Niger J Paed 2014; 41 (2): 116 –119
ORIGINAL
Ezema CI
Effect of neuro-developmental
Lamina S
Nkama RE
therapy (NDT) on disability level
Ezugwu UA
of subjects with cerebral palsy
Amaeze AA
receiving physiotherapy at the
Nwankwo MJ
University of Nigeria Teaching
Hospital, Enugu, Nigeria
DOI:http://dx.doi.org/10.4314/njp.v41i2,7
Accepted: 6th December 2013
Abstract:
Aim and Objective:
[NDT]) exercises using GMFCS.
Cerebral palsy (CP) describes a
Simple percentage (%), Kruskal
Lamina S (
)
group of disorders causing activity
Wallis and Mann-Whitney tests
Department of Biomedical Technol-
limitation which is attributed to
ogy
, School of Health Technology,
were
used in data analyses.
Federal University of Technology,
non-progressive disturbances that
Results: The
highest number
of
Owerri. Imo State, Nigeria.
occur in the developing fetal or
disability recovery cases are in the
Email: siklam_86@yahoo.co.uk
infant brain. The rehabilitation of
treatment frequency group of > 2
Tell: +234-8035319469
children with CP has focused on
treatment per week 17(56.68%)
increasing functionality in their
and the first 3-6 months of treat-
Ezema CI, Nkama RE
daily activities. The objective of
ment duration15 (50%) of NDT-
Department of Medical Rehabilitation,
this study was to assess the disabil-
Physiotherapy. However, Disabil-
Faculty of Health Sciences and Tech-
ity levels of cerebral palsy patients
ity level reduces with longer (>12
nology, University of Nigeria, Enugu
receiving physiotherapy treatment
Campus. Enugu State, Nigeria.
months) treatment duration.
Re-
at
Physiotherapy department, Uni-
sults also showed significant fre-
Ezugwu UA, Amaeze AA
versity of Nigeria Teaching Hospi-
quency and duration treatment
Department of Physiotherapy,
tal, Enugu, Nigeria.
effects on disability level follow-
University of Nigeria Teaching
Methods: The
study is
a retrospec-
ing
NDT-Physiotherapy at
p<
Hospital, Ituku Ozalla,
tive-repeated
measures
design,
0.05.
Enugu State, Nigeria.
involving the use of Gross Motor
Conclusion: It
was concluded
that
Function
Classification
System
both
duration and frequent of treat-
Nwankwo MJ
(GMFCS) and the medical records
ment were important factors in the
Department of Medical Rehabilitation,
of
the patients. The duration and
Faculty of Health Sciences and
management of CP using NDT-
Technology, Nnamdi Azikiwe
frequency of treatment were ob-
Physiotherapy.
University,
tained from the patients’ folders.
Anambra State. Nigeria.
They were initially assessed on the
Key words: Cerebral
palsy, Dis-
first visit and re-assessed after 3, 6
ability, Gross Motor Function,
and ≥ 12 months of physiotherapy
Neuro-developmental therapy,
(Neuro-developmental
therapy
Introduction
genetic factors, malformations and vascular complica-
tions
4,
5
.
The above aetiological factors are classified as
prenatal, perinatal and postnatal
6,
7
Cerebral palsy (CP) refers to a group of non-
.
progressive, but often changing motor impairment syn-
dromes secondary to lesions or anomalies of the brain
Cerebral palsy cannot be cured, but treatment will often
1,
2
arising in the early stages of development
.
Cerebral
improve a child’s capabilities. Early treatment of chil-
palsy
is a major cause of childhood disability and has
dren with CP will often improve a child’s capabilities,
been described as one of the three most common life-
functions and many children go on to enjoy near normal
3,
5
long developmental disabilities in childhood. The other
adult lives if their disabilities are properly managed
.
