Quantitative Analysis of the Effectiveness of Pediatric Therapy : Emphasis on the Neurodevelopmental Treatment Approach Kenneth J Ottenbacher, Zena Biocca,

Gwyneth DeCremer, Marcia Gevelinger, Kathleen B Jedlovec and Mary Beth Johnson PHYS THER. 1986; 66:1095-1101.

The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/66/7/1095 Collections This article, along with others on similar topics, appears in the following collection(s): Motor Development Therapeutic Exercise To submit an e-Letter on this article, click here or click on "Submit a response" in the right-hand menu under "Responses" in the online version of this article. Sign up here to receive free e-mail alerts

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Quantitative Analysis of the Effectiveness of Pediatric Therapy

Emphasis on the Neurodevelopmental Treatment Approach
KENNETH J. OTTENBACHER, ZENA BIOCCA,
GWYNETH D E C R E M E R ,

MARCIA GEVELINGER, KATHLEEN B. JEDLOVEC, and MARY BETH JOHNSON We investigated the effectiveness of neurodevelopmental treatment when used both in isolation and in combination with other developmental therapies. The data were analyzed using recently developed methods of quantitatively synthesizing research results in which the literature review process is regarded as a unique type of research. Our analysis revealed that the subjects who received NDT performed slightly better than the control-comparison subjects who did not receive the intervention. The study outcomes are discussed in relation to several design variables and study characteristics associated with subject performance. The advantages and limitations of quantitative reviewing are identified briefly, and the potential use of the procedures in clinical research is emphasized. Key Words: Child development disorders, Handicapped, Physical therapy.

The development and therapeutic application of intervention programs for patients with either central nervous system dysfunctions or developmental delays have increased dramatically during the past decade. This process has been true particularly for the school-age population. The impetus provided by Public Law 94-142 has resulted in record numbers of handicapped students receiving therapy services.1 Despite the expansion of therapeutic services for handicapped infants and young children, considerable controversy exists among health care professionals and educators regarding the effectiveness of these intervention programs. Recent articles in Pediatrics have reflected this dissension.23 One article optimistically reported that, based on the available evidence, the benefits of intervention programs for at-risk and handicapped children clearly outweigh the disadvantages.2 Another author concluded that no valid scientific evidence exists that these programs alter neuro-

Dr. Ottenbacher is Associate Professor, School of Allied Health Professions, University of Wisconsin, 2120 Medical Sciences Center, 1300 University Ave, Madison, WI 53706 (USA). Ms. Biocca, Ms. DeCremer, Ms. Gevelinger, Ms. Jedlovec, and Ms. Johnson are graduate students at the University of Wisconsin. This article was submitted May 20, 1985; was with the authors for revision four weeks; and was accepted November 21, 1985.

logic development in high-risk or neurologically handicapped children.3 Neurodevelopmental treatment is one intervention approach that has been a popular form of therapy for infants and children with neuromotor dysfunction.45 Harris recently observed that "one of the most widely accepted methods of treatment used by pediatric physical therapists working with the developmentally disabled is the neurodevelopmental approach."6 Neurodevelopmental treatment emphasizes three basic components related to neuromotor control: postural tone, reflexes and reactions, and movement patterns.7 One of the primary objectives of the NDT approach is the facilitation of normal muscle tone to maintain normal postural and movement patterns.8 This objective may be achieved through a complex process of inhibition and facilitation that has evolved over a period of 30 years. The rationale for NDT has been described extensively by the Bobaths4.5 and others.8 Important professional questions concerning the effectiveness of NDT-based intervention cannot be answered without empirical evidence.9 To date, several researchers have reported using the NDT approach to facilitate the neuromotor performance and development of handicapped children, but the results of their studies have been inconclusive.8 A

common conclusion of those studies is that more research is needed before a decision regarding the efficacy of NDT can be rendered.10 This call for additional research is based on the belief that empirical evidence of the effectiveness of an intervention strategy should be cumulative. Evidence from multiple studies can be used effectively by therapists, parents, and educators only when it is accumulated in a systematic, logical manner. The subjective and judgmental nature of traditional attempts to review and synthesize research literature is unfortunate because comprehensive reviews often are instrumental in establishing or refuting the empirical legitimacy of a research finding. In our study, we used recently developed quantitative reviewing procedures to synthesize the evidence of the effectiveness of NDT with handicapped infants and children. In the quantitative reviewing method, also referred to as meta-analysis, the literature review process is regarded as a unique type of research that requires the same rigorous methodology 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 of integrating the findings. It connotes a rigorous alternative to the casual, nar1095

