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1986; 66:1095-1101.PHYS THER.Mary Beth JohnsonDeCremer, Marcia Gevelinger, Kathleen B Jedlovec andKenneth J Ottenbacher, Zena Biocca, GwynethNeurodevelopmental Treatment ApproachPediatric Therapy : Emphasis on theQuantitative Analysis of the Effectiveness of

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Quanti tat ive Analysis of the Effect iveness ofPedia t r ic TherapyEm phas is on t he Neur odeve l opm ent a l T r ea tm ent A ppr oachK E N N E T H J . O T T E N B A C H E R ,Z E N A B I O C C A ,GWYNETH D E C R E M E R ,M A R C I A G E V E L I N G E R ,K A T H L E E N B . J E D L O V E C ,a n d M A R Y B E T H J O H N S ON

W e i n v e s t ig a te d t h e e f f e c t iv e n e s s o f n e u r o d e v e l o p m e n t a l t re a t m e n t w h e n u s e db o th i n is o l a t io n a n d in c o m b in a t io n w it h o t h e r d e v e l o p m e n t a l t h e r a p i e s . T h e d a t aw e r e a n a l y z e d u s i n g r e c e n t l y d e v e l o p e d m e t h o d s o f q u a n t i t a t i v e l y s y n t h e s i z i n gr e s e a r c h r e s u l t s i n w h i c h t h e l i t e r a t u r e r e v i e w p r o c e s s i s r e g a r d e d a s a u n i q u et y p e o f r e s e a r c h . O u r a n a l y s i s r e v e a l e d t h a t t h e s u b j e c t s w h o r e c e i v e d N D Tp e r f o r m e d s l i g h t l y b e t t e r t h a n t h e c o n t r o l - c o m p a r i s o n s u b j e c t s w h o d i d n o tr e c e i v e t h e i n t e r v e n t i o n . T h e s t u d y o u t c o m e s a r e d i s c u s s e d in r e la t io n t o s e v e r a ld e s i g n v a r i a b le s a n d s t u d y c h a r a c t e r is t ic s a s s o c i a t e d w it h s u b je c t p e r f o r m a n c e .T h e a d v a n t a g e s a n d l i m i t a t i o n s o f q u a n t i t a t i v e r e v i e w i n g a r e i d e n t i f i e d b r i e f l y ,a n d t h e p o t e n ti a l u s e o f t h e p r o c e d u r e s in c l in i c a l re s e a r c h is e m p h a s i ze d .K e y W o r d s : Child development disorders, Handicapped, Physical therapy.

The development and therapeutic application of intervention programs forpatients with either ce ntral nervous system dysfunctions or developmental delays have increased dramatically duringthe past decade. This process has beentrue pa rticularly for the school-age pop ulation. The im petus provided by PublicLaw 94-142 has resulted in record num bers of handicapped students receivingtherapy services.1 Despite the expansionof therapeutic services for handicappedinfants and young children, considerable controversy exists among health careprofessionals and educators regardingthe effectiveness of these interventionprograms. Recent articles in Pediatricshave reflected this dissensio n.23 One article optimistically reported that, basedon the available evidence, the benefitsof intervention programs for at-risk andhandicapped children clearly outweighthe disadvantages.2 Another author concluded that no valid scientific evidenceexists that these programs alter neuro

logic development in high-risk or neu-rologically h andicapped children.3Neurodevelopmental treatmen t is oneintervention approach that has been apopular form of therapy for infantsand children with neuromotor dysfunction.45 Harris recently observed that"one of the most widely accepted methods of treatment used by pediatricphysical therapists working w ith the de-velopmentally disabled is the neurodevelopmental approach."6Neurodevelopmental treatment emphasizes three basic com ponents relatedto neuromotor control: postural tone,reflexes and reactions, and movementpatterns.7 One of the primary objectivesof the NDT approach is the facilitationof normal muscle tone to maintain normal postural and movement patterns.8This objective m ay be achieved througha complex process of inhibition andfacilitation that has evolved over a period of 30 years. The rationale for NDThas been described extensively by theBobaths4.5 and others.8Impo rtant professional questions concerning the effectiveness of NDT-basedintervention cannot be answered without emp irical evidence.9 To date, severalresearchers have reported using theNDT approach to facilitate the neuromotor performance and development ofhandicapped children, but the results oftheir studies have been inconclusive.8 A