two being autism and mental retardation. CP is more
The treatment approaches in the management of CP in-
prevalent in the more socio-economically deprived
clude: counselling, drug therapy, education, surgery,
populations of the world . A reasonable estimate of the
1
physiotherapy, orthotics and assistive technology. In
prevalence of CP at school age is two per 1000 live
physiotherapy treatment of CP, various approaches are
births in industrialised nations . Causes of CP include
3
based on different theories of motor learning. Com-
prematurity, asphyxia, trauma, severe jaundice, hypogly-
monly used physiotherapeutic approaches in treatment
caemia, intrauterine virus infection, neonatal meningitis,
of
children with CP are neuro-developmental treatment
117
(NDT) or Bobath therapy, conductive education (CE) by
Data
Analysis: The results were presented with the use
Petö, reflex locomotion therapy by Vojta, and functional
of
numbers (n) and simple percentage (%). Mann Whit-
task-oriented training. Other methods used are the pat-
ney U and Kruskal Wallis tests were used to determine
terning method by doman & delacato, and sensory inte-
the
association between variables. All statistical analysis
gration by Ayres. In the last decade, especially, the use
was performed using Statistical Package for the Social
of
NDT in treatment of children with CP has been con-
Sciences (SPSS) (Windows Version 16.0 Chicago IL,
troversial, with the most common concern that NDT
USA). A probability level of 0.05 or less was used to
insufficiently targets functional activities and participa-
indicate statistical significance.
tion by using only neuro-maturational strategies in
learning . However, literature seems silent on CP sub-
7
jects’ responses to NDT in this part of the world. The
purpose of this study was therefore to investigate the
Results
disability level
in
CP
subjects
receiving
NDT-
Physiotherapy at the University of Nigeria Teaching
In
the study, 17(56.67%) male and 13 (43.33%) females
Hospital, Enugu, Nigeria.
participated. Age group > 2 years reported the highest
number cases of CP; reported cases for age group <
2years for male and females are 11 (36.67%) and 8
(26.67%) respectively. Detailed age group demographic
Methods and Materials
data are depicted on table 1. In all, about 15(50%) of the
subjects reported improvement in disability level.
Population and Subjects:
Population for
the study
was
40
male and female CP patients attending the Physio-
Table 1: Age
demographic data
of the
subjects with
CP
therapy Department of the University of Nigeria Teach-
(N=30)
ing Hospital (UNTH), Enugu. Sample size was deter-
Male
Females
Total
mined using the sample size calculator by Creative Re-
Age
group
n
(%)
n
(%)
n(%)
search System Survey Software (CRSSS) (Petaluma,
<
2years
11(36.67)
8(26.67)
19(63.33)
CA, USA). Thirty (17 males and 13 females) CP pa-
2-3
years
4(13.33)
3(10.00)
7(23.33)
tients (with Gross Motor Function Classification System
> 3years
2(6.67)
2(6.67)
4(13.33)
Total
17(56.67)
13(43.33)
30(100)
[GMFCS] Levels II to IV) served as subjects. The pa-
tients’ age ranged between one and six years. Subjects’
parents/carers
were fully informed about the experimen-
Table
2 shows the duration of treatment by gender; treat-
tal
procedures, risk and protocol, after which they gave
ment duration group of 3-6 months reported the highest
their signed informed consent. Ethical approval was
cases. In this treatment group male and female reported
granted by the research and ethics committee of the
8
(26.33%) and 7 (23.33) respectively. Detailed treat-
UNTH, Enugu.
ment duration by gender cases are on table 2.
Research design: A
retrospective repeated measures
Table 2: Duration
of treatment
and gender
responses to
design was used to assess the disability level of CP sub-
treatment (N=30)
jects’ receiving NDT-Physiotherapy at the UNTH,
Male
Females
Total
Enugu, Nigeria.
Duration of treatment
n
(%)
n
(%)
N
(%)
Procedure: The
demographic data
of the
patients, time
3 -
6 months
8
(26.67)
7
(23.33)
15
(50.00)
of
commencement of treatment, duration of treatment
6 -
12 months
5
(16.87)
4(13.33)
9
(30.00)
and frequency of treatment were obtained from the case
>12month
4
(13.33)
2(6.67)
6
(20.00)
folders. The patients’ mobility status was assessed at the
Total
17
(56.67)
13(43.33)
30
(100)
time of contact and reassessed after 3, 6 and ≥ 12 months
of
physiotherapy treatment and treatment frequency of >
The highest number of disability recovery cases 17
2
session per week and ≤ 2 (a session is 1 to 2hrs). Sub-
(56.67%) are in the treatment frequency group of > 2
jects’ parents/carers also provided information on the
treatment per week. The highest number of disability
mobility status of the patients.