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Some studies that used a combination of NDT and other forms of developmental therapy were included in the analysis. We decided to include those studies because of the small number of METHOD research studies that used only NDT and because of the difficulty in identifying Potentially relevant studies were idenwhether the treatment provided in a tified through an on-line computer study was exclusively NDT. Sommersearch of List of Journals Indexed in feld et al, for example, conducted a Index Medicus, Psychological Abstracts, study in which three experienced pediCurrent Index to Journals in Education, atric therapists, who had received recent Resources in Education, and Dissertaformal postgraduate training in neurotions Abstracts International. An examdevelopmental procedures and other apination of the references contained in proaches to the treatment of cerebral those studies (citation tracking) resulted palsy, provided intervention to handiin the compilation of additional inforcapped students.19 The authors reported mation. that their: Our search of the literature yielded a Therapy goals included inhibition of total of 37 nonoverlapping research reprimitive and pathological reflexes, ports that were construed broadly as facilitation of postural reactions, potentially relevant to the efficacy of normalization of muscle tone, stimulation of gross motor skills, and preNDT. We then judged the relevance of vention of further musculoskeletal the abstracts and full reports according deformities by range of motion and to several specific criteria. positioning.19 Criteria for Including Studies in Sample Thefirstcriterion for inclusion in our quantitative analysis involved the nature of the independent variable. To be included in the quantitative review, the study had to investigate the effect of NDT as at least one of the independent variables. To qualify as NDT, the treatment procedures had to include some combination of the facilitation and inhibition procedures developed by the Bobaths and be based on the theoretical work of the Bobaths.4,5,16,17 We did not consider treatment techniques that involved the isolated application of a specific form of sensory stimulation to qualify as NDT and, therefore, studies 1096 We included their study in our analysis because the treatment provided obviously included some NDT components. We categorized the studies on the basis of whether they provided NDT in combination with some other intervention approach versus using NDT as the only form of intervention. This information then was used in a later analysis to determine whether different outcomes existed for the two types of studies. The second criterion for inclusion of a study in our sample was related to the type of dependent variable used in the study. One advantage of quantitative reviewing methodology is that it permits the use of broad dependent variables.15 One purpose of our investigation was to

rative discussions of research studies which typify our attempts to make sense of the rapidly expanding research literature.13 The methods of meta-analysis allow the reviewer to aggregate quantitatively several research studies and to make consensual judgments based on their results.14 The procedures also allow systematic investigation of the effects of variation in study methods on study results.15 The purposes of our study were 1) to introduce the various techniques of quantitative reviewing to therapists, educators, and researchers and 2) to use quantitative reviewing methods to evaluate the effectiveness of clinically applied NDT to enhance developmental and motor factors in handicapped infants and children.

that involved only this type of treatment were not included in the analysis. We did not include in our review the studies providing intervention that used terminology frequently associated with NDT but that did not provide a rationale for intervention associated with work by the Bobaths. For example, Solokoff et al reported using "handling" to improve the development of premature infants.18 We did not include their study in the review because the independent variable (handling) was defined operationally as providing tactile stimulation (rubbing) to the neck, back, and arms of the infants.

evaluate the effectiveness of NDT applied to at-risk and handicapped infants and children. We broadly categorized improvement or enhancement of development according to the level of performance on any outcome measure that evaluated motor-reflex function or overall development. Outcome measures that did not fit into one of these categories but that still were considered developmental (eg, specific measures of self-help skills) were placed in a category labeled "other." Studies that used nondevelopmental measures such as respiration rate were not included in the review. The third criterion for including a study in our quantitative analysis was related to the characteristics of the study's sample group. To be included in the review, the study had to include pediatric subjects with developmental disabilities or delay. Studies in which the average (mean) age of the students was 15 years or more were not included in the review. The final two criteria were related to the study's design and method of analysis. To be included in our quantitative analysis, the study had to report a comparison between at least two groups of subjects: one that received NDT and one that did not. In some studies, when a within-subjects design was used, the comparison or control group was the same as the experimental group. When more than two comparisons were made among groups (multiple degree-of-freedom tests), the comparisons were separated into two-group comparisons between control-comparison groups and the 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 of an effect size. That is, the investigation had to present the results of statistical tests (t or F ratios, means, standard deviations, and df and p values) in sufficient detail so that the appropriate effect-size measure could be computed. We eliminated 17 of the 37 studies after a review of their abstracts and titles because they did not meet these criteria. Another 11 studies were eliminated after the full report was reviewed (Appendix 1). The remaining 9 studies met the criteria and were included in our analysis (Appendix 2). PHYSICAL THERAPY

