Bioethics Paper

PEDIATRIC NEUROLOGY (WE KAUFMANN, SECTION EDITOR)

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

Iona Novak1 & Catherine Morgan1 & Michael Fahey2,3 & Megan Finch-Edmondson1 & Claire Galea1,4 & Ashleigh Hines1 &
Katherine Langdon5 & Maria Mc Namara1 & Madison CB Paton1 & Himanshu Popat1,4 & Benjamin Shore6 &
Amanda Khamis1 & Emma Stanton1 & Olivia P Finemore1 & Alice Tricks1 & Anna te Velde1 & Leigha Dark7 &
Natalie Morton8,9 & Nadia Badawi1,4

Published online: 21 February 2020

Abstract
Purpose of Review Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is
lessening. We conducted a systematic overview of best available evidence (2012–2019), appraising evidence using GRADE and
the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article
summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019.
Recent Findings Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal
hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual
training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training,
hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical
stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight
support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants,
bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry,
hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy.
Summary We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for
more research.

Keywords Cerebral palsy . Systematic review . Traffic light system . Evidence based . GRADE

This article is part of the Topical Collection on Pediatric Neurology

Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s11910-020-1022-z) contains supplementary
material, which is available to authorized users.

* Iona Novak
[email protected]

1 Cerebral Palsy Alliance Research Institute, Discipline of Child &
Adolescent Health, Faculty of Medicine & Health, The University of
Sydney, PO Box 6427, Frenchs Forest, Sydney, NSW 2086,
Australia

2 Department of Paediatric Neurology, Monash Health,
Clayton, Victoria, Australia

3 Department of Paediatrics, Monash University, Clayton, Victoria,
Australia

4 Grace Centre for Newborn Care, Children’s Hospital at Westmead,
Westmead, New South Wales, Australia

5 Department of Paediatric Rehabilitation, Kids Rehab WA, Perth
Children’s Hospital, Perth, Australia

6 Department of Orthopedic Surgery, Boston Children’s Hospital,
Harvard Medical School, Boston, MA, USA

7 Allied and Public Helath, Faculty of Health Sciences, Western
Sydney University, Sydney, New South Wales, Australia

8 Allied and Public Helath, Faculty of Health Sciences, Western
Sydney University, Sydney, New South Wales, Australia

9 School of Allied Health, Australian Catholic University, North
Sydney, New South Wales, Australia

Current Neurology and Neuroscience Reports (2020) 20: 3
https://doi.org/10.1007/s11910-020-1022-z

# The Author(s) 2020

http://crossmark.crossref.org/dialog/?doi=10.1007/s11910-020-1022-z&domain=pdf

http://creativecommons.org/licenses/by/4.0/

mailto:[email protected]

Introduction

Cerebral palsy is the most common physical disability of
childhood. In the last decade, major discoveries have been
made in early diagnosis, prevention, and treatment, altering
incidence, prognosis, and treatment responsivity. In high-
income countries such as Australia, motor severity has less-
ened and the incidence of cerebral palsy has fallen by a stag-
gering 30% [1]. Non-ambulant forms of cerebral palsy, co-
occurring epilepsy, and co-occurring intellectual disability
are less frequent, meaning more children than ever before
can walk [2]. Epidemiologists propose that the reduction in
incidence and severity is likely due to a combination of com-
prehensive obstetric and neonatal intensive care interventions.

In recent years, the cerebral palsy treatment evidence base
has continued to expand rapidly, providing clinicians and fam-
ilies with the possibility of newer, safer, and more effective
interventions. Since we last provided a comprehensive sum-
mary of the cerebral palsy intervention evidence in 2013, an-
other 200+ systematic reviews have been published [3•]. This
increasing volume of research evidence makes keeping up-to-
date challenging for busy clinicians and overwhelming for
families. Furthermore, the introduction of new interventions
extends what clinicians need to know to allow sound clinical
reasoning and decision-making [4].

This paper aimed to systematically describe the best avail-
able evidence for cerebral palsy interventions in 2019. We
searched for the best available evidence published after 2012
and aggregated the new findings with our previous 2013 sum-
mary of evidence, using the updated GRADE system and the
Evidence Alert Traffic Light System [5, 6]. The purpose of the
paper was to describe what treatments have demonstrated ev-
idence and highlight areas for more research. We rated the
whole cerebral palsy intervention evidence base within the
one paper to provide families, clinicians, managers, and policy
makers with a helicopter view of best available intervention
evidence to (a) inform decision-making by succinctly describ-
ing effective, emergent, and ineffective care; (b) aid compar-
ative clinical decision-making about alike interventions and
indications; and (c) provide a comprehensive resource to aid
the creation of knowledge translation tools to promote evi-
dence implementation.