recovery cases 15 (50%) are in the first 3-6 months of
NDT treatment duration. Number of number of disabil-
The materials used for outcome variable assessment
ity recovery cases reported for male and females are 9
include Gross Motor Function Classification System
(30.0%) and 8 (26.67) respectively. The treatment fre-
(GMFCS). The scale is one of the scales popularly used
quency group by gender are shown on table 3.
for assessment of disability/functional status of patients
with cerebral palsy. The GMFCS for cerebral palsy is a
Table 3: Frequency
of treatment
and gender
responses to
treat-
motor assessment scale, based on self-initiated move-
ment (N=30)
ment, with emphasis on sitting, transfers, and mobility.
Treatment sessions
Male
Female
Total
The scale is classified as follows: level I - walks without
n
(%)
n
(%)
n
(%)
limitations; level II - walks with limitations; level III -
≤ 2
times per weekly 8(26.67)
5(16.67)
13(43.33)
walks using a hand-held mobility device; level IV - self-
> 2times per week
9(30.00)
8(26.67)
17(56.67)
mobility with limitations; may use powered mobility;
Total
17(56.67)
13(43.33)
30
(100)
level V - transported in a manual wheelchair
4,
8
.
118
Krukal Wallis and Mann U Whitneny’s tests (table 4)
effectiveness of a year-long integrated rehabilitation
indicated significant treatment duration effect (X =
2
program for young children (less than 6 years old) with
9.174, p= .010) and treatment frequency (U= 55.000,
cerebral palsy in Italy. A sample of 40 children took
p=
.011) respectively. Mann U Whitney’s test (table 4)
part. Gross Motor Function Measure Classification Sys-
also indicated no significant (U= 389.000, P= .404)
tem at baseline and after one year of treatment was
groups’ effect between treatment duration and treatment
taken. They reported an improvement in gross motor
frequency at p, 0.05.
function, with 37% of children improving and no chil-
dren showing lowered function. In their study a larger
Table 4: Kruskal
Wallis and
Mann U
Whitneny’s summary
percentage of the patients attended up to one year
for
groups’ disability level (N= 30)
period.
X
-values
2
Variables
p-values
Groups treatment duration
9.174
.010*
Results of the present study also indicated significant
Groups treatment frequency
55.000
.011*
improvement in disability level following NDT in both
Groups duration and
398.000
.404
treatment and frequency of treatment. This above find-
frequency treatment
ing is in agreement with the findings of Tsorlakis et al.
10
who studied the effect of NDT and differences in in-
significant* P<0.05
tensity on gross motor function of children with cerebral
palsy (CP) in Greece. Their results showed that the gross
Figure 1 and 2 depicted disability level responses to
motor function of the children improved significantly
treatment duration and frequency groups. Disability
after intervention. The present study indicated that fre-
level decreases in the treatment duration and frequency
quent and long term NDT management (>12months &
groups of > 12months and > 2 session per week respec-
>1 times/weekly respectively) of CP gives better im-
tively.
provement in disability level than short and few fre-
quency (<12months & <1 weekly respectively). This
Fig 1: Disability
level responses
to treatment
duration
finding agreed with the study by Lilly and Powell [11]
who looked at the effects of short-term therapy (1 to 2
hours/week for 12 weeks) using a crossover design in
which two children acted as their own controls produc-
ing level II evidence suggesting there was no difference
between physiological motor function following NDT
versus play. Other similar studies
12-14
have showed sig-
nificant effect of NDT on GMFM among subjects with
CP.
Fig 2: Disability
level responses
to treatment
frequency
Conclusion and Recommendation
The
study supports the notion and findings that NDT-
Physiotherapy (Bobath exercise) is effective therapeutic
modalities for in the rehabilitation of CP. It was recom-
mended that NDT-Physiotherapy treatment frequency
and duration for CP be immediate and increased for bet-
ter recovery.