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RESEARCH

Quantifying Study Outcomes Glass and Cohen have popularized procedures for uncovering systematic variation in study results. These procedures involve the calculation of study effect sizes and the analysis of these effect sizes in relation to study and design characteristics. Cohen defines an effect size as "the degree to which the null hypothesis is false."21 Effect-size measures appropriate for use with a wide variety of research designs and analytic procedures have been presented by Cohen.21 The primary effect-size measure used in our investigation was the d index. The d index is an effect-size measure specifically designed to evaluate the statistical comparison between two groups. One criterion for inclusion in our review was that at least one two-group comparison be included in the study. Several of the studies included in our review contained multiple two-group comparisons. Harris, for example, compared the performance of infants with Down syndrome who received NDT with handicapped infants who did not receive the intervention.6 Four outcome measures were evaluated during the study, including performance on the Bayley Scales of Infant Development (Mental and Motor), the Peabody Gross Motor Scale, and a set of individually developed therapy objectives. Thus, multiple comparisons were included in several studies because more than one outcome measure was obtained. Effect sizes were computed for each two-group comparison statistically analyzed in each of the reviewed studies. The nine studies included in our review contained a total of 35 statistical hypothesis tests of two-group comparisons of the effectiveness of NDT procedures with handicapped infants and children. As noted previously, the effect-size measure computed for each two-group comparison was the d index. The d index gauges the difference between two groups' means in terms of their common (average) standard deviation. A d index of 0.30, for example, indicates that three tenths of standard deviation separates the two sample means. Cohen has defined a d index of 0.20 to 0.50 as small, a d index of 0.50 to 0.80 as medium, and a d index greater than 0.80 as a large effect size.21 Because this classification system may leave something to be desired in terms of intuitive appeal,
20 21

TABLE 1 Stem-and-Leaf Plot of All d Indexesa Included in the Reviewed Studies Stem 1.2 1.1 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 2 2 8 Leaf

1 2 1 1 1 0 1 1 0

5 3 8 4 5 0

9 5 9 6 8 8 9 0 0 0 0 0 0 0 0 0 0

a = 0.31, Median = 0.19, s = 0.37, Minimum = 0.00, Maximum = 1.28, Q1 = 0.00, Q3 = 0.41.

Cohen also presented a percentage of distribution overlap measure designated U3.21 This measure indicates the percentage of the population with the smaller mean that is exceeded by 50% of the population with the larger mean. The U3 value for a d index of 0.30 is 61.8. This value means that the average person in the group with the larger mean (usually the treatment group) has a higher "score" than about 62% of the individuals in the lower mean group. A table for converting the d index to U3 was presented by Cohen.21 Friedman has presented formulas for computing d-index estimates using traditional inferential statistical values such as t and F ratios.22 Effect sizes also can be computed using group means and standard deviations.11 In addition, Glass has described procedures for computing effect sizes when nonparametric statistics or percentages are used.20 Hedges recently demonstrated that d indexes may become biased as the sample size becomes smaller (<50).23 Hedges introduced correction factors that we used in our investigation to adjust for potentially inflated effect sizes from the studies with a sample of fewer than 50 subjects. Finally, when a study reported a nonsignificant result, but not enough information was provided to determine an effect size, an estimated effect size of 0.00 was assumed. RESULTS A total of 371 subjects participated in the nine studies (35 hypothesis tests) included in our review. About 51% of

