Running head: NDT AND MOTOR TRANSITIONS

Neurodevelopmental Treatment and Motor Transitions for Children with Spastic Cerebral Palsy
Jennifer Tom and Michelle Versten
Touro University Nevada

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How Does This Study Relate to Your Research Question?

Neurodevelopmental treatment (NDT) emphasizes techniques that promote proper body
alignment and normal movement pattern and is commonly used to treat children with cerebral
palsy (CP) in the clinic (Alireza, 2010). The PICO question, Does neurodevelopmental
treatment facilitation improve motor transitions for children with spastic cerebral palsy? was
formulated to further explore the effectiveness of NDT. The research article written by Alireza
(2010) relates to the PICO question because it examines the effect of NDT in improving
foundational motor skills such as lying, rolling, sitting, crawling, kneeling, and standing in
children diagnosed with CP. If NDT is effective in improving such foundational motor skills, it
is likely that this would translate into improved motor transitions because one must have mastery
in the foundational skills before successfully transitioning in and out of these positions.
What is the Purpose of the Study and Does the Literature Review Justify the Need for this
Study?
While there were no specified research questions or hypotheses, the objective of the study
by Alireza (2010) was to examine the strengths of NDT and sensory integration therapy (SIT) on
gross motor function in children diagnosed with cerebral palsy. Alireza (2010) explained that
SIT and NDT are commonly used in the clinic to address sensory dysfunction and physical
deficits such as abnormal muscle tone, poor posture, and motor dysfunction, and both of these
treatments have revealed positive outcomes. According to Alireza (2010), NDT is the most
widely used approach for children with CP because it strives to teach the childs brain normal

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patterns of movement and postural control despite limitations of the central nervous system and
neuromuscular system. Another approach is SIT, which addresses specific sensory input to
increase adaptive responses, ultimately facilitating functional mobility and performance.
Based on the literature review presented by Alireza (2010), research has proven NDT to
be effective in addressing gross motor ability, largely in the areas of postural control and
stability. Other research has shown that children with CP have difficulties with sensory
integration as a result of injury to their central nervous system or as a secondary deficit attributed
to reduced opportunity to explore and tax their sensory system due to motor dysfunction. This
research has shown improvement in motor performance through the use of SIT (Alireza, 2010).
Furthermore, a study done by Ketelaar, Vermeer, Hart, van Petegem-van Beek, and Helders
(2001) found that NDT improved rolling, sitting, and kneeling. Another study conducted by
Carlsen (1975) examined the effect of SIT on movements such as sitting and crawling compared
to a control group that did not receive any therapeutic intervention and found that participants
that received SIT had better outcomes. From the literature review, NDT and SIT both appear to
be effective methods to improve certain deficits in children with cerebral palsy. However,
according to Alireza (2010), there had not yet been any research done that specifically compared
NDT and SIT. Thus, the purpose of this study was to compare the two treatment methods and
their impact on gross motor skills for children with CP.
Study Design and Participants
What is the Study Design/Type of Study? What is the Level of Evidence?
This was a cohort study as all the children who participated had cerebral palsy. Cohort
studies fall under the Level 2 level of evidence (MacDermid & Law, 2014).
How Many Participants and How were Participants Recruited and Selected?

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Twenty-two children between the ages of 2 and 6 years were recruited in this study. They
were selected from a group of people with CP who received care from Baqiyatallah Hospital.
Inclusion criteria were being diagnosed with spastic cerebral palsy by a medical professional,
having no other severe abnormalities, not receiving any therapy services other than occupational
therapy, being between the ages of 2 and 6 years, and having been referred to the pediatric
occupational therapy clinic at Baqiyatallah Hospital for the 12-week treatment. Exclusion
criteria were having had received medical treatment that would probably affect motor function,
such as botulinum toxin injections, having orthopedic remedial surgery, or having a learning
disability or intellectual disability.
How were Participants Assigned to Groups?
The 22 children were randomly divided into two treatment groups. Eleven participants
were assigned to the NDT group and received neurodevelopmental treatment intervention, and
the other 11 participants were assigned to the SIT group and received sensory integration therapy
intervention.
How are the Participants Described?
Overall, the participants included 14 males and 8 females. Eleven of the participants,
including seven males and four females, were described as having diplegia, and the other eleven
participants, also including seven males and four females, were described as having quadriplegia.
The SIT group consisted of six male and five female participants and had an average age of 3.6
years. The NDT group consisted of eight male and three female participants and had an average
age of 3.1 years.
Variables and Measures
What are the Variables?