common conclusion of those studies isthat more research is needed before adecision regarding the efficacy of NDTcan be rendered.10 This call for additional research is based on th e belief thatempirical evidence of the effectivenessof an intervention strategy should becumulative. Evidence from multiplestudies can be used effectively by therapists, parents, and educators only whenit is accumulated in a systematic, logicalmanner. The subjective and judgmentalnature of traditional attempts to reviewand synthesize research literature isunfortunate because comprehensivereviews often are instrum ental in establishing or refuting the empirical legitimacy of a research finding.In our study, we used recently devel

oped quantitative reviewing proceduresto synthesize the evidence of the effectiveness of NDT with handicapped infants and children. In the quantitativereviewing method, also referred to asmeta-analysis, the literature reviewprocess is regarded as a unique type ofresearch that requires the same rigorousmethodology demanded of primary researchers.11,12 Glass characterizes metaanalysis as:

The statistical analyses of a large collection of analysis results from individual studies for the purpose ofintegrating the findings. It connotes arigorous alternative to the casual, nar-

D r. Ottenbacher is Associate Professor, School ofAllied Health Professions, University of Wisconsin,2120 Medical Sciences Center, 1300 UniversityAve, Madison, WI 53706 (USA).

Ms. Biocca, Ms. DeCremer, Ms. Gevelinger, Ms.Jedlovec, and Ms. Johnson are graduate students atthe University of Wisconsin.This article was submitted May 20, 1985; waswith the authors for revision four weeks; and w asaccepted November 21, 1985.

Volume 66 / Number 7, July 1986 1095by guest on April 26, 2012http://ptjournal.apta.org/Downloaded from

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rative discussions of research studieswhich typify our attempts to makesense of the rapidly expanding research literature.13The methods of meta-analysis allowthe reviewer to aggregate quantitativelyseveral research studies and to makeconsensual judgments based on their r esults.14 The procedures also allow systematic investigation of the effects ofvariation in study methods on study

results.15The purposes of our study were 1) tointroduce the various techniques ofquantitative reviewing to therapists, educators, and researchers and 2) to usequantitative reviewing methods to evaluate the effectiveness of clinically applied ND T to enhance developmentaland motor factors in handicapped infants and children.

M E T H O DPotentially relevant studies were identified through an on-line computersearch of List of Journals Indexed in

Index Medicu s, Psychological Abstracts,Current Index to Journals in Education,Resources in Education, and Disserta-tions Abstracts International. An examination of the references contained inthose studies (citation tracking) resultedin the compilation of additional information.

Our search of the literature yielded atotal of 37 nonoverlapping research reports that were construed broadly aspotentially relevant to the efficacy ofN D T . We then judged the relevance ofthe abstracts and full reports accordingto several specific cr iteria.

Cri ter ia for Inc luding Studies inS a m p l eThefirstcriterion for inclusion in our

quantitative analysis involved the nature of the independent variable. To beincluded in the quantitative review, thestudy had to investigate the effect ofND T as at least one of the independentvariables. To qualify as ND T, the treatment procedures had to include somecombination of the facilitation and inhibition procedures developed by theBobaths and be based on the theoreticalwork of the Bobaths.4,5,16,17 We did notconsider treatment techniques that involved the isolated application of a specific form of sensory stimulation toqualify as ND T and, therefore, studies