the total were male subjects and about 49% were female subjects. The most frequently reported diagnosis was cerebral palsy (62%). The mean age of the participants was 71 months (s = 58.6 months). For those studies that reported ages at both the beginning and end of the investigation, we used only the initial ages to determine the mean age of the subjects in the nine studies included in our analysis. The mean year of report publication was 1975 (s = 8.14 years). The mean d index for the 35 hypothesis tests of the efficacy of intervention was 0.31. The d indexes for all of the hypothesis tests included in our analysis are presented in Table 1. Each d index is indicated by a combination of "stem" and "leaf," according to the system of data presentation suggested by Tukey.24 The stem represents the initial value of the d index. The leaf values represent individual numbers, each of which is associated with the corresponding stem. For example, the numbers 1 and 3 (leaf) to the right of 0.4 (stem) in Table 1 represent d indexes of 0.41 and 0.43, respectively. The stem-and-leaf system of data presentation provides all the information of a histogram but also shows the actual values of all d indexes. Table 1 also includes the minimum and maximum d indexes; the first- and thirdquartile values (Q1, Q3); and the mean, the median, and the standard deviation of the effect-size values. Hedges accurately observed that the statistical results of studies and their associated effect sizes will vary based on chance.25 That is, because researchers use samples from populations, the sample means will not always be identical to the population mean, nor to other sample estimates. The amount of variability in sample means taken from a single population will be a function of the number of data points on which the sample means are based. The possibility exists, therefore, that considerable variance may exist in a collection of effect sizes because of a sampling error. Hedges25 and Rosenthal and Rubin26 have proposed the use of a homogeneity analysis to test whether the variance exhibited in a set of effect sizes is the result of a sampling error. If the homogeneity analysis reveals that the variance in effect sizes is greater than that expected by chance, the investigator then may investigate other potential sources of variance, such as study characteristics or design variables. The homogeneity sta1097

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TABLE 2 Mean d Indexes for Type of Research Design and Subject Assignment Procedures Na Type of research design Preexperimental Quasi-experimental True experimental Type of assignment Random Combination Preexisting groups
a b

s 0.34 0.30 0.31 0.28 0.31 0.37 0.26 0.23 0.22 0.21 0.22 0.26

SEMb 0.11 0.06 0.07 0.07 0.05 0.11

Us 63.2 61.8 62.2 61.0 62.2 64.4

7 17 11 9 19 7

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

TABLE 3 Mean d Indexes for Each Category of Dependent Variable and How the Variable Was Recorded Na Dependent variable Motor-reflex Overall development Other Recording method Blindly recorded Not blindly recorded-no information provided
a b

be reliably different from one another if they were more than two standard errors apart. This criterion provides the reader with a simple measure of differences in mean effect sizes. For example, the mean d index for preexperimental research designs was 0.34 with a standard error of 0.11. Using the proposed criterion, effect sizes ranging from SEM = +2 (0.56) to SEM = - 2 (0.12) would not be considered reliably different from the mean effect size for preexperimental research designs. We, therefore, used this convention to determine that no reliable differences existed between the mean effect sizes for type of research design or assignment procedure. Dependent Variable and Effect Size As we noted in the Method section, the outcome measures in each study were categorized as motor-reflex, overall developmental, or other. At least two independent raters categorized each outcome measure with an overall agreement of 91%. The mean d indexes for the three types of dependent measures are presented in Table 3. The mean d indexes for motor-reflex measures and measures of overall development were similar, and both of these values were larger than the mean d index for outcome measures categorized as other (Tab. 3). Our use of the two-standarderrors criterion revealed that the mean d indexes for motor-reflex measures and measures of overall development were reliably larger than the mean d index for outcome measures labeled as other. There was no reliable difference between the mean d indexes for motor-reflex and overall developmental measures. Also presented in Table 3 are the mean d indexes for the methods used to record the variables. Our use of the twostandard-errors convention revealed that the mean d index for measures that were recorded blindly was reliably smaller than the mean d index for measures that were not recorded blindly or for which adequate information on recording strategies was not reported. We also performed a related analysis to determine the relationship among the d indexes and whether the dependent measure that was used was standardized or informal Standardized measures were those, such as the Bayley Motor Scales, that were developed for a specific population, adPHYSICAL THERAPY