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The independent variable in this study was the treatment. For the SIT group, this was the
sensory integration therapy intervention, and for the NDT group, this was the
neurodevelopmental treatment intervention. The dependent variable in this study was gross
motor function. More specifically, the five dimensions of gross motor function that were
measured included lying and rolling, sitting, crawling and kneeling, standing, and walking,
running, and jumping.
What Measures were Used?
The Gross Motor Function Measure (GMFM) was used to determine the gross motor
function of the participants in the study across the five aforementioned dimensions. The GMFM
has 88 items total that are measured by observing the child. Each item receives a score between
0 and 3, where 0 means the child does not initiate a specific activity, and 3 means the child
completes the activity. Of the 88 items total, 17 items look at lying and rolling, 20 items look at
sitting, 14 items address crawling and kneeling, 13 items address standing, and 24 items address
walking, running, and jumping (Alireza, 2010).
Intervention and Analysis
What is the Intervention?
The intervention in this study was either neurodevelopmental treatment or sensory
integration therapy depending on if the participant was in the NDT group or SIT group,
respectively. Both interventions occurred three days per week for 12 weeks, and each session
lasted 90 minutes. All participants received the intervention in the same rehabilitation center
from occupational therapists who had a minimum of eight years of experience in the field.
What Statistical Analyses were Used?

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SPSS was used for statistical analysis in this study. The Kolmogrov-smirnov test
assessed normal distribution of variables. A paired-sample t-test analyzed the mean scores for
each group both before and after the interventions. This was done to see if there were significant
differences between the pre- and post- intervention scores. Additionally, it is worth mentioning
that P-values that were less than 0.05 were said to be statistically significant.
Research Findings
What are the Findings? Do these Findings Support the Hypothesis?
The GMFM-88 was administered to the 22 participants before and after the assigned
intervention treatment. A paired t-test was calculated to compare the mean of the same treatment
group before and after an intervention. The results showed significant improvements for
children in the SIT group in lying and rolling, sitting, crawling and kneeling, and standing but
did not show significant improvements for walking, running and jumping. On the other hand,
children in the NDT group showed significant improvements in all gross motor areas assessed.
The overall results for comparison of the two groups indicated that both NDT and SIT were
effective in improving foundational motor skills, but when examining the pre and post GMFM88 scores of each group, the NDT group had significant outcomes in walking, running and
jumping whereas the SIT group did not show such results. It is unknown whether these findings
support the hypothesis as the author did not state one in the article.
How do the Findings Relate to Previous Research as Described in the Literature Review?
The results of this study relate to previous research in the literature review because they
are similar to the results from the study done by Ketelaar et al. (2001). The data in both studies
showed improvement in rolling, sitting and kneeling after receiving NDT. In addition, the
randomized controlled trial study conducted by Carlsen (1975) explored the effectiveness of an

