Assessment of conductive education for children and adolescents with brain damage: a health technology assessment
Health technology assessment
|Published
Conductive education, or the Petö method, is one of several therapeutic programs for children and adolescents with brain damage. We systematically summarized and graded clinical effectiveness and safety. We also performed a health economic analysis as a cost description in a health care perspective.
Key message
Conductive education, or the Petö method, is one of several therapeutic programs for children and adolescents with brain damage. Dr András Petö provided the foundation for the method in Hungary in the 1940s. There are uncertainties regarding the effect of the method. We systematically summarized and graded clinical effectiveness and safety. We also performed a health economic analysis as a cost description in a health care perspective.
- We found three small randomized controlled studies and six non-randomized controlled studies on the clinical effect of conductive education. All studies included children and adolescents with cerebral palsy. The studies had few participants and methodological weaknesses.
- We found no statistical differences in effect between conductive education and standard care on gross motor function, fine motor function, cognitive function, and quality of life. Our certainty to the evidence was low to very low judged by Grading of Recommendations Assessment, Development and Evaluation (GRADE).
- None of the studies examined psychological health, or safety.
- In 2015, the total cost of conductive education was 13,351,367 Norwegian kroner. The average cost was 79,002 Norwegian kroner per participant with family.
Summary
Background
The rights of children and adolescents with brain damage to therapeutic treatment are established in the Patients’ Rights Act (Lov om pasient- og brukerrettigheter). Conductive education or the Petö method is one of several therapeutic programs for children and adolescents with brain damage. The efficacy of the method, developed by Dr. András Petö in Hungary in the 1940s is under debate.
In this health technology assessment, we have systematically summarized and quality-assessed available research on clinical effects and adverse events associated with conductive education for children and adolescents with brain damage. We also performed a health-economic analysis that catalogues treatment costs. The health technology assessment is prepared for the Norwegian System for New Health Technologies.
Method
Clinical efficacy and safety
We conducted systematic literature searches in the CINAHL, Cochrane library, Ovid, Epistemonicos, PEDro and SveMed databases through October 2016. Two researchers assessed the search results independently. We read relevant publications in full text and included publications that met our inclusion criteria. We assessed study bias using the Risk of Bias tool. The main outcomes were gross motor function, fine motor function, cognitive function, quality of life, mental health and stress, as well as adverse events. Secondary outcomes were activities of daily life, communication and language, behaviour, social participation and skills, and school skills. Secondary outcomes also included outcomes related to the family, such as family functioning, stress, parents’ mental health and quality of life, quality of life of siblings, and parents' occupational participation. We compiled data using the Review Manager 5.03 software, and calculated standardized mean differences between groups and 95% confidence intervals. We assessed the quality of the effect estimates using Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Health Economics Analysis
We have described costs related to the conductive education program. The total cost of the conductive education program consists of costs related to the program as implemented in Norway, and travel and in-patient and/or hotel stays associated with treatment. In order to obtain the most realistic description of the costs, we have based our calculations on actual processes of the programs. All costs are expressed in Norwegian kroner, and we present an estimate of average cost per participant with family. We have described costs from a health service perspective, with a time horizon of one year. A health service perspective includes costs that are paid from the Norwegian health service’s budget.
Results
Clinical efficacy and safety
Nine studies, with 11 publications, and 293 participants, fulfilled the inclusion criteria and were included. Of these, three were randomized controlled studies, and six were controlled studies without randomization. All studies included children with cerebral palsy. The studies were conducted in Norway, Sweden, United Kingdom, Australia, the United States and Iran. Only two studies were conducted during the past 10 years.
We found no statistical difference between conductive education and control groups in gross motor function, fine motor function, cognitive function, quality of life, activities of daily life, communication and language, behaviour, social functioning, and parent’s mental health and quality of life. We did not find studies that examined mental health and stress in children, children's school skills, family functioning and stress, quality of life for siblings, or parents' occupational participation. None of the studies systematically reported adverse events, but one study noted that no adverse events occurred in the conductive education or the control group.
The Risk of Bias assessment showed that seven out of nine studies had a high risk of bias. The certainty to the overall documentation was judged to be low to very low using the GRADE tool.
Health Economics
The PTØ centers in the South-Eastern, Western and Central Norwegian health districts, had 147 participants between 0-18 years in 2015. In addition, 22 children attend the conductive education program in Northern Norwegian health district in 2015.
Based on 2015 costs in the South-Eastern, Western and Central Norwegian health districts, the estimated average cost per participant with family was 87,339 Norwegian kroner (12,838,840 Norwegian kroner / 147 participants). In the Northern Norwegian health district, the average cost per participant with family was 23,297 Norwegian kroner (512,527 Norwegian kroner / 22 participants). The estimated average cost per participant with family was 79,002 Norwegian kroner (13,351,367 Norwegian kroner / 169 participants), across all health regions.
Discussion
Clinical efficacy and safety
We calculated standardized mean differences between the conductive education and control groups, both in meta-analysis and for each outcome in each of the included studies. Mainly, we found no statistical differences between the conductive education and control groups for any of the outcomes. However, in a few analyses we found statistically significant differences between the intervention and the control groups, both in favour of conductive education and in favour of controls. This could reflect either chance or baseline differences between the groups, so these results must be interpreted with caution.
Health Economics
In the absence of guidelines and lack of documentation for the effect of conductive education it was not useful to perform a complete economic evaluation, only an economic analysis. In our economic analysis, we used the health service perspective. This is relevant for the Decision Forum in the Norwegian System for New Health Technologies, which assesses the distribution of resources in the specialist health service.
Further research
The available research on clinical effect and adverse events in conductive education for children and adolescents with brain injury is limited. More research may be needed on the effects and adverse events associated with conductive education, especially if the program is to be financed by the regional health authorities. Because of the small number of Norwegian patients, new studies may require international cooperation.
Conclusion
We found no statistical differences in efficacy between conductive education and other forms of training for children with brain damage on gross motor function, fine motor function, cognitive function or quality of life, and the certainty to the documentation was low to very low.
For 2015, the total cost of the conductive education programs was 13,351,367 Norwegian kroner. The average cost per participant with family for an average of two treatment periods with a duration of three to five hours per day for one to three weeks was 79,002 Norwegian kroner.