s 0.32 0.38 0.19 0.21 0.57 0.24 0.21 0.11 0.18 0.51

SEMb 0.05 0.08 0.05 0.04 0.17

U3 62.5 64.8 57.5 58.3 71.6

21 8 6 25 10

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

tistic (HT) described by Hedges25 was computed for the set of effect sizes (d indexes) and indicated that the amount of variability in the collection of effect sizes exceeded the amount of variability that would have been expected by chance (HT = 67.9, p < .05). Based on this result, we considered an analysis of effect sizes by specific design characteristics and study variables to be justified. Design Characteristics and Effect Size Individual studies were categorized according to the type of research design that was used. At least two raters reviewed each study and classified the research designs as preexperimental, quasi-experimental, or true experimental using criteria originally developed by Campbell and Stanley.27 An overall agreement index of 89% was obtained for labeling the research designs of the nine studies included in our review. When two raters disagreed about the classification of a research design, a third rater classified the research design. The classification chosen by consensus then was used in the subsequent analysis. Each study also was classified according to the type of subject assignment 1098

procedures used. The assignment categories were 1) random assignment, 2) matching or a combination of matching and random assignments, and 3) preexisting groups. The subject assignment procedures were classified by at least two independent raters with an overall agreement exceeding 95%. The mean d indexes for the type of research design and subject assignment procedures are presented in Table 2. The mean d indexes for all three types of research design (preexperimental, quasiexperimental, and true experimental) are relatively equal. The mean d indexes for the three types of subject assignment procedures also are relatively equal with the largest mean d index associated with studies that used preexisting groups in the assignment of subjects. Because our d indexes were based on comparisons that were not independent of one another (ie, more than one comparison was obtained from some studies), we decided that the use of inferential statistics to test whether effect sizes differed significantly across various study characteristics, such as the type of research design, may not be warranted.15 On the basis of the procedure developed by Smith,28 we considered d indexes to

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RESEARCH ministered in a prescribed manner, and resulted in a standardized score. Assessments that we categorized as informal included check lists or individualized measures that frequently were developed by the authors for a particular study. Each outcome measure was classified as either standardized or informal by at least two independent raters with an interrater agreement of 86%. The mean d index for the 17 comparisons associated with a standardized measure was 0.29 (s = 0.21), and the mean d index for the 14 comparisons based on an informal measure was 0.33 (s = 0.29). We were unable to determine whether the outcome measure was standardized or informal in four of the comparisons. The mean d index for these four comparisons was 0.33 (s 0.24). No reliable differences existed among the mean effect sizes based on whether the outcome measure was standardized or informal. DISCUSSION The effectiveness of the NDT approach and other pediatric therapies is currently an issue generating considerable professional debate.2,3,6,9 Jenkins and Sells recently raised the central question, "Does pediatric physical and occupational therapy really work?"29 They observed that the economic viability of NDT and other therapeutic intervention strategies will continue to be questioned until a more empirical database can be generated supporting them. Previous studies of the efficacy of NDT with handicapped infants and children have reported conflicting or inconsistent findings and have not resulted in any empirical consensus.8 Cooper and Rosenthal have noted, however, that "some of the confusion and contradiction we convey about our research may not be a function of the results but of how we have chosen to synthesize them."30 The quantitative reviewing procedures that we used in our investigation have demonstrated a quantifiable treatment effect for NDT. The overall mean effect size for the studies that we reviewed was 0.31. This effect size was associated with a U3 value of 62.2, which suggests that the average subject who received NDT or a combination of NDT and some related therapy performed better than about 62.2% of the subjects in the control or comparison groups who did not receive the intervention. The overall mean effect of 0.3.1 was in the range Cohen considered a small treatment effect.21 Ottenbacher reported that much of the research in applied fields such as physical or occupational therapy will be concerned with small effect sizes because of the nature of the variables under investigation, the small sample sizes that generally are available, and the lack of rigorous experimental control in most clinical situations.31 When small treatment effects are expected, clinical researchers must be concerned with statistical sensitivity and experimental power evaluations. Many of the small effect sizes reported in the clinical literature are associated with low statistical power and, therefore, do not achieve the traditionally accepted .05 level of statistical significance.32,33 This lack of statistical significance is a problem particularly in studies dealing with handicapped subject populations in which the sample sizes tend to be small and very heterogeneous. Harris acknowledged this problem in her investigation of the effectiveness of NDT in children with Down syndrome.6 She stated that "the failure to find significant differences between the two groups of infants on three of the four dependent measures used suggests that this study had several limitations. The obvious one is the size of the sample."6 The relationship between sample size, significance level, effect size, and statistical power should be familiar to all clinical researchers. An awareness of these factors during the formulation of hypotheses before conducting a study can help reduce the incidence of Type II errors in clinical research when small treatment effects are expected.21 Limitations Our decision to include only studies that met certain criteria in our quantitative review eliminated several studies of the efficacy of NDT. Several studies identifying NDT as the independent variable were not included in the review because of the lack of a control or comparison group or the inability to generate a d index from the information provided. Generally, those studies involved some type of intensive single-subject or single-case design. For example, Laskas et al recently evaluated the immediate therapeutic effects of four NDT activities on the motor performance of a young child with spastic quadriplegia.34 They used a single-subject experimental design that included baseline and treatment phases. Their results demonstrated that the NDT activities resulted in increased dorsiflexor muscle activity during an equilibrium reaction and increased frequency of heel contact when the child assumed a standing position. Intensive-design studies can provide important supplemental information to the multiple-subject, group-comparison studies included in the quantitative review, but their outcomes typically were not founded on formal statistical analyses. A listing of several related studies of the effectiveness of NDT that were not included in the review is provided in Appendix 1. These studies did not meet the criteria presented previously for inclusion in the quantitative analysis; they, however, do contribute to the growing empirical literature on NDT and should be considered in any corn1099

