5 randomised controlled trials and 104 or 27 observational studies, respectively. Only six reviews were of high quality. These found some evidence supporting strength training, constraint-induced movement therapy or hippotherapy, and insufficient evidence on comprehensive interventions. Based on the original studies included in the reviews on orthotic devices we found some short-term effects of lower limb casting on passive range of movement, and of ankle-foot orthoses on equinus walk. Long term effects of lower limb orthoses have not been studied. Evidence of upper limb casting or orthoses is conflicting.
In the sample of 14 RCTs, most trials used simple randomisation, complemented with matching or stratification, but only three specified the concealed allocation. Numerous studies provided sufficient details on the components of a complex intervention, but the overlap of outcome measures across studies was poor and the clinical interpretation of observed score changes was mostly missing. Almost half (48%) of the applicable CONSORT-based items (range 28–32) were reported adequately. Most reporting inadequacies were in outcome measures, sample size determination, details of the sequence generation, allocation concealment and implementation of the randomization, success of assessor blinding, recruitment and follow-up dates, intentionto- treat analysis, precision of the effect size, co-interventions, and adverse events.
The systematic review identified 22 trials on eight intervention categories. Four trials were of high quality. Moderate evidence of effectiveness was established for upper extremity treatments on attained goals, active supination and developmental status, and of constraint-induced therapy on the amount and quality of hand use. Moderate evidence of ineffectiveness was found for strength training’s effect on walking speed and stride length. Conflicting evidence was found for strength training's effect on gross motor function. For the other intervention categories the evidence was limited due to the low methodological quality and the statistically insignificant results of the studies.
The high-quality reviews provide both supportive and insufficient evidence on some physiotherapy interventions. The poor quality of most reviews calls for caution, although most reviews drew no conclusions on effectiveness due to the poor quality of the primary studies. A considerable number of RCTs of good to fair methodological and reporting quality indicate that informative and well-reported RCTs on complex interventions in children and adolescents with CP are feasible. Nevertheless, methodological improvement is needed in certain areas of the trial design and performance, and the trial authors are encouraged to follow the CONSORT criteria. Based on RCTs we established moderate evidence for some effectiveness of upper extremity training. Due to limitations in methodological quality and variations in population, interventions and outcomes, mostly limited evidence on the effectiveness of most physiotherapy interventions is available to guide clinical practice. Well-designed trials are needed, especially for focused physiotherapy interventions.
Keywords: cerebral palsy, children, adolescents, physical therapy, conductive education, orthotic devices, systematic review

This report in its entirety (free, open access):

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