Methods

Study Design

We conducted a systematic overview of best available evi-
dence using the systematic review of systematic reviews
methodology in order to provide an overview of the current
state of the evidence [7].

Search Strategy

Our review was carried out using a protocol based upon rec-
ommendations from the Cochrane Collaboration and reported
according to the PRISMA statement [8, 9••]. Relevant articles
were identified by searching: CINAHL (2012 to 2019);
Cochrane Database of Systematic Reviews [www.cochrane.
org]; EMBASE (2012 to 2019); ERIC (2012 to 2019);
PubMED (2012 to 2019), PsycINFO (2012 to 2019),
MEDLINE (2012 to 2019), OTSeeker [www.otseeker.com];
Physiotherapy Evidence Database (PEDro) [www.pedro.fhs.
usyd.edu.au]; Psychological database for Brain Impairment
Treatment Efficacy (PsycBITE) [www.psycbite.com];
PsycINFO (1935 to 2012); PubMED; and Speech Pathology
Database for Best Interventions and Treatment Efficacy
(speechBITE) [www.speechbite.com]. We sought to update
and amalgamate the findings of our 2013 original paper [3•].
Searches were supplemented by hand searching. The search
was performed in March–July 2019. Search terms for
investigation replicated the same search strategy as our
original paper and were supplemented by contributing
authors’ knowledge of the field, e.g., names of new
interventions published since 2012 to add to the search. We
also searched for the intervention evidence about preventative
treatments in the obstetric or neonatal period, given the
considerable reduction in the incidence of cerebral palsy
since our last publication.

Electronic databases were searched with OVID host soft-
ware using PICOs search terms. The full search strategy is
available from the authors on request.

Inclusion Criteria

Published studies about interventions for children with cere-
bral palsy or at risk of cerebral palsy fulfilling the following
criteria were included:

Type of Study

First, systematic reviews were preferentially sought [10].
Where multiple systematic reviews existed and newer evi-
dence superseded the findings of earlier evidence, GRADEs
were assigned based on the most recent high-quality evidence.
We also searched for randomized controlled trials published
after the latest systematic review, to account for new trials that
might increase our confidence in the estimate of the treatment
effect. For interventions where no systematic reviews existed,
randomized controlled trials were preferentially sought, and
where no randomized controlled trials existed, lower levels of
evidence were included and appraised. New data (2012–2019)
was then aggregated together with our data published in 2013
in order to review the entire evidence base. Second, retrieved
bodies of evidence were appraised using the GRADE and

3 Page 2 of 21 Curr Neurol Neurosci Rep (2020) 20: 3

http://www.cochrane.org

http://www.cochrane.org

http://www.otseeker.com

http://www.pedro.fhs.usyd.edu.au

http://www.pedro.fhs.usyd.edu.au

http://www.psycbite.com

Home

Evidence Alert Traffic Light System using two independent
raters, with unanimous agreement. GRADE is the evidence
rating system endorsed by the World Health Organization [5,
6]. GRADE rates both (1) the quality of the evidence on a 4-
point continuum of High–Moderate–Low–Very Low.
Randomized trials start at a score of 4/4 (High) and can be
downgraded based on methodological flaws; observational
studies start at a score of 2/4 (Low) but can be upgraded based
on methodological strengths or downgraded if methodological
flaws exist; and (2) the strength of the recommendation for
use, which weighs up the balance between the benefits and
harms, the resource usage’ cost effectiveness, health equity,
acceptability to consumers, and implementation feasibility
[5]. When available, published outcomes of benefits were
used to inform the strength of the recommendation. If no pub-
lished literature was available, expert opinion was used.
Recommendations were developed by the panel using the
GRADE updated Evidence to Decision framework [5]. The
Evidence Alert Traffic Light System was also applied to assist
clinicians in obtaining clear, clinically useful answers within
minutes [6]. The Evidence Alert uses a three-level traffic light
color coding that recommends a course of action for imple-
mentation of the evidence within clinical practice. Green
means go, because high-quality evidence from RCTs and sys-
tematic reviews indicates intervention effectiveness. Red
means stop, because high-quality evidence from RCTs and
systematic reviews indicates ineffectiveness or harm. Yellow
means measure clinical outcomes, because either (i) promis-
ing evidence suggests possible effectiveness, but more re-
search would increase our confidence in the estimate of the
effect; or (ii) no research exists and therefore effects are un-
known; or (iii) conflicting findings exists and therefore it is
unclear how a patient might respond.