that involved only this type of treatmentwere not included in the analysis.We did not include in our review thestudies providing intervention that usedterminology frequently associated withND T but that did not pr ovide a rationale for intervention associated with workby the Bobaths. For example, Solokoffet al reported using "handling" to improve the development of premature infants.18 We did not include their studyin the review because the independentvariable (handling) was defined operationally as pr oviding tactile stimulation(rubbing) to the neck, back, and arms ofthe infants.Some studies that used a combinationof ND T and other forms of developmental therapy were included in theanalysis. We decided to include thosestudies because of the small number ofresearch studies that used only ND T andbecause of the difficulty in identifyingwhether the treatment provided in astudy was exclusively N D T. Sommer-feld et al, for example, conducted astudy in which three experienced pediatric therapists, who had received recentformal postgraduate training in neuro-developmental procedures and other approaches to the treatment of cerebralpalsy, provided intervention to handicapped students.19 The authors r eportedthat their:Therapy goals included inhibition ofprimitive and pathological reflexes,facilitation of postural reactions,normalization of muscle tone, stimulation of gross motor skills, and prevention of further musculoskeletaldeformities by range of motion andpositioning.19

We included their study in our analysisbecause the treatment provided obviously included some ND T components. We categorized the studies on thebasis of whether they provided N D T incombination with some other intervention approach versus using N D T as theonly form of intervention. This information then was used in a later analysisto determine whether different outcomes existed for the two types of studies.The second criterion for inclusion ofa study in our sample was related to thetype of dependent variable used in thestudy. One advantage of quantitative

reviewing methodology is that it perm itsthe use of broad dependent variables.15One purpose of our investigation was to

evaluate the effectiveness of ND T applied to at-risk and handicapped infantsand children. We broadly categorizedimprovement or enhancement of development according to the level of performance on any outcome measure thatevaluated motor-reflex function or overall development. Outcome measuresthat did not fit into one of these categories but that still were considered developmental (eg, specific measures ofself-help skills) were placed in a categorylabeled "other." Studies that used non-developmental measures such as respiration rate were not included in thereview.

The third criterion for including astudy in our quantitative analysis wasrelated to the characteristics of thestudy's sample group. To be included inthe review, the study had to includepediatric subjects with developmentaldisabilities or delay. Studies in whichthe average (mean) age of the studentswas 15 years or more were not includedin the review.The final two criteria were r elated tothe study's design and method of analysis. To be included in our quantitativeanalysis, the study had to r eport a comparison between at least two groups ofsubjects: one that received N D T andone that did not. In some studies, whena within-subjects design was used, the

comparison or control group was thesame as the experimental group. Whenmore than two comparisons were madeamong groups (multiple degree-of-free-dom tests), the comparisons were separated into two-group comparisons between control-comparison groups andthe treatment groups to compute an effect-size index (explanation follows).The study also had to report the results in a manner that allowed quantitative synthesis and the computation ofan effect size. That is, the investigationhad to present the results of statisticaltests (t or F ratios, means, standard deviations, and df and p values) in sufficient detail so that the appropriate effect-size m easure could be com puted.We eliminated 17 of the 37 studiesafter a review of their abstracts and titlesbecause they did not meet these criteria.Another 11 studies were eliminated afterthe full report was reviewed (Appendix

1). The remaining 9 studies met thecriteria and were included in our analysis (Appendix 2 ).1096 PHYSICAL THERAPYby guest on April 26, 2012http://ptjournal.apta.org/Downloaded from

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RESEARCHQ u a n t i f y i n g S tu d y Ou tc o m e s

Glass20 and Cohen21 have popularizedprocedures for uncovering systematicvariation in study results. These procedures involve the calculation of studyeffect sizes and the analysis of theseeffect sizes in relation to study and design characteristics. Cohen defines aneffect size as "the degree to which thenull hypothesis is false."21

Effect-size measures appropriate foruse with a wide variety of research designs and analytic pr ocedures have beenpresented by Cohen.21 The primary effect-size measure used in our investigation was the d index. The d index is aneffect-size measure specifically designedto evaluate the statistical comparisonbetween two groups. One criterion forinclusion in our review was that at leastone two-group comparison be includedin the study.Several of the studies included in ourreview contained multiple two-groupcomparisons. Harris, for example, compared the performance of infants withD own syndrome who received ND Twith handicapped infants who did notreceive the intervention.6 Four outcomemeasures were evaluated during thestudy, including performance on theBayley Scales of Infant D evelopment(Mental and Motor), the Peabody GrossMotor Scale, and a set of individuallydeveloped therapy objectives. Thus,multiple comparisons were included inseveral studies because more than oneoutcome measure was obtained. Effectsizes were computed for each two-groupcomparison statistically analyzed ineach of the reviewed studies. The ninestudies included in our review containeda total of 35 statistical hypothesis testsof two-group comparisons of the effectiveness of ND T pr ocedures with handicapped infants and children.