Miscellaneous Analyses of Effect Size As we noted in the previous section, some studies used a combination of treatments, at least one of which was NDT, and other studies included only NDT procedures as the independent variable. A total of 19 comparisons was included in studies that used a combination of treatments. The mean d index for those 19 comparisons was 0.33 (s = 0.27). The remaining 16 comparisons involved only NDT procedures as the independent variable. The mean d index for those comparisons was 0.29 (s = 0.26). The mean d index for the combined-treatments comparisons was slightly larger than for the NDT-alone comparisons, but we found that the mean d indexes were not reliably different using the two-standard-errors criterion. Finally, correlations were computed between year of report publication and the d indexes (r = .03, p = NS), the number of subjects in each study and the effect size (r = .04, p = NS), the average age of the subjects in the study and the effect size (r = -.27, p = NS), and the duration of the investigation in weeks and the effect size (r = .22, p = NS). None of these correlations were statistically significant at the .05 level of confidence.

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APPENDIX 1
Related Studies 1. DeGangi GA, Hurley L, Linschied TR: Toward a methodology of measuring the short-term effects of neurodevelopmental treatment. Am J Occup Ther 37:479-484, 1983 2. Haberfellner H, Muller G: Bobath therapy, tonic reflex activity and processing of acoustic stimuli. Neuropediatrics 7:379-383, 1976 3. Kong E: Very early treatment of cerebral palsy. Dev Med Child Neurol 8:198-202, 1966 4. 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 65:11-16,1985 5. Noonan MJ: Evaluating Neurodevelopmental Theory and Training with Cerebral-palsied, Severely Handicapped Students. Doctoral Dissertation. Lawrence, KS, University of Kansas, 1982 6. Norton Y: Neurodevelopmental and sensory integrative training of young children with cerebral palsy. Am J Occup Ther 29:93-100,1975 7. Paine RS: On the treatment of cerebral palsy: The outcome of 177 patients, 74 totally untreated. Pediatrics 29:605-616,1962 8. Rizk TE, Christopher RP, Feldman J, et al: l-cell disease and its rehabilitation: A case study. Arch Phys Med Rehabil 63:138-140, 1982 9. Rothman JG: Effects of respiratory exercises on the vital capacity and forced expiratory volume 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 Occup Ther 30:437-440,1976 11. Woods GE: The outcome of physical treatment in cerebral palsy. Cerebral Palsy Review 25:3-9,1964