Limitations
A
major limitation of the study was its restriction to
Enugu South-East Nigeria. However, the findings can-
not be generalized automatically to the whole Nigeria
Discussion
and
other countries. Another limitation was non ran-
domization of subjects, and randomized controlled trials
Results of the present study indicated that 50% of the
(RCTs) are generally accepted as the most valid method
subjects reported improvement in disability status. The
for
determining the efficacy of a therapeutic interven-
result of this study was closely related to the work of
tion, because the biases associated with other experi-
mental designs can be avoided .
15
Gagliardi et al who studied the feasibility and
9
119
References
1.
Abiola LI, Olubayo AB, Jakotade
8.
Palisano R, Rosenbaum P, Walter
13.
Sherry A, Lynette C, Jane S, Ann
FO.
Risk Factors for Epilepsy in
S,
Russell D, Wood E, Galuppi B.
SM,
Johnson MJ. Effects of a Neu-
Children with Cerebral Palsy.
Dev
GMFCS. Dev
Med Child
Neurol
rodevelopmental Treatment-Based
Med Child Neurol 1991; 33: 241-
1997; 39: 214-223.
Trunk Protocol for Infants with
245.
9.
Gagliardi C, Maghini C, Germini-
Posture and Movement Dysfunc-
2.
Raj
GS. Physiotherapy in Neuro-
asi
C, Stefanoni G, Molteni F,
tion. Pediatric
Physical Therapy
conditions. New Delhi: Jaypee
Burt DM, Turconi AC. The effect
2008; 20(1): 11-22
Brothers Medical Publishers Ltd;
of
frequency of cerebral palsy
14.
Bar-Haim S, Harries N, Belokopy-
2006.
treatment: a matched-pair pilot
tov
M, Frank A, Copeliovitch L,
3.
Downie PA. Cash’s Textbook of
study.
Pediatr Neurol 2008; 39
Kaplanski J, Lahat E. Efficacy of
Chest, Heart and Vascular Disor-
(5): 335-40.
Adeli suit and neurodevelopmental
ders for Physiotherapists. 4th ed.
treatments in children with cere-
London: Mosby year book; 1993.
10.
Tsorlakis N, Evaggelinou C,
bral palsy. Dev
Med Child
Neurol.
4.
O’Sullivan SB, Siegelman RP. Na-
Grouios
G, Tsorbatzoudis C. Ef-
2006;
48(5): 325-30.
tional physical therapy examina-
fect of intensive neurodevelop-
15.
Laupacis A. What are the advan-
t i
o n :
R
evi e w
an
d
st
u d y
mental treatment in gross motor
tages and disadvantages of ran-
guide .United States of America:
function of children with cerebral
domized controlled trials for guid-
International Educational re-
palsy. Dev
Med Child
Neurol
ing
health policy. Abstr
Int Soc
sources; 2004.
2005; 47(4): 287.
Technol Assess Health Care Meet
5.
Porter SB. Tidy’s Physiotherapy.
1993; 9: 27.
13
ed. New Delhi: Butterworth –
th
Heinemann; 2005.
11.
Lilly L, Powell N. Measuring the
6.
Sunder S. Textbook of Rehabilita-
effects of neurodevelopmental
tion. 2
nd
ed.
New Delhi: Medical
treatment on the daily living skills
Publishers (P) Ltd; 2002.
of
2 children with cerebral palsy.
7.
Damiano DJ. Physiotherapy man-
American Journal of Occupational
agement in cerebral palsy: moving
Therapy 1990; 44: 139–45.
beyond philosophies. In: Scrutton
12.
Dirks T, Blauw-Hosper, Hulshof
D,
Damiano DJ, Mayston MJ,
LJ,
Hadders-Algra MH. Differ-
editors. Management of the motor
ences between the Family-
disorders of cerebral palsy. 2
nd
Centered “COPCA” Program and
edn. London: MacKeith Press: pp.
Traditional Infant Physical Ther-
161–169; 2004.
apy
Based on Neurodevelopmental
Treatment Principles.
Physical
Therapy 2011;
91(9):
1303-1322