As noted previously, the effect-sizemeasure computed for each two-groupcomparison was the d index. The d index gauges the difference between twogroups' means in terms of their common (average) standard deviation. A dindex of 0.30, for example, indicatesthat three tenths of standard deviationseparates the two sample means. Cohenhas defined a d index of 0.20 to 0.50 assmall, a d index of 0.50 to 0.80 as medium, and a d index greater than 0.80as a large effect size.21 Because this classification system may leave somethingto be desired in terms of intuitive appeal,

Cohen also presented a percentage ofdistribution overlap measure designatedU3.21 This measure indicates the percentage of the population with thesmaller mean that is exceeded by 50%of the population with the larger mean.The U 3 value for a d index of 0.30 is61.8. This value means that the averageperson in the group with the larger mean(usually the treatment group) has ahigher "score" than about 62% of theindividuals in the lower mean gr oup. Atable for converting the d index to U 3was presented by Cohen.21Friedman has presented formulas forcomputing d-index estimates using traditional inferential statistical valuessuch as t and F ratios.22 Effect sizes alsocan be computed using group meansand standard deviations.11 In addition,Glass has described procedures for computing effect sizes when nonparametricstatistics or percentages are used.20

Hedges r ecently demonstrated that dindexes may become biased as the sample size becomes smaller (

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T A B L E 2M e a n d I n d e x e s f o r T y p e o f R e s e a r c h D e s i gn a n d S u bje c t A s s i gn m e n t P r o c e d u r e s

Ty pe o f re s e a rc h de s ignPreexperimenta lQuasi-experimenta lTrue e xpe rime nta lTy pe o f a s s ig nme ntRandomCombinationPreexisting groups

N a

71 71 191 97

0.340.300.310.280.310.37

s0.260.230.220.210.220.26

SE M b

0.110 .0 60 .0 70 .0 70 .0 50 .1 1

Us63.26 1 . 862.26 1 . 062.264.4

T A B L E 3M e a n d I n d e x e s f o r E a c h C a t e g o r y o f D e p e n d e n t V a r i a b le a n d H o w t h eV a r ia b l e W a s R e c o r d e d

Dependent var iableMotor-reflexOveral l developmentOtherRecording methodBlindly recorded

Not bl indly recorded-no information provided

N a

2186

251 0

0.320.380 .1 90.210 .5 7

s0.240.210.110 .1 80.51

SEMb

0.050 .0 80 .0 50.040.17

U362.564.85 7 .55 8 .37 1 . 6

tistic (HT) described by Hedges25 wascomputed for the set of effect sizes (dindexes) and indicated that the amountof variability in the collection of effectsizes exceeded the amount o f variabilitythat would have been expected bychance (HT = 67.9, p < .05). Based onthis result, we considered an analysis ofeffect sizes by specific design characteristics and study var iables to be justified.D e s i gn C h a r a c t e r is t ic s a n dEf fe c t S i ze

Individual studies were categorizedaccording to the type of research designthat was used. At least two raters reviewed each study and classified the research designs as preexperimental,quasi-experimental, or true experimental using criteria or iginally developed byCampbell and Stanley.27 An overallagreement index of 89% was obtainedfor labeling the research designs of thenine studies included in our review.When two raters disagreed about theclassification of a research design, a thirdrater classified the research design. Theclassification chosen by consensus thenwas used in the subsequent analysis.