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experimental group receiving SIT compared to a control group. The experimental group
received 2 hours of occupational therapy services per week over a 6 week period, and the results
of this study were similar to those in Alireza (2010) in that both reported SIT as having a positive
impact on sitting and crawling.
Clinical Implications and Future Research
Does the Author State any Clinical Implications for the Findings?
The author mentioned that gross motor function improvement is one of the biggest goals
when treating children with cerebral palsy. He also stated that the results of the study showed
that NDT and SIT did improve the gross motor functioning of the children who participated in
the study. Therefore, while not explicitly stated by the author, taking these two points together
shows that with more expansive research to support this studys results, the clinical implication
would be the use of NDT and/or SIT in occupational therapy practice to improve gross motor
functioning in children with spastic cerebral palsy.
Does the Author Discuss Implications for Future Research?
The author mentioned that this was the first study that compared the effects of NDT and
SIT on gross motor function for children with spastic CP. Therefore, while not specifically
discussed by the author, an implication for future research would be conducting the research
again with a larger sample size to determine if the results are repeatable and thus, reliable. In
addition, it would be recommended that participants be recruited from more than one hospital to
increase diversity of the sample so results could be more generalizable. Finally, although it was
a strength that the occupational therapists in the study had over 8 years of experience, it would be
recommended to include the therapists qualifications in using NDT or SIT such as having had

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additional training in those areas or have treated children with cerebral palsy using those
techniques which would increase the therapists credibility.
What would you Say about the Sample Size? Do you Think it is Adequate?
With just 22 children total in the study, the sample size was quite small. However, the
sample size was adequate for this studys purpose as it was the first study to compare NDT and
SIT effectiveness for gross motor function in children with spastic CP. On the other hand, the
studys small sample size limits its generalizability and reliability. Therefore, future studies that
expand upon this topic should have a much larger and more representative sample as opposed to
just 22 children from a single hospital in Iran.
If the Researcher did not Find a Significant Difference Between the Groups, is it Possible
that this is Due to a Type II Error? If so, Why do you Think so?
The researcher did find a significant difference between the two groups in that the NDT
group showed improvements in walking, running and jumping where the SIT group did not.
Therefore, it is not possible that this could have been due to a Type II error. A Type II error
would mean that the results did not show differences between the two groups when in actuality
there was a difference.
Group Assignment
Is there a Control or Comparison Group? If so, is the Control or Comparison Group
Comparable to the Experimental Group on Key Features?
There was no control group in this study, and both the NDT and SIT groups were
technically experimental groups because they both received treatment. However, for the
purposes of this paper, the focus is on the NDT group because the PICO question looks at the
effectiveness of NDT facilitation in improving motor transitions for children with spastic CP.

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Therefore, the results from the SIT group can serve as a comparison to analyze the effectiveness
of NDT. The two groups are comparable because they used the same outcome measures and
measurement tool, the interventions were equal in duration, each group had similar
demographics, and the same number of participants were in each group.
Are Those Administering the Outcome Measures and the Participants Blind to Group
Assignment?
The article did not state whether or not those administering the outcome measures were
blind to the group assignment. Additionally, while this was not explicitly stated in the article, the
participants were so young that they probably did not know the difference between NDT and
SIT. Therefore, they were likely unintentionally blind to the group assignment. Furthermore, the
children most likely did not have a bias toward one specific intervention, so even if they were
explicitly told to which treatment group they were assigned, it probably would not have affected
any outcomes.
Does the Research Account for Drop-Outs in the Study? Could Drop-Outs have Influenced
the Outcomes?
No children withdrew from this study, but drop-outs could have influenced the outcome
of the results. For example, a reduction in sample size would further reduce generalizability
because there would be less diversity in the sample. It would decrease the overall reliability,
validity and statistical importance of the results which implies that childrens improvement in
their gross motor skills after receiving treatment may actually be due to random chance versus
actual effectiveness of the intervention process. Additionally, if there were drop-outs in one of
the treatment groups and not the other, the mean results for that group could become skewed

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closer to the scores of the remaining participants. Therefore, the results of the group that had
drop-outs would not be as representative as those of the other group.
Reliability, Validity, and Confounding Factors
Does the Researcher Report Reliability and Validity of the Outcome Measures? Are there
Questions about the Outcome Measures Chosen?
The researcher addressed the reliability and validity of the GMFM, the criterion reference
tool, for evaluation of the childrens motor functions before and after the