Saturday, 22 March 2014

ANATOMY OF A RESEARCH PROJECT

Another supposedly poor result for CE

An outcome study, published last year from the Misr University for Science and Technology, Cairo, looks like what a lot of people accept as 'CE research', It has a quasi-experimental design, statistical tests of significance, histograms, an impressive list of top-flight references The following has been exerpted from its formal summary –
...to determine the effect of conductive education technique on gait pattern in hemiplegic cerebral palsied children... Thirty hemiplegic cerebral palsied children (20 left and 10 rights) with age ranging from 6 to 8 years... 17 males and 13 females... free from any associated disorders other than spasticity... IQ level within normal average range... divided randomly into two groups of equal numbers... Double blind evaluation... three months of treatment... Group A received a specially designed exercise program, while group B received a program of conductive education technique in addition to the same exercise program given to group A... no significant difference was evident in the post-treatment results in group B, when comparing the post-treatment mean values of the two groups... The non-improvement occurred in the measuring variables of group B may be attributed to the failing of conductive education technique in controlling spasticity of the lower limb muscles, which is manifested by the non-improvement, occurred in the hemiplegic gait pattern.

And what extra did Group B do?
The conductive education technique is widely used by occupational therapist and my by used by physiotherapist in the treatment of cerebral palsy. The general idea is to improve sensory integration with motor control which leads to more modulated motor responses, betters perception of the movements and improved coordination of line and gross motor patterns [7].

Conductive education is a systematic and holistic approach to develop problem-solving skills through an educational program for children with cerebral palsy and motor disorders. It is not a therapy but a multidisciplinary system that enhances the child's physical, cognitive, social skills and emotional well being [8]. Conductive education not just an exercise, it is “learning to learn” by intensive and repetitive practice, and the application of various activities necessary for progress. This applied to motor skills, balance, sensory for perceptual functions, emotional development, language and cognitive functions [9].

[7] Blondis, T. A; (1999) Motor disorders and attention, Pediatric Clinics of North America. Vol, 46, no 5, pp. 899-913.
[8] Bower, E. (1997) : The multiply handicapped child, Cambridge, Cambridge University Press, pp. 315-356.
[9] Horak, F.B. (2001) Motor control models underlying neurologic rehabilitation of posture in children, Basel, Karger, pp. 21-30.

No further details are given on what actually happened, at whose hands and under what circumstances.

Some of the discussion
The findings in our post-treatment results of study group on gait parameters in children with spastic hemiplegic cerebral palsy showed non-significant improvement when compared with the post-treatment results of the control group. This contradicts the results of an earlier study on flexion reflexes in patient with hemiplegic cerebral palsy (15), who reported that conductive education technique have an major effect on the improvement of motor skills in hemiplegic cerebral palsy.

On the other hand, the non-significant differences of all mean values of the gait parameters of the post-treatment results of the study group when compared with the post-treatment results of the control group. This findings agree with Gilliar (16) who concluded that the conductive education technique have no role on the modulation of muscle tone in spastic cerebral palsy.

Regarding to the non-significant difference in the non treatment results in both groups, this could be interpreted as, the oral translation into Arabic language of the conductive education program may be the cause of these non-significant results, as the songs, which used in the conductive education technique were conducted through the Engish language (17), or may be need of longer period of treatment.

[15] Dimitrijevic, M. R. (2001) : Studies of spasticity in cerebral palsy. Brain, vol. 91, pp.349-368.
[16] Gilliar, W. G. (1999) Neurologic basis of manual therapy in cerebral palsy, New England Journal of Medicine, vol. 11, pp. 1013-1020
[17] Patriquin, D. A. (2000) : Conductive education approaches to cerebral palsy. Journal of the American Osteopathic Association, vol. 12, pp. 92-95.

I should to seen discussed in the first place why it was thought that whatever was done was thought likely to affect gait – and what other effects of these three months were noticed in the children, their families and carers, and those providing this intervention. I would have also liked to air the lack of reference to the literature on Conductive Education (including but hardly exlusively previous research)..

Conclusion
As significant but equal improvement was recorded in the two groups after treatment, the results of this work exclude the conductive education technique (in English) as an effective procedure to be used in conjunction with physical therapy program in improving gait pattern of spastic hemiplegic cerebral palsy children.

Along time ago now Ludwig et al. drew perhaps the most important lesson to be found in reviewing CE research: the need for researchers to create and provide treatment manuals. The years since only emphasises the importance of this. I do not like blanket prohibitions but I now feel that the default position for interpreting outcome evaluations should be to discount all studies that do not manualise.

This minor study illustrates the problem all too well. The authors grant some space to describing their therapeutic and specially designed exercise programs but not a word about the conductive education, not even on where they obtained their understanding.

We must assume that everybody involved worked very hard and with the best intentions in the world. Perhaps they all enjoyed it all immensely and maybe gained in all sorts of ways (unfortunately not reported). 

The result here, however, is another supposedly scientific documentation to show that something or other did not achieve its desired effect – and this something or other, whatever it was, has been graced with the name Conductive Education.

Reference

Ludwig, S., Leggett, P., Hartsal, C, (2000) Conductive Education for children with cerebral palsy, Edmonton, Alberta Heritage Foundation for Medical Research

Olama, K. A., Kassem, H. I. (2013) Role of Conductive Education on gait in hemiplegic cerebral palsy, Advances in Bio-Medical Sciences [no volume or issue numbers]
http://www.mustirpj.com/index.php/Biomedical/article/view/22/18


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