Each study also was classified according to the type of subject assignment

procedures used. The assignment categories were 1) random assignment, 2)matching or a combination of matchingand random assignments, and 3) preexisting groups. The subject assignmentprocedures were classified by at least twoindependent raters with an overallagreement exceeding 95%.The mean d indexes for the type ofresearch design and subject assignmentprocedures are presented in Table 2. Themean d indexes for all three types ofresearch design (preexperimental, quasi-experimental, and true experimental)are r elatively equal. The mean d indexesfor the three types of subject assignment

procedures also are r elatively equal withthe largest mean d index associated withstudies that used preexisting groups inthe assignment of subjects.Because our d indexes were based oncomparisons that were not independentof one another (ie, more than one comparison was obtained from some studies), we decided that the use of inferential statistics to test whether effect sizesdiffered significantly across variousstudy char acteristics, such as the type of

research design, may not be warranted.15

On the basis of the procedure developedby Smith,28 we considered d indexes to

be reliably different from one another ifthey were more than two standard errorsapart. This criterion provides the readerwith a simple measure of differences inmean effect sizes. For example, themean d index for preexperimental research designs was 0.34 with a standarderror of 0.11. Using the proposed criter ion , effect sizes ranging from SEM =+2 (0.56) to SEM = - 2 (0.12) wouldnot be considered reliably different fromthe mean effect size for preexperimentalresearch designs. We, therefore, usedthis convention to determine that noreliable differences existed between themean effect sizes for type of researchdesign or assignment procedure.

D e p e n d e n t V a r i a b l e a n dEf fe c t S i zeAs we noted in the Method section,the outcome measures in each studywere categorized as motor-reflex, overalldevelopmental, or other. At least twoindependent raters categorized each outcome measure with an overall agreement of 91%. The mean d indexes forthe three types of dependent measuresare presented in Table 3. The mean dindexes for motor-reflex measures andmeasures of overall development weresimilar, and both of these values werelarger than the mean d index for outcome measures categorized as other

(Tab. 3). Our use of the two-standard-errors criterion revealed that the meand indexes for motor-reflex measures andmeasures of overall development werereliably larger than the mean d index foroutcome measures labeled as other.There was no reliable difference betweenthe mean d indexes for m otor-reflex andoverall developmental measures.Also presented in Table 3 are themean d indexes for the methods used torecord the variables. Our use of the two-

standard-errors convention revealedthat the m ean d index for m easures thatwere recorded blindly was reliablysmaller than the mean d index for measures that were not recorded blindly orfor which adequate information on recording strategies was not r eported.We also performed a related analysisto determine the relationship amongthe d indexes and whether the dependent measure that was used was standardized or informal Standardized

measures were those, such as theBayley Motor Scales, that were developed for a specific population, ad-

a Number of d indexes in each catego ry.b Standard error of the mean.

a Number of d indexes in each category.b Standard error of the mean.

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RESEARCHministered in a prescribed manner, andresulted in a standa rdized score. Assessments that we categorized as informalincluded check lists or individualizedmeasures that frequently were developed by the authors for a particularstudy. Each outcome measure was classified as either standardized or informalby at least two independent raters withan interrater agreement of 86%. Themean d index for the 17 comparisonsassociated with a standardized measurewas 0.29 (s = 0.21), and the mean dindex for the 14 comparisons based onan informal measure was 0.33 (s =0.29). We were unable to determinewhether the outcome measure wasstandardized or informal in four of thecomparisons. The mean d index forthese four comparisons was 0.33 (s -0.24). No reliable differences existedamong the mean effect sizes based onwhether the outcome measure wasstandardized or informal.

M i s c e ll a n e o u s A n a l y s e s o fEf fect S izeAs we noted in the previous section,some studies used a combination oftreatments, at least one of which wasNDT, and other studies included onlyNDT procedures as the independentvariable. A total of 19 comp arisons wasincluded in studies that used a combination of treatments. The mean d indexfor those 19 comparisons was 0.33 (s =0.27). The remaining 16 comparisonsinvolved only NDT procedures as theindependent variable. The m ean d indexfor those comparisons was 0.29 (s =0.26). The mean d index for the combined-treatments comparisons wasslightly larger than for the NDT-alonecomparisons, but we found that themean d indexes were not reliably differ

ent using the two-standard-errors criterion.