Types of Intervention

Studies that involved the provision of intervention either by a
medical practitioner, an allied health professional, or an alter-
native and complementary medicine practitioner.

Types of Participants

Studies that explicitly involved human subjects. In the cere-
bral palsy preventative treatments evidence base, the partici-
pants were pregnant mothers or neonates. In the intervention
evidence base, the participants were children living with cere-
bral palsy, in which > 25% of the participants had a diagnosis
of cerebral palsy. We used a low cut off because many allied
health interventions are provided using the exact same ap-
proach across multiple diagnostic groups (e.g., dysphagia
management for stroke, brain injury, and cerebral palsy). We
did not want to overlook important evidence that had been

shown feasible and efficacious in the cerebral palsy popula-
tion that was published within mixed population studies.

Studies were excluded from the review if (a) they were
diagnostic, prognostic, or instrumentation studies; (b) they
had lower levels of evidence, unless no systematic review or
clinical trial had been published; (c) participants were adults;
(d) they reviewed generic preventative interventions, e.g.,
good parenting; (e) they reviewed an entire discipline (e.g.,
physiotherapy, occupational therapy, speech pathology) and
did not specify or sub-analyze individual named interventions
but rather aggregated them together; (f) a second publication
of the same study published the same results or participants;
and/or (g) studies were unpublished or non-peer reviewed.

Data Abstraction

A data abstraction sheet based on the Cochrane’s recommen-
dations was used [8]. Abstracts identified from searches were
screened by two independent raters to determine eligibility for
further review. Abstracts were retained for full review if they
met the inclusion criteria or if more information was required
from the full-text to confirm the study met all eligibility
criteria. Two independent reviewers then reviewed full-text
versions of all retained articles and all additional articles iden-
tified by hand searching. Full-text articles were retained if they
met inclusion criteria. Agreement on inclusion and exclusion
assignment of the full-text articles was unanimous. Data ex-
tracted from included studies comprised citations, domains of
impact of the intervention, level of the International
Classification of Disability and Function (ICF) the interven-
tion was aimed at, participants, study design, and dose. All the
data required to answer the study questions were published
within the papers, so no contact with authors was necessary.

Ethics and Registration

The study did not involve contact with humans, so the need
for ethical approval was waived by the Cerebral Palsy
Alliance’s Human Research Ethics Committee. This system-
atic review was not registered.

Results

One thousand five hundred eighty-four citations were identi-
fied using the search strategy, of which 247 articles met the
inclusion criteria for review [9••, 10, 11••, 12–248]. The study
flow is summarized in the PRISMA diagram (Fig. 1) [249].

We identified 182 interventions using our search strategy,
an increase of 118 interventions from our 2013 review. Of
these interventions, 41/182 (23%) were strategies aiming to
prevent cerebral palsy and 141/182 (77%) were interventions
aiming to manage cerebral palsy. The prevention strategies

Curr Neurol Neurosci Rep (2020) 20: 3 Page 3 of 21 3

were categorized into antenatal prevention strategies (11/41,
27%) and neonatal prevention strategies (30/41, 73%). The
interventions were categorized into allied heath interventions
(83/141, 59%), pharmacological interventions (25/141, 18%),
surgical interventions (19/141, 13%), regenerative medicine
interventions (4/141, 3%), and complementary and alternative
medicine (10/141, 7%). From these 182 interventions, we
identified 393 intervention outcome indicators that had been
studied in children with cerebral palsy. In five indications, two
separate gradings were assigned, because the quality of the
evidence was different in two sub-populations (e.g., ambulant
versus non-ambulant) for the same intervention aim. This took
the GRADE count by indication to a total of 398 indications.

Some of the included systematic reviews had already con-
ducted quality ratings on the body of evidence using the
GRADE system. As per the GRADE process, we confirmed
whether or not we agreed with these findings and also carried

out assignment of GRADE coding for all other included pa-
pers. Across the 398 intervention outcomes, the GRADE rat-
ings were as follows: 14% of outcomes assessed (54/398)
were graded “do it” (i.e., Green light, go interventions); 66%
(264/398) were graded “probably do it” (i.e., Yellow light,
weak positive); 17% (68/398) were graded “probably don’t
do it” (i.e., Yellow light, weak negative); and 3% (n = 12/
398) were graded “don’t do it” (i.e., Red light, stop
interventions).

