Wednesday, 12 March 2014

RESEARCH REVIEW: SAME OLD SONG

'Further investigation is clearly warranted'

The Center on Personnel Studies in Special Education is a cooperative agreement between the University of Florida and the Office of Special Education Programs of the US Department of Education. Its research is intended to inform scholars and policymakers about advantages and disadvantages of preparation alternatives and the effective use of public funds in addressing personnel shortages.

In 2007 it published a report by Susan K. Effgen (U. of Kentucky) and Irene R. McKewen (U. of Oklahoma), a review of selected physical therapy interventions for school-age children with disabilities.

One of the 'physical therapy interventions ' included was Conductive Education –
This paper reports on physical therapy procedural interventions with enough research available to have been the topic of one or more systematic reviews. The interventions covered include:
adapted seating for children with cerebral palsy [CP];
conductive education;
constraint-induced movement therapy;
lower extremity casting, orthoses, and splints for children with neurological disorders;
neurodevelopmental treatment;
partial body weight supported treadmill training;
passive stretching to improve range of motion [ROM];
strengthening for children with CP; and
weight bearing interventions for children with CP.
The paper also provides recommendations for application to physical therapy school-based practice and future research.
(p. 1)

The report's specific attention to Conductive Education reads as follows, in full –

Conductive Education (CE)
CE is a holistic approach to the development and education of children with neurological dysfunction, predominantly CP. Individuals trained to provide this intervention are called conductors. Although conductors are available in many parts of the world, an increasing trend, including in the U.S., is for physical therapists to provide the integrated gross motor portion of this curriculum. Parents frequently request this intervention for their children in school settings (Feinberg, Beyer, & Moses, 2002).

CE is not a therapy system but a system of education that aims to teach and motivate the child to function in society. Emphasis is placed on motivation, developing self-esteem, emotional and cognitive growth, and motor function. This school-based comprehensive program has gained popularity around the world, and a number of studies have been done in England and Australia. See the findings in Table 6
A systematic review by Darrah, Watkins, Chen, and Bonin (2004) of 15 articles published between 1966 and 2001 found only 1 study with the highest level of evidence; 9 of the 15 studies were classified as Level III or IV. Most studies received weak ratings for control of threats to internal validity. These authors concluded that: “The present literature base does not provide conclusive evidence either in support of or against CE as an intervention strategy. The limited number of studies and their weak quality makes it impossible for the literature alone to guide decision-making regarding CE” (p. 202). The Darrah et al. review and a review by the Alberta Heritage Foundation for Medical Research (Ludwig , Leggett, & Harstall, 2000) suggest that CE is no more effective than “traditional educational and therapeutic intervention” and “there is no good scientific evidence to support the use of CE in place of other treatment programs for children with cerebral palsy” (p. ii).

A study by Stiller, Marcoux, and Olson (2003), published after the systematic review, investigated the effects of intensive therapy (1 hour of individual physical therapy, occupational therapy, speech therapy and group therapy per day), CE (6 hours/day), and special education (6 hours/day with therapy provided as indicated in the child’s IEP) on the function of 19 children with CP. After a program of 5 days/week for 5 weeks, there were no statistical differences between groups; however, further analyses indicated statistically significant changes for the intensive therapy group on the Pediatric Evaluation of Disability Inventory (PEDI) self-care and social function scales and on the crawling and kneeling scales of the Gross Motor Function Measure (GMFM). The secondary findings of this non-randomized controlled trial study suggest that intensive therapy may be more effective for children with CP than CE or special education services; however, further investigation is clearly required.

In summary, the systematic reviews indicated that CE is as effective as traditional physical therapy when intensity of intervention is controlled. In general practice not involving research, CE has a higher level of intensity of intervention than traditional therapy. The lack of significant benefits of CE over traditional physical therapy when intensity is controlled for, coupled with the findings of Stiller et al. (2003), which suggest that intensive therapy is more effective for children with CP than CE or special education services, raises concerns about this intervention.

Further investigation is clearly warranted.

(pp. 12-33)

Commentary

1.  The criterion of having been 'the topic of one or more systematic reviews' is potentially useful, both vouching some substantive interest in given topics and offering a wider range of authoritative critical opinion. Empirical outcome studies on Conductive Education have attracted a number of critical reviews over the years.

2.  The nine 'physical therapy interventions' listed have in common only that they are regarded as such for the purposes of this review. 