Finally, correlations were computedbetween year of report publication andthe d indexes (r = .03, p = NS), thenumber of subjects in each study andthe effect size (r = .04, p = NS), theaverage age of the subjects in the studyand the effect size (r = - .27 , p = NS),and the duration of the investigation inweeks and the effect size (r = .22, p =NS). None of these correlations werestatistically significant at the .05 level ofconfidence.

DISCUSSIONThe effectiveness of the NDT approach and other pediatric therapies iscurrently an issue generating considerable professional debate.2,3,6,9 Jenkins andSells recently raised the central question,"Does pediatric physical and occupational therapy really work?"29 They ob

served that the economic viability ofND T and other therapeutic interventionstrategies will continue to be questioneduntil a more empirical database can begenerated supporting them. Previousstudies of the efficacy of NDT withhandicapped infants and children havereported conflicting or inconsistent findings and have not resulted in any empirical consensus.8 Cooper and Rosenthal have noted, however, that "some ofthe confusion an d contradiction we convey about our research may not be afunction of the results but of how wehave chosen to synthesize them."30

The quantitative reviewing procedures that we used in our investigationhave demonstrated a quantifiable treatmen t effect for ND T. The overall meaneffect size for the studies that we reviewed was 0.31. This effect size wasassociated w ith a U 3 value of 62.2, whichsuggests that the average subject whoreceived ND T or a combination of NDTand some related therapy performedbetter than about 62.2% of the subjectsin the control or comparison groupswho did not receive the intervention.The overall mean effect of 0.3.1 was inthe range Cohen considered a smalltreatment effect.21 Ottenbacher reportedthat much of the research in appliedfields such as physical or occupationaltherapy will be concerned with smalleffect sizes because of the nature of thevariables under investigation, the smallsample sizes that generally are available,and the lack of rigorous experimentalcontrol in most clinical situations.31When small treatment effects are expected, clinical researchers must be concerned with statistical sensitivity and experimental power evaluations. Many ofthe small effect sizes reported in theclinical literature are associated with lowstatistical power and, therefore, do notachieve the traditionally accepted .05level of statistical significance.32,33 Thislack of statistical significance is a problem particularly in studies dealing withhandicapped subject populations inwhich the sample sizes tend to be small

and very heterogeneous. Harris acknowledged this problem in her investigation of the effectiveness of NDT inchildren with Down syndrome.6 Shestated that "the failure to find significantdifferences between the two groups ofinfants on three of the four dependentmeasures used suggests that this studyhad several limitations. The obvious o neis the size of the sa mple."6 The relationship between sample size, significancelevel, effect size, and statistical powershould be familiar to all clinical researchers. An awareness of these factorsduring the formulation of hypothesesbefore conducting a study can help reduce the incidence of Type II errors inclinical research when small treatmenteffects are expected.21

Limitat ionsOur decision to include only studiesthat met certain criteria in our quantitative review eliminated several studiesof the efficacy of NDT. Several studiesidentifying NDT as the independentvariable were not included in the reviewbecause of the lack of a control o r comparison group or the inability to generate a d index from the information provided. Generally, those studies involvedsome type of intensive single-subject orsingle-case design. For examp le, Laskas

et al recently evaluated the immediatetherapeutic effects of four NDT activities on the motor performance of ayoung child with spastic quadriplegia.34They used a single-subject expe rimentaldesign that included baseline and treatment phases. Their results demonstratedthat the NDT activities resulted in increased dorsiflexor muscle activity during an equilibrium reaction and increased frequency of heel contact whenthe child assumed a standing position.Intensive-design studies can provideimportant supplemental information tothe multiple-subject, group-comparisonstudies included in the quantitative review, but their outcomes typically werenot founded on formal statistical analyses. A listing of several related studiesof the effectiveness of NDT that werenot included in the review is providedin Appendix 1. These studies did notmeet the criteria presented previouslyfor inclusion in the quantitative analy

sis; they, however, do contribute to thegrowing empirical literature on NDTand should be considered in any corn-Volume 66 / Number 7, July 1986 1099by guest on April 26, 2012http://ptjournal.apta.org/Downloaded from