Each intervention was coded using the ICF by the interven-
tion’s desired outcome. Out of the 383 intervention outcomes
for children with CP identified in this study, n = 241/383
(62%) were aimed at the body structures and function level;
n = 49/383 (13%) were aimed at the activity level; n = 12/383
(3%) were aimed at the participation level; n = 11/383 (3%)
were aimed at the environmental factors level; n = 1/383 (< 1%) were aimed at the personal factors level; n = 58/383 Fig. 1 Flow diagram of included articles 3 Page 4 of 21 Curr Neurol Neurosci Rep (2020) 20: 3 (15%) were aimed at a combined body structures and activi- ties level; and n = 11/383 (3%) were aimed at a combined activities and participation level. Participants This study included participants with cerebral palsy, a complex and heterogeneous condition. We included studies involving any motor sub-type [spastic, dyskinetic, or ataxic], any topog- raphy [hemiplegic/unilateral, diplegic/bilateral, or quadriplegic/ bilateral], and any functional ability level [Gross Motor Function Classification System (GMFCS) levels I–V and Manual Ability Classification System (MACS) levels I–V [250, 251]]. In the detailed supplementary extraction table (Online Resource, Table 1), we noted which interventions had been tested in the various sub-groups and severities. The main results are detailed in the online table, which out- lines the citation, the name of the intervention, the intervention indicator, the types of participants the intervention had been tested on, the dose/intensity used within the research studies, the GRADE ratings, the panels reflections on the evidence to decision recommendation process, and the clinical nuance of findings and considerations for interpretation. We strongly urge readers to read the detailed online resource to gain the necessary specifics for understanding the evidence base. To provide a summary of the online table and to assist with comparative clinical decision-making amongst intervention options for the same desired outcome, we mapped the inter- ventions that seek to provide analogous outcomes, using bub- ble charts. In the bubble charts, the name of the circle is the intervention, and the italics under the title is the outcome mea- sured and obtained. The size of the circle correlates to the volume of published evidence. The circle size was calculated by the amount and quality of evidence published. Bubble size 1, observational studies (OBS) only; size 2, 1–3 RCTs; size 3, 4–15 RCTs; and size 4, 15+ RCTs. The location of the circle on the y-axis of the graph corresponds to the GRADE system rating and estimate of effect (i.e., no effect was placed close to the worth it line, whereas a large treatment effect was placed further away from the worth it line). The color of the circle correlates to the Evidence Alert System (Fig. 2). Discussion High levels of evidence exist in the literature summarizing effective preventive strategies and intervention options for children with cerebral palsy. There was an exponential in- crease in the number of systematic reviews and clinical trials published about cerebral palsy interventions since our last review. We observed a substantial increase in the number of systematic reviews published about acupuncture, pharmaco- logical agents for managing tone, orthopedic surgery, dysphagia management, physical activity, participation, and clinical trials in regenerative medicine. Prevention of Cerebral Palsy Undoubtedly, the most notable breakthroughs in the field of cerebral palsy research in the last decade have been made in the area of prevention [9••, 10, 11••, 12–18]. The rate of cere- bral palsy has fallen by 30% in some high-income countries, bringing the prevalence down to 1.4 per 1000 [1, 2]. Babies born preterm constitute 43% of all cerebral palsy [2]. Antenatal magnesium sulfate before delivery of an infant less than 30 weeks’ gestation prevents 30% of cerebral palsy (green light) [9]. Antenatal corticosteroids decrease intracra- nial hemorrhage and thereby also act as an effective neuroprotectant (green light) and have become the standard of care [9]. More research would increase our confidence