3.  '...an increasing trend, including in the U.S., is for physical therapists to provide the integrated gross motor portion of this curriculum': interesting but unevidenced assertion. 

4.  'Parents frequently request this intervention for their children in school settings (Feinberg, Beyer, & Moses, 2002)'. This may or may not be true but the report cited neither supports nor even documents what is said here, being a book of a quite different kind. Its only mention of CE is on page 11: 
...Parents and districts have also argued over such specialized reading methodologies [sic] as Orton-Gillingham, sensory integration and conductive education. In the last few decades, a range of interventions has emerged that offer the possibility of extraordinary outcomes. However, some of these therapies tend to be expensive and require highly specialized personnel. The intensive applied behavior analysis methodology of Dr. Ivar Lovaas, for example, was the major cause of disputes between parents of young children and early intervention systems and school districts during the 1990s [ref.] Parents and districts have also argued over such specialized reading methodologies as Orton-Gillingham, sensory integration and conductive education.
 (p, 11)
5.  Table 6 cites only one study, Darrah et al., (20o4), quoting as its main conclusion – 
The present literature base does not provide conclusive evidence either in support of or against CE as an intervention strategy. The limited number of studies and their weak quality makes it impossible for the literature alone to guide decision-making regarding CE.
This is repeated in the text 

6.  Also in the text is citation of the review by Ludiwg et al. (2000). A badly constructed sentence leaves it unclear the origin of a quotation given to say that  CE is no more effective than 'traditional educational and therapeutic intervention' and that 'there is no good scientific evidence to support the use of CE in place of other treatment programs for children with cerebral palsy'. 

It comes in fact from Ludwig et al

7.  The article by Stiller et al is important for reaching this review's conclusion. The reference is, however, given at the foot of this posting, along with the URL of its full text on line. Readers may draw their on opinion about its relevance. 

8.  'In summary, the systematic reviews indicated...' In fact this review fails to justify its opening claim to 'inform scholars and policymakers about advantages and disadvantages of preparation alternatives and the effective use of public funds in addressing personnel shortages'.

9.  'Further investigation is clearly warranted.' By whom? To what end? What kind? No answer to such questions, or even hypotheses, emerge from this review. 
Conclusion

The review itself concludes –
CE is an intervention method that parents often request and is a frequent area of dispute in school settings (Feinberg, Beyer, & Moses, 2002). Systematic reviews indicated that CE is as effective as traditional physical therapy when intensity of intervention is controlled. The lack of significant benefits of CE over traditional physical therapy coupled with the findings of Stiller et al. (2003), which suggest that intensive therapy is more effective for children with CP than CE or special education services, raises concerns about this intervention. The intensive and integrative nature of CE, combining education and therapy into meaningful, functional activities, however, could serve as a best-practices model for therapeutic interventions.
(p.23)

In other words, it doesn't work – but we could do it.

I do not know what weight 'scholars and policymakers' attach to such documents – or parents and practitioners. Precious little, I suspect, if they ever see them. One could dismiss them as being of only the most minor historical interest – except that the academic repute of CE does seem to decline, or at the very least fail to rise, and it is hard not to see reviews of this quality as this being just another straw...

References

Darrah, J., Watkins, B., Chen, L., Bonin, C. (2004). Effects of conductive education intervention for children with a diagnosis of cerebral palsy: An AACPDM evidence report. Developmental Medicine and Child Neurology, vol. 46, pp. 187-203

Effgen, S. K., McKewen, I.R. (2007) Review of selected physical therapy interventions for school age children with disabilities, Gainsville, University of Florida, Center on Personnel Studies in Special Education

Feinberg, E., Beyer, J., Moses, P. (2002) Beyond Mediation: Strategies for Appropriate Early Dispute Resolution in Special Education, Eugene, OR, Consortium for Appropriate Dispute Resolution in Special Education (CADRE)

Ludwig, S., Leggett, P., Harstall, C. (2000). Conductive education for children with cerebral palsy, Edmonton, Alberta Heritage Foundation for Medical Research http://www.ihe.ca/documents/cond_edu.pdf

Stiller, C., Marcoux, B. C., Olson, R. E. (2003). The effect of conductive education, intensive therapy, and special education services on motor skills in children with cerebral palsy,
Physical and Occupational Therapy in Pediatrics, vol. 23, no 3, pp. 31-50


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