Critical Appraisal of "State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy."

Critical Appraisal by Matt Huebert, PT, DPT, CTRI of the paper  "State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy." 

Novak I, Morgan C, Fahey M, et al. State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy. Current Neurology and Neuroscience Reports. 2020;20(3). https://doi.org/10.1007/s11910-020-1022-z

Introduction: The most common physical disability affecting children is cerebral palsy (CP). New treatment strategies have followed major discoveries made in early diagnosis, prevention, and intervention. Novak et al. 2020 compiled and reviewed 182 prevention methods and interventions for children with CP published in peer reviewed journals. This systematic review highlights the strength of evidence underlying these interventions using an easy-to-digest infographic based on The Evidence Alert Traffic Light System.

Methods: Authors searched 11 major research databases for studies of interventions for children with, or at risk of, CP published between January 2012 and July 2019. Systematic reviews were considered the strongest source of evidence for each intervention. If no systematic review existed for a given intervention, then the authors sought randomized controlled trials (RCTs). Lastly, if no systematic reviews or RCTs were found, then other study designs were included but weighed as weaker sources of evidence. These findings were then added to the authors’ previous systematic review of interventions for children with CP published in 2013 to review the entire evidence base. Quality and strength of individual studies was rated using the GRADE system. This system is endorsed by the World Health Organization. Researchers use this system to evaluate scientific studies and give them a score 1-4 with 4 being the highest quality and strength of recommendation. The Evidence Alert Traffic Light System was then applied and presented as a three-level, color-coded infographic to quickly recommend course of action within clinical practice. The three tiers included: green light (“do it” interventions with strong evidence), yellow light (“probably do it” with weak evidence), and red light (“don’t do it” with harmful or ineffective evidence).

Results: Authors included 247 articles in this review. These articles added 118 interventions to their 2013 systematic review, for a total of 182 in the present review. The largest subset of these interventions (83/182) represented allied health interventions. The findings were presented in the three-tiered color-coded infographic, with interventions grouped by targeted outcome (e.g., hippotherapy and treadmill training for motor aspects of CP). The interested reader can learn more about each specific intervention in the supplementary material. Hippotherapy received a green light with strong evidence for improving balance and symmetry. It also received a yellow light for decreasing spasticity. It received a yellow light for improving self care/function; however, this recommendation fell beneath the author’s “worth it line.”

Limitations: Several limitations to this systematic review exist. For one, authors followed methodology established by Cochrane that heavily favors RCTs and may have excluded or under-emphasized other study designs for each intervention. Authors presented findings on all possible interventions for children with CP and, therefore, were unable to provide detailed explanations of each given intervention or treatment tool. Authors also note that they only included articles that were published in English.

Critique: This study provides a big picture perspective of the evidence base supporting various prevention, intervention, and treatment tools for children with CP. The authors provide figures that are easy to interpret and may quickly inform evidence-based practice. However, a notable critique is the authors use the collective term “interventions” to describe all prevention and management tools, techniques, and medications assessed. This contributes to terminology ambiguity within the healthcare community and greater public, but hippotherapy is best described as a treatment tool, rather than as an intervention in and of itself. This review also does not link interventions to the disciplines that implement them, making it difficult to discern who can and cannot perform each intervention effectively and legally.

Clinical Bottom Line: This free-to-access systematic review provides a broad summary of ways to prevent and treat CP among children. It presents findings for clinicians to easily follow recommendations and evaluates the strengths of existing evidence supporting interventions. This comprehensive list of interventions may be useful for physical, occupational, and speech therapists when referring clients to other evidence-based services. This systematic review includes 9 articles (citations 103-111) focused on hippotherapy for children with CP. This study highlights the need for more RCTs to be conducted that evaluate the effectiveness of using hippotherapy as a treatment tool for children with CP.

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