in the estimate of the effect, but further trials are not feasible as it would be unethical to withhold antenatal corticosteroids in premature birth. Once an infant is born preterm and is me- c h a n i c a l l y v e n t i l a t e d , p r o p h y l a c ti c c a ff e i n e (methylxanthines) prior to extubation effectively prevents ce- rebral palsy (green light) [11••]. For babies born at term with neonatal encephalopathy or asphyxia, therapeutic hypother- mia commenced within 6-h of delivery is neuroprotective and prevents 15% of cerebral palsy associated with intrapartum hypoxia (green light) [11••]. There is now a press- ing ethical imperative to translate prevention breakthroughs and a range of public health initiatives from high-income countries to low-income and middle-income countries, where the disease burden is high [252]. For example, in Bangladesh, the rate of cerebral palsy is more than double that of Australia (3.4 versus 1.4 per 1000). Twice as many Bangladeshi chil- dren have severe motor impairments (GMFCS IV–V = 43.6%, compared with 26% in Australia), and 78.2% do not receive any rehabilitation [252]. Delayed umbilical cord clamping is also under investigation. As yet there is no spe- cific data pertaining to whether delayed clamping prevents cerebral palsy, but we anticipate this will change in the near future and clinicians should stay abreast of this evidence base. In recent years, our understanding of the genetic basis for cerebral palsy has advanced substantially [253]. A genetic contribution is likely in one-third of all children with cerebral palsy, especially in those without traditional risk factors such as prematurity and hypoxia [253]. As our understanding of neurobiology and genomics expands, the revolutionized field will result in the development of new prevention and treat- ment targets [253]. Experts also predict that future neuropro- tective interventions will take advantage of trimester-specific brain development knowledge and that development of novel treatments will be informed by advances in biomarkers of brain injury, genetics, and neuroimaging [254]. Curr Neurol Neurosci Rep (2020) 20: 3 Page 5 of 21 3 WORTH IT LINE EFFECTIVE INEFFECTIVE S+ W + W - S - MOTOR CIMT Action Observation Bimanual Goal Directed Training Home Program NDT [Original Passive Form] Casting Mobility Training Selective Dorsal Rhizotomy Sensory Integration Fitness Training Suit Therapy Task Specific Training Acupuncture Strength Training Cranial Osteopathy Vojta Hydro Therapy HABIT-ILE Physical Activity Conductive Education Reflexology DBS Taping SEMLS Neural Stem Cells EARLY INTERVENTION AFOs Motor Training CIMT <2yrs NDT [Original Passive Form] GAME CIMT or Bimanual General Stimulation Conductive Education Vojta COPCA Yoga Intrathecal Baclofen Mirror Therapy DO IT YLBAB OR P DO IT T’N OD DO IT YLBAB ORP TI OD T’N OD Umbilical Cord Blood Electrical Stimulation Animal Assisted Therapy Orthotics Night Hand Splint Coaching Hyperbaric Oxygen Hand Function Activity & Participation Hand FunctionGross Motor Hand Function Hippo therapy Balance Symmetry Mobility Training Walking Speed Gross Motor Upper Limb Strength Function Strength Training Muscle Strength Treadmill Training Walking Speed Walking Endurance Gross Motor Hand Function Hand Function Gross Motor Environ- mental Enrichment Gross Motor Gross Motor BoNT + OT Goal Achievement Partial Body Weight Support Treadmill Training Walking Speed Gross Motor Gross Motor Gross Motor Gross Motor Gross Motor Massage Gross Motor Gross Motor Gross Motor Walking BoNT + Physiotherapy Gross Motor Walking BoNT + Resistance Muscle Strength BoNT + Electrical Stimulation Hand Function Function Levodopa Hand Function Trihexy phenidyl Hand FunctionGross MotorGross MotorHand Function Bone Marrow MNCs Gross Motor Hand Function Gross Motor Walking Speed Gross Motor Stride Length Kinematics AT Robotics Hand Function AT Virtual Reality + Gaming Hand Function Walking Balance AT Wii Fit Balance Bio Feedback Hand Function Walking Gross Motor Walking Gross Motor Gross Motor Walking Speed Gross Motor Hand Function Gross Motor Motor Function Gross Motor Walking for GMFCS IV-V Hand Function