REFERENCES 1. Mullins J: New challenges for physical therapy practitioners in educational settings. Phys Ther 61:496-502.1981 2. Denhoff E: Current status of infant stimulation or enrichment programs for children with developmental disabilities. Pediatrics 67:32-35, 1981 3. Ferry PC: On growing new neurons: Are early intervention programs effective? Pediatrics 67:38-41,1981 4. Bobath K: A Neurophysiologies Basis for the Treatment of Cerebral Palsy. London, England, William Heinemann Medical Books Ltd, 1980 5. Bobath B: The treatment of neuromuscular disorders by improving patterns of coordination. Physiotherapy 55:18-22, 1969 6. Harris SR: Effects of neurodevelopmental therapy on motor performance of infants with Down's syndrome. Dev Med Child Neurol 23:477-483, 1981 7. Seamans S: The Bobath concept in treatment of neurological disorders. Am J Phys Med 46:732-788, 1967 8. Harris SR, Tada WL: Providing developmental therapy services. In Garwood SG, Fewell RR (eds): Educating Handicapped Infants: Issues in Development and Intervention. Rockville, MD, Aspen Systems Corp, 1982, pp 344-365 9. Sahrmann S: Perspectives: Should there be NDT certification? View 1. Phys Ther 63:552553, 1983 10. DeGangi GA, Hurley L, Linschied TR: Toward a methodology of measuring the short-term effects of neurodevelopmental treatment. Am J Occup Ther 37:479-484,1983 11. Glass GV, McGaw B, Smith ML: Meta-Analysis in Social Research. Beverly Hills, CA, Sage Publications Inc, 1981 12. Cooper HM: Scientific guidelines for conducting integrative research reviews. Review of Educational Research 52:291 -301, 1982 13. Glass GV: Primary, secondary and meta-analysis of research. Educational Researcher 5:39, 1976 14. Pillmer DB, Light RJ: Synthesizing outcomes: How to use research from many studies. Harvard Education Review 50:170-189 1980 15. Cooper HM: The Integrative Research Review: A Systematic Approach. Beverly Hills, CA, Sage Publications Inc, 1984 16. Bobath K, Bobath B: The neurodevelopmental approach to treatment. In Pearson PH, Williams CE (eds): Physical Therapy Services in the Developmental Disabilities. Springfield, IL, Charles C Thomas, Publisher, 1972, pp 3 1 104 17. Bobath B: The very early treatment of cerebral palsy. Dev Med Child Neurol 9:373-390, 1967 18. Solokoff N, Yaffe E, Weintraub D, et al: Effects of handling on the subsequent development of premature infants. Developmental Psychology 11:755-801,1969 19. Sommerfeld D, Fraser BA, Hensinger RN, et al: Evaluation of physical therapy service for severely mentally impaired students with cerebral palsy. Phys Ther 61:338-344, 1981 20. Glass GV: Integrating findings: The meta-analysis of research. In Shulman L (ed): Review of Research in Education. Itasca, IL, F E Peacock Publishers Inc, 1978, vol 5, pp 67-97 21. Cohen J: Statistical Power Analysis for the Behavioral Sciences, rev ed. New York, NY, Academic Press Inc, 1977, pp 9, 22 22. Friedman H: Magnitude of experimental effect and table for its rapid estimation. Psychol Bull 70:245-248, 1968 23. Hedges LV: Unbiased estimation of effect size. Evaluation in Education 4:25-31, 1980 24. Tukey JW; Exploratory Data Analysis. Boston, MA, Addison-Wesley Publishing Co Inc, 1977 25. Hedges LV: Estimation of effect size from a series of independent experiments. Psychol Bull 92:490-499, 1982

prehensive effort to evaluate the effectiveness of NDT. Regardless of whether an intensivedesign or a multiple-subject, groupcomparison approach is used in a study, certain factors important to the intervention outcome cannot be assessed easily across primary studies. For example, the intensity and the integrity of the treatment program often are difficult or impossible to evaluate comprehensively. A report may contain a very convincing description of the treatment, but provide little information concerning how effectively the treatment program was implemented. Issues related to the strength and integrity of the independent variable may have an influence on treatment outcomes that affect the conclusions of both quantitative reviews and traditional narrative reviews. The quantitative reviewing procedures that we used in our investigation are not a panacea. Meta-analysis procedures may be misapplied and misinterpreted.35 The methodology, however, represents a significant advance over traditional narrative attempts to integrate a body of research literature. As Rosenthal has noted, the "procedures are not perfect, we can use them inappropriately, and we will make mistakes. Nevertheless, the alternative to the systematic, explicit, quantitative procedures is even less perfect, even more likely to be applied inappropriately, and even more likely to lead us to error."36

CONCLUSIONS Our application of quantitative reviewing procedures revealed that NDT effects are detectable if meta-analysis techniques are used to identify them. The overall effects of NDT are small and appear to be related to some specific research design and study characteristics. These findings have obvious implications for therapists interested in conducting research on the efficacy of NDT. Researchers should anticipate "small" treatment effects and plan their investigations accordingly. Future investigators may wish to emphasize clinical significance by reporting measures of relationship strength and place less emphasis on statistical significance testing.37 Many questions related to the effectiveness of NDT as an intervention strategy for handicapped infants and children remain unanswered. For example, is NDT more effective for students in certain diagnostic categories or age groups? When should students be enrolled to achieve maximum benefit? How long do the effects of the treatment last? These are important questions that need to be addressed in future investigations. Therapists currently providing intervention services, however, cannot wait for the one definitive study that will answer these questions. The results of this investigation demonstrate that therapists can begin to answer some of these questions if current research is synthesized properly and if future research is designed properly.

