Intensive training/habilitation of children with congenital and acquire brain damage
Systematic review
|Updated
Key message
Background
The Norwegian Knowledge Centre for the Health Services was asked by the Norwegian Directorate of Health to review national and international research concerning intensive training/rehabilitation of children with brain damage.
Objective
In order to clarify the objective we addressed this question:
What does research on the effectiveness of intensive training/habilitation for children with brain damages show?
Methods
We searched systematically for articles in relevant international databases, included articles that met our inclusion criteria, critically appraised and summarised the results descriptively.
Results
We summarised results from seven systematic reviews and 20 separate studies. According to the summary, the Constraint Induced (Movement) Therapy (CIMT/CI) may be better to improve upper limb function for children with spastic unilateral CP than usual treatment. There is uncertainty related to this result. Early intervention for infants at risk for brain damage or with acquired brain damage, may also improve motor and cognitive development better than usual treatment. The quality of the evidence was from moderate to low according to GRADE.
Since the rest of the included reviews and studies were characterised by heterogeneity, sparse data and methodological flaws, we do not know whether other intensive training interventions are better than usual training according to our evidence. Due to heterogeneity in population, interventions and outcome measurements, it was not possible to perform meta-analysis.
We did not find evidence of programmes like Advanced Bio-Mechanical Rehabilitation, Doman, Family Hope program and the method of Kozijavkin that met our inclusion criteria.
Conclusion
Only evidence of CIMT/CI and early intervention showed possible promising effect. More and rigorous research is required to answer the question addressed.
Summary
Background
Demands for intensive training/habilitation for children with brain damage have increased in recent years. To approach these requests, central health authorities have initiated intensive training/habilitation projects around the country.
The National Knowledge Centre for Health Care was commissioned by the Norwegian Health Directorate to produce a systematic review of the present knowledge about the effect of intensive training/habilitation of children with brain damage.
Objective
To specify the purpose of the assignment, we posed a main question with sub questions.
The purpose of the report was to address the following questions:
What effects are shown from research on the intensive training/habilitation for children with brain damages?
The sub questions were compared to usual training/habilitation and explored the effects of :
- intensive training of movement- related bodily functions
- intensive training of language, supplementary and alternative communication forms
- intensive training of concentration and memory
- intensive training of activities of daily life
- national and international treatment/training programs (such as Petø and similar)
- efforts aimed towards the child, family and close relatives (as early intervention)
Methods
Based on the commission, the Knowledge centre established a multidisciplinary research group with specialists and researchers within child habilitation and with a consumer representative to assist in the report.
We performed a systematic search for articles in the Cochrane Database of Systemic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE Cochrane), Health Technology Assesment Database (HTA), Medline, Embase, Pedro, Cochrane Central, Cinahl, ERIC, PsycInfo and Swemed.
Two people independently selected studies that fulfilled the inclusion criteria.
The inclusion criteria for the report were:
Population : Children and young people in the age group 0-18 years with acquired and congenital brain damage
Intervention : Systematic and focused training and habilitation efforts with a minimum range of 3 times a week up to several times a day for one of more periods of time. The interventions are to be focused and contribute to the childs development of movements functions, social, mental and communication skills. The interventions were required to be performed through limited time periods.
Outcomes related to the child: Quality of life, language/communication, ability to care for themselves (including nourishment), ability to move around, social functioning, cognitive functions, executive functions, motor abilities, ADL and general health.
Outcomes related to the family: Quality of life, sense of coherence, parents competence, satisfaction with the services offered, compliance, the parents physical and mental health, economy, stress and optimism
Study design: Systematic reviews, randomized controlled trials RCT, non-randomized controlled trials CCT and controlled before- and after trials (CBA)
We performed critical appraisal of the relevant articles that met our inclusion criteria for quality of method, and described the included reviews and studies in text and tables. Furthermore we summarized the results from the included reviews and controlled studies descriptively, as the participants, interventions and outcome measures were too heterogeneous to assimilate in a meta-analysis.
Results
We have summarized the results from 7 systematic reviews and 20 separate studies. The summary showed that Constraint Induced (Movement) therapy (CIMT/CI) possibly improved the functioning of the hand more for children with spastic unilateral CP than usual care. The results were significant for some measurements, but not for all. The strength of the documentation was low. There is uncertainty related to this result.
The collective documentation also indicated that education of parents in specific habilitation (early intervention) possibly improved motoric and cognitive skills more in children with, or at the risk of developing, brain damage more than usual care. The results were significant for most of the measurements. The strength of the documentation varied from moderate to low.
Large segments of the documentary basis were characterized by inconsistent results, few participants and methodical weakness regarding reporting and execution. Consequently we do not know whether intensive training of movement related bodily functions, intensive cognitive training, intensive language training, intensive training of activities of daily life and treatment- and training programs that are given in Norway (such as Petø, Bobath and Vojta), are better than other training /habilitation efforts.
None of the reviews or single RCTs was judged by GRADE as of high documentation value. Most of the documentation was of moderate or low quality. We also judged some of the documentation to be of very low quality. Consequently there is a large uncertainty attached to the results and that we are not certain about the effects of the interventions.
We have not found systematic reviews or controlled studies that have evaluated the effect of foreign programs such as Advanced Bio-Mechanical Rehabilitation (ARB), Institute of Human Potential program (IAHP/Doman), Family Hope program og Kozijavkin-metoden. That implies that we do not know the effects of these programs.
Conclusions
The summarized documentation showed that only CIMT/CI and early intervention was possibly better than usual training/habilitation for children with brain damages. There are uncertainties related to these results. For the other intensive treatments which are evaluated in the present report, we do not know whether they are better than usual training/habilitation interventions. More and better research is required generally in this field, especially regarding the international programmes.
Norwegian Knowledge Centre for the Health Services summarizes and disseminates evidence concerning the effect of treatments, methods, and interventions in health services, in addition to monitoring health service quality. Our goal is to support good decision making in order to provide patients in Norway with the best possible care. The Centre is organized under The Directorate for Health and Social Affairs, but is scientifically and professionally independent. The Centre has no authority to develop health policy or responsibility to implement policies.
Defined by us as training less than 3 times per week.