Gross Motor Physical Activity Physical Activity Walking Fitness Participation Quality of Life Motor SkillsGross Motor Gross Motor Gross Motor Hand Function tDCS Walking Mobility Balance Hand Function Vestibular Stimulation Training Partial Body Weight Support Treadmill Training Gross Motor Walking Endurance 15+ RCTs 4-15 RCTs 1-3 RCTs Observational Studies ONLY Gross Motor Muscle Strength Flexibility Gross Motor Function Participation Gross Motor Walking Speed Walking Hand Function Function BoNT + Orthotic Herbal Medicine Gross Motor Gross Motor Hippo Therapy Gross Motor Hand Function Hippotherapy Simulation Gross Motor Hand Function Focal Vibration Gross Motor Gabapentin Modified Sport Gross Motor Walking Hand Function Seating Gross Motor Gross Motor Gross Motor Gross Motor Gross Motor Cognition Gross Motor Cognition Hand Function Hand Function Gross Motor Mesenchymal Stromal Cells Motor Speech Speech Intelligibility Hand Function Walking Speed CO-OP Activity Performance Context Focused Gait Parameters Muscle Strength Yoga Gross Motor Sensory Processing Function Baclofen [Oral] Intrathecal Baclofen BoNT Selective Dorsal Rhizotomy Diazepam TONE ↓ Lower Limb Spasticity ↓ Upper Limb Spasticity ↓ Drooling ↓ Spasticity Gait Kinematics ↓ Spasticity ↓ Spasticity ↓ Spasticity Tizanidine Acupuncture BoNT + Physiotherapy Whole Body Vibration DBS Hippo- Therapy ↓ Spasticity ↓ Spasticity ↓ Spasticity ↓ Dystonia Gabapentin ↓ Spasticity ↓ Dystonia ↓ Spasticity BoNT ↓ Cervical Dystonia tDCS ↓ Dystonia tDCS ↓ Spasticity Trihex- phenidylReflexology Massage Stretching SEMLS Phenol ↓ Spasticity ↓ Spasticity ↓ Spasticity ↓ Spasticity ↓ Spasticity ↓ Dystonia↓ Spasticity Dantroline ↓ Spasticity Alcohol CONTRACTURE & ALIGNMENT BoNT + Casting Lower Limb Casting Passive Range Passive Range Scoliosis Surgery Scoliosis Correction Upper Limb Casting Postural Management Whole Body Vibration Soft Tissue Crouch Surgery SEMLS BoNT Biofeedback AT Robots Passive Range Prevent Hip Displacement Ankle/Knee Passive Range Passive Range Knee Passive Range Soft Tissue Pelvis Surgery ↓ Hip Internal Rotation Passive Range Active Range Ankle Passive Range Prevent Hip Displacement Equinus Correction ↓ Foot Deformity Femoral Osteotomy ↓ Hip Rotation Hand Surgery ↓ Thumb Posture Reconstructive Hip Surgery ↓ Hip Displacement BoNT + Hip Brace Prevent Hip Displacement Selective Dorsal Rhizotomy Prevent Hip Displacement Stretching Passive Range Orthotics Passive Range NDT [Original Form] Prevent Contracture NDT ↓ Spasticity Hip Surveillance ↓ Displacement Whole Body Vibration Gross Motor LEGEND: AFOs= Ankle Foot Orthoses; AT= Assistive Technology; BoNT= Botulinum Toxin; CIMT= Constraint Induced Movement Therapy; CO-OP= Cognitive Orientation to Occupational Performance; COPCA= Coping with and Caring for infants with special needs - a family centered program; DBS= Deep Brain Stimulation; GAME= Goals Activity Motor Enrichment; NDT= Neurodevelopmental Therapy; OT= Occupational Therapy; SEMLS= Single Event Multi Level Surgery; tDCS=Transcranial Direct Current Stimulation AT Adaptive Equipment Mobility AT VR + Biofeedback WORTH IT LINE EFFECTIVE INEFFECTIVE S+ W + W - S - DO IT YLBAB ORP DO IT T’N OD DO IT YLBAB ORP TI OD T’ N OD 15+ RCTs 4-15 RCTs 1-3 RCTs Observational Studies ONLY PAIN Pain Animal Assisted Therapy Pain Pain Intrathecal Baclofen Pain Yoga Pain BoNT Pain Massage Pain Pain Pain Gabapentin DBS Radio Frequency Dorsal Root Ganglion Pain Scoliosis Surgery Sleep System Pain Salvage Hip Surgery SLEEP Sleep Hyperbaric Oxygen Sleep Cranial Sacral Therapy SleepMassage Sleep Sleep System Sleep Sleep Melatonin Sleep Sleep Hygiene PULM- ONARY Pulmonary AT Seating MEALTIME Dysphagia Compensation Safe Swallow Oral Sensory Motor Oral function Chewing Feeding ↓ Stress Parent Education Electrical Stimulation + Oral Motor Feeding Gastrostomy Safety Growth Fundo- plication Diet Consistency Safe Swallow Feeding ↓ Tongue Thrust Oral Sensory Motor ↓ Reflux Fundo- plication ↓ Gastric Emptying ↓ Postprandial Electrical Stimulation + Oral Motor ↓ Drooling ↓ Drooling Oral Sensory Motor Dental Dental Health DROOLING …

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