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PHYSICAL THERAPY

RESEARCH
26. Rosenthal R, Rubin DB: Comparing effect sizes of independent studies. Psychol Bull 92:500504, 1982 27. Campbell DT, Stanley JC: Experimental and Quasi-Experimental Designs for Research. Chicago, IL, Rand McNally & Co, 1966 28. Smith ML: Sex bias in counseling and psychotherapy. Psychol Bull 87:392-407, 1980 29. Jenkins J, Sells CJ: Physical and occupational therapy: Effects related to treatment, frequency, and motor delay. Journal of Learning Disabilities 17:89-95, 1984 30. Cooper HM, Rosenthal R: Statistical versus traditional procedures for summarizing research findings. Psychol Bull 87:442-449, 1980 31. Ottenbacher K: Measures of relationship strength in occupational therapy research. Occupational Therapy Journal of Research 4:271-285,1984 32. Ottenbacher K: Statistical power and research in occupational therapy. Occupational Therapy Journal of Research 2:13-26, 1982 33. Rosenthal R, Rubin DB: A simple, general purpose display of magnitude of experimental effect. Journal of Educational Psychology 74:166-169, 1982 34. Laskas CA, Mullen SL, Nelson DL, et al: Enhancement of two motor functions of the lower extremity in a child with spastic quadriplegia. PhysTher 65:11-16,1985 35. Strube MJ, Hartmann DP: A critical appraisal of meta-analysis. Br J Clin Psychol 21:129139,1982 36. Rosenthal R: Meta-Analytic Procedures for Social Research. Beverly Hills, CA, Sage Publications Inc, 1984, p 17 37. Carver RP: The case against statistical significance testing. Harvard Education Review 48:378-379, 1978

APPENDIX 2
Studies Included in the Quantitative Review 1. Carlsen PN: Comparison of two occupational therapy approaches for treating the young cerebral-palsied child. Am J Occup Ther 29:268-272, 1975 2. d'Avigon M, Moren L, Arman T: Early physiotherapy ad modum Vojta or Bobath in infants with suspected neuromotor disturbance. Neuropediatrics 12:232-241,1981 3. Footh WK, Kogan KL: Measuring the effectiveness of physical therapy in the treatment of cerebral palsy. J Amer Phys Ther Assoc 43:867-873, 1963 4. Harris SR: Effects of neurodevelopmental therapy on motor performance of infants with Down's syndrome. Dev Med Child Neurol 23:477-483,1981 5. Wright T, Nicholson J: Physiotherapy for the spastic child: An evaluation. Dev Med Child Neurol 15:146-163,1973 6. Jenkins JR, Sells CJ, Brady P, et al: Effects of developmental therapy on motor-impaired children. Physical and Occupational Therapy in Pediatrics 2:19-28, 1982 7. Karlsson B, Nauman B, Gardestrom L: Results of physical treatment of cerebral palsy. Cerebral Palsy Bulletin 2:278-285, 1960 8. Scherzer AL, Mike V, llson J: Physical therapy as a determinant of change in the cerebral palsied infant. Pediatrics 58:47-52, 1976 9. Sommerfeld D, Fraser BA, Hensinger RN, et al: Evaluation of physical therapy service for severely mentally impaired students with cerebral palsy. Phys Ther 61:338-344, 1981

Volume 66 / Number 7, July 1986

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Quantitative Analysis of the Effectiveness of Pediatric Therapy : Emphasis on the Neurodevelopmental Treatment Approach Kenneth J Ottenbacher, Zena Biocca, Gwyneth DeCremer, Marcia Gevelinger, Kathleen B Jedlovec and Mary Beth Johnson PHYS THER. 1986; 66:1095-1101.

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