A systematic review of interventions for children with cerebral palsy

A systematic review of interventions for
children with cerebral palsy: state of the
Rohini R Rattihalli
Why this paper
• Relevant to practice
• Good learning points re: practical aspects of EBM
Oxford Centre for Evidence-Based Medicine 2011
Levels of Evidence
Treatment benefits:
1. Systematic review of randomized trials or n-of-1 trials
2. Randomized trial or observational study with dramatic
3. Non-randomized controlled cohort/follow-up study
4. Case-series, case-control studies, or historically
controlled studies
5. Mechanism-based reasoning
Grading of Recommendations, Assessment,
Development and Evaluations (GRADE)
GRADE score: high (4), moderate (3), low (2), or very low quality
(1 or less)
Quality of evidence on
– outcome of interest
– in our population of interest.
Initial score based on type of evidence
RCTs/ SR of RCTs, +/– other types of evidence
Observational evidence (e.g., cohort, case-
Grading of Recommendations, Assessment,
Development and Evaluations (GRADE)
Quality: Based on
Blinding and allocation process, Follow-up and withdrawals,
Sparse data, Other methodological concerns (e.g., incomplete
reporting, subjective outcomes)
No problems
Problem with 1 element
Problem with 2 elements
Problem with 3 or more elements
Similar +/- regarding Consistency, Directness, Effect size
World Health Organization’s International Classification of
Functioning, Disability and Health
Classification of health and health-related domains
• body functions and structure (BF),
• activity (A)
• Participation (P),
• environmental factors (E),
• Personal factors (P)
Background: Interventions in CP
• 40% no reported evidence- based
• 20% ineffectual, unnecessary, or harmful.
Inclusion criteria
• Level 1 preferred
• Level 2 to 4 only if
– No level 1
– New level 2 after most
recent level 1
Full search strategy
available on request
Results- Green
Results: Red
Neurodevelopmental therapy
1. Did the review ask a clearly focused question?
Clear, but not focused (but this was intentional)
2. Did the authors look for the appropriate sort of papers?
Full description of search strategy not available in the paper,
but assumed to be “yes”.
3. Do you think important relevant studies were included?
Yes (assumed)
4. Did the review’s authors do enough to assess the quality
of the included studies?
Yes (GRADE recommendations)
5. If the results of the review have been combined, was it
reasonable to do so?
6. What are the overall result of the reviews?
Majority of the interventions in CP were “Amber”. This was
mainly due to no sufficient evidence.
7. How precise are the results?
Precise within the constraints of information available to the
8. Can the results be applied to the local population?
– Yes
9. Were all important outcomes considered?
Yes (and divided as per WHO International Classification of
10. Are the benefits worth the harms and costs?
– NA
Bottom line
• Green and Red interventions helpful, but majority of
interventions are Amber:
– Evidence of inadequate effect OR Lack of evidence
• What is the realistic possibility of having Level 1, Strong
High quality, strong recommendation evidence for all
interventions? So what is the solution?

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