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Guideline Summary
Guideline Title
Best evidence statement (BESt). Biofeedback intervention for children with hemiplegic cerebral palsy.
Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Biofeedback intervention for children with hemiplegic cerebral palsy. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 Apr. 4 p. [10 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Hemiplegic cerebral palsy

Guideline Category
Assessment of Therapeutic Effectiveness
Treatment
Clinical Specialty
Family Practice
Neurology
Pediatrics
Physical Medicine and Rehabilitation
Intended Users
Advanced Practice Nurses
Nurses
Occupational Therapists
Physical Therapists
Physician Assistants
Physicians
Guideline Objective(s)

To evaluate if biofeedback (augmented feedback) compared to usual care improves function and/or decreases impairment among children diagnosed with hemiplegic cerebral palsy

Target Population
  • Children up to 12 years of age who present with a diagnosis of hemiplegic cerebral palsy and hemiparesis according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) criteria

    and

  • Children with impairments in: strength, range of motion, balance, posture, body coordination, motor control, joint mobility, pain, muscle tone, functional independence and/or gross motor skill development

Note: The following children are excluded from this guideline:

  • Children with significant cognitive delay who are unable to follow multi-step directions or to comply with recommendations
  • Children not ambulatory by age 3
Interventions and Practices Considered

Surface electromyogram (EMG) biofeedback

Major Outcomes Considered

Functional status including muscle control, strength, posture, gait, and dorsiflexion

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Search Strategy

  1. Databases

    OVID MEDLINE

    OVID CINAHL

    Search Terms: cerebral palsy, biofeedback, hemiplegia, children, physical therap$, occupational therap$

  2. Limits and Filters: English, humans; dates: January 1982 to April 2008. This search was opened up to include those studies that also investigated biofeedback in adults with a hemiplegic stroke diagnosis.
  3. Additional Articles: from reference lists
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

The guideline was reviewed by the Health Policy and Clinical Effectiveness Division at Cincinnati Children's Hospital Medical Center.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a-5) are defined at the end of the "Major Recommendations" field.

It is recommended that biofeedback be considered by a physical therapist as an adjunct to other forms of traditional physical therapy. Physical therapists may use surface electromyogram (EMG) biofeedback to facilitate improvements in strength, coordination, muscle control, and peak muscle power during gait as well as to improve gait parameters such as velocity, cadence and stride length (Schleenbaker & Mainous, 1993 [1a]; Dursun, Dursun, & Alican, 2004 [2b]; Bolek, 2006 [4a]; Bolek, 2003 [4b]; Toner, Cook, & Elder, 1998 [4b]; Colborne, Wright, & Naumann, 1994 [4b]; James, 1992 [5]; Local Consensus [5]).

Note: Studies generally included daily use of biofeedback with short varied duration periods of:

  • 30 minutes per day for 10 days (Dursun, Dursun, & Alican, 2004 [2b])
  • 30 minutes daily for 60 days (Hartveld & Hegarty, 1996 [5])
  • And 45-60 minutes twice daily for 4 weeks (Colborne, Wright, & Naumann, 1994 [4b])
  • To longer treatment periods of 5 hours each week for 6 weeks (Toner, Cook, & Elder, 1998 [4b]).

Definitions:

Table of Evidence Levels

Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5 Other: General review, expert opinion, case report, consensus report, or guideline

†a = good quality study; b = lesser quality study

Table of Recommendation Strength

Strength Definition
"Strongly recommended" There is consensus that benefits clearly outweigh risks and burdens (or vice-versa for negative recommendations).
"Recommended" There is consensus that benefits are closely balanced with risks and burdens.
No recommendation made There is a lack of consensus to direct development of a recommendation.
Dimensions: In determining the strength of a recommendation, the development group makes a considered judgment in a consensus process that incorporates critically appraised evidence, clinical experience, and other dimensions as listed below.
  1. Grade of the Body of Evidence
  2. Safety/Harm
  3. Health benefit to the patients (direct benefit)
  4. Burden to patient of adherence to recommendation (cost, hassle, discomfort, pain, motivation, ability to adhere, time)
  5. Cost-effectiveness to healthcare system (balance of cost/savings of resources, staff time, and supplies based on published studies or onsite analysis)
  6. Directness (the extent to which the body of evidence directly answers the clinical question [population/problem, intervention, comparison, outcome])
  7. Impact on morbidity/mortality or quality of life
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Studies of biofeedback (augmented feedback) provide evidence to suggest beneficial outcomes in improved striated muscle control, strength, posture correction, and gait training in children with cerebral palsy.
  • Two studies provide evidence that biofeedback improves dorsiflexion. This improvement was sustained at the post-training level for 14 months and 3 months after the treatment period.
  • Gains made during gait training in children diagnosed with hemiplegic cerebral palsy, including increased weight bearing on the heel and heel force of the hemiparetic leg, are clinically and statistically significant and demonstrate short-term carryover for one month following training.
Potential Harms

When using surface electromyogram (EMG) a slight skin reaction may occur at the electrode site.

Qualifying Statements

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Biofeedback intervention for children with hemiplegic cerebral palsy. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2010 Apr. 4 p. [10 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Apr 6
Guideline Developer(s)
Cincinnati Children's Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding

Cincinnati Children's Hospital Medical Center

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Development Group: Stacey Maignan, PT, MPT, Team Leader, Division of Occupational Therapy and Physical Therapy; Sherrie Conner, PT, MHS, Primary Developer, Division of Occupational Therapy and Physical Therapy; Carol Burch, PT, DPT, Division of Occupational Therapy and Physical Therapy; Catie Christensen, PT, DPT, Division of Occupational Therapy and Physical Therapy; Caroline Colvin, PT, MSPT, Division of Occupational Therapy and Physical Therapy; Kari Hall, PT, DPT, Division of Occupational Therapy and Physical Therapy

Senior Clinical Director: Rebecca D. Reder, OTD, OTR/L, Senior Clinical Director, Occupational Therapy and Physical Therapy

Financial Disclosures/Conflicts of Interest

Conflict of interest declarations were completed by members of the Best Evidence Statement (BESt) development team and none were found.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Cincinnati Children's Hospital Medical Center Web site External Web Site Policy.

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Availability of Companion Documents

The following are available:

Print copies: For information regarding the full-text guideline, print copies, or evidence-based practice support services contact the Cincinnati Children's Hospital Medical Center Health James M. Anderson Center for Health Systems Excellence at EBDMInfo@cchmc.org.

Patient Resources

None provided

NGC Status

This NGC summary was completed by ECRI Institute on December 7, 2010.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children's Hospital Medical Center (CCHMC) External Web Site Policy Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

  • Copies may be provided to anyone involved in the organization's process for developing and implementing evidence based care
  • Hyperlinks to the CCHMC website may be placed on the organization's website
  • The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents
  • Copies may be provided to patients and the clinicians who manage their care

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

Disclaimer

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