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APPENDIX 1Related Studies

1 . DeGangi GA, Hurley L, Linschied TR: Toward a methodology of measuring the short-termeffects of neurodevelopmental treatment. Am J Occup Ther 37:479-484, 1983

2. Haberfellner H, Muller G: Bobath therapy, tonic reflex activity and processing of acousticstimuli. Neuropediatrics 7:379-383, 1976

3. Kong E: Very early treatment of cerebral palsy. Dev Med Child Neurol 8:198-202, 19664. Laskas CA, Mullen SL, Nelson DL, et al: Enhancement of two motor functions of the lower

extremity in a child with spastic quadriplegia. Phys Ther 65:11-16,19855. Noonan MJ: Evaluating Neurodevelopmental Theory and Training with Cerebral-palsied,

Severely Handicapped Students. Doctoral Dissertation. Lawrence, KS, University of Kansas, 19826. Norton Y: Neurodevelopmental and sensory integrative training of young children withcerebral palsy. Am J Occup Ther 29:93-100,1975

7. Paine RS: On the treatment of cerebral palsy: The outcome of 177 patients, 74 totallyuntreated. Pediatrics 29:605-616,1962

8. Rizk TE, Christopher RP, Feldman J, et al: l-cell disease and its rehabilitation: A casestudy. Arch Phys Med Rehabil 63:138-140, 1982

9. Rothman JG: Effects of respiratory exercises on the vital capacity and forced expiratoryvolume in children with cerebral palsy. Phys Ther 58:421-425, 1978

10 . Tyler NB, Kahn N: A home treatment program for the cerebral-palsied child. Am J OccupTher 30:437-440,1976

1 1 . Woods GE: The outcome of physical treatment in cerebral palsy. Cerebral Palsy Review25:3-9,1964

prehensive effort to evaluate the effectiveness ofN D T .

Regardless of whether an intensive-design or a multiple-subject, group-comparison approach is used in a study,certain factors important to the intervention ou tcome c annot be assessed easily across primary studies. For example,the intensity and the integrity of thetreatment program often are difficult orimpossible to evaluate com prehensively.A report may contain a very convincingdescription of the treatment, but provide little information concerning howeffectively the treatment program wasimplemented. Issues related to thestrength and integrity of the independent variable may have an influence ontreatment outcomes that affect the conclusions of both quantitative reviewsand traditional narrative reviews.

The quantitative reviewing procedures that we used in our investigationare not a panacea. Meta-analysis procedures may be misapplied and misinterpreted.35 The methodology, however,represents a significant advan ce over traditional narrative attempts to integratea body of research literature. As Rosenthal has noted, the "procedures are notperfect, we can use them inappropriately, and we will make mistakes.Nevertheless, thealternative to the systematic, explicit, quantitative procedures is even less perfect, even morelikely to be applied inappropriately, andeven more likely to lead us to error."36

CONCLUSIONSOur application of quantitative re-viewing procedures revealed that NDTeffects are detectable if meta-analysistechniques are used to identify them.The overall effects of NDT are smalland appea r to be related to some specificresearch design and study characteristics. These findings have obvious implications for therapists interested in conducting research on the efficacy of ND T.Researchers should anticipate "small"treatment effects and plan their investigations accordingly. Future investigators may wish to emphasize clinicalsignificance by reporting measures ofrelationship strength and place lessemp hasis on statistical significance test-ing.37Many questions related to the effectiveness of NDT as an interventionstrategy for handicapped infants andchildren remain unanswered. For ex-ample, is NDT more effective for stu

dents in certain diagnostic categories orage groups? When should students beenrolled to achieve maximum benefit?How long do the effects of the tre atm entlast? These are important questions thatneed to be addressed in future investigations. Therapists currently providingintervention services, however, cannotwait for the one definitive study th at willanswer these questions. The results ofthis investigation dem onstrate that therapists can begin to answer some of thesequestions if current research is synthesized properly and if future research isdesigned properly.

REFERENCES

1 . Mullins J: New challenges for physical therapypractitioners in educational settings. Phys Ther61 :496-502 .19812. Denhoff E: Current status of infant stimulationor enrichment programs for children with developmental disabilities. Pediatrics 67:32-35,19813. Ferry PC: On growing new neurons: Are earlyintervention programs effective? Pediatrics67:38-41 ,19814. Bobath K: A Neurophysiologies Basis for theTreatment of Cerebral Palsy. London, England,William Heinemann Medical Books Ltd, 1 9805. Bobath B: The treatment of neuromusculardisorders by improving patterns of coordination. Physiotherapy 55:1 8-2 2, 1 9696. Harris SR: Effects of neurodevelopmental therapy on motor performance of infants withDown's syndrome. Dev Med Child Neurol23:477-483, 19817. Seamans S: The Bobath concept in treatmentof neurological disorders. Am J Phys Med46:732-788, 19678. Harris SR, T ada W L: Providing developmentaltherapy services. InGarwood SG, Fewell RR(eds): Educating Handicapped Infants: Issuesin Development and Intervention. Rockville,MD, Aspen Systems Corp, 1982, pp 344-3659. Sahrmann S: Perspectives: Should there beNDT certification? View 1 . Phys Ther 63 :55 2-553, 19831 0. DeGangi GA, Hurley L, Linschied TR : Tow arda methodology of measuring the short-termeffects of neurodevelopmental treatment. AmJ Occup Ther 37:479-484,1983

1 1 . Glass GV, McGaw B, Smith ML: Meta-Analysisin Social Research. Beverly Hills, CA, SagePublications Inc, 198112. Cooper HM: Scientific guidelines forconducting integrative research reviews. Review ofEducational Research 52:291 - 3 0 1 , 19821 3. Glass GV: Primary, secondary and m eta-analysis of research. Educational Researcher 5:3-9, 197614 . Pillmer DB, Light RJ : Synthesizing outcomes:How to use research from many studies. Harvard Education Review 50 :1 70-1 89 198015. Cooper HM : The Integrative Research Review:A Systematic Approach. Beverly Hills, CA,Sage Publications Inc, 1 9841 6. Bobath K, B obath B: The neurodevelopmentalapproach to treatment. In Pearson PH, Williams CE(eds): Physical Therapy Services inthe Developmental Disabilities. Springfield, IL,Charles C Thomas, Publisher, 1972, pp 3 1 -104

1 7. Bobath B: The very early treatment of cerebralpalsy. Dev Med Child Neurol 9:373 -390 , 196 71 8. Solokoff N, Yaffe E, W eintraub D, et al: Effectsof handling on the subsequent development ofpremature infants. Developmental Psychology11 :755-801 ,19691 9. Sommerfeld D, Fraser BA, Hensinger RN, etal: Evaluation of physical therapy service forseverely mentally impaired students with cerebral palsy. Phys Ther 61 :338 -344 , 1 98120 . Glass GV: Integrating findings: The meta-analysis of research. InShulman L (ed): Review ofResearch in Education. Itasca, IL, F E PeacockPublishers Inc, 1 978 , vol 5,pp 67-97

21 . Cohen J: Statistical Power Analysis for theBehavioral Sciences, rev ed . NewYork, NY,Academic Press Inc, 1977, pp 9, 2222 . Friedman H: M agnitude of experimental effectand table for its rapid estimation. Psychol Bull70:245-248, 196823 . Hedges LV: Unbiased estimation of effect size.Evaluation in Education 4:25-31 , 198024. Tukey JW; Exploratory Data Analysis. Boston,MA, Addison-Wesley Publishing Co Inc, 1 97725. Hedges LV: Estimation of effect size from aseries of independent experiments. PsycholBull 92:490-499 , 1 982

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Volume 66 / Number 7, July 1986 1101by guest on April 26, 2012http://ptjournal.apta.org/Downloaded from

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1986; 66:1095-1101.PHYS THER.Mary Beth JohnsonDeCremer, Marcia Gevelinger, Kathleen B Jedlovec andKenneth J Ottenbacher, Zena Biocca, GwynethNeurodevelopmental Treatment ApproachPediatric Therapy : Emphasis on theQuantitative Analysis of the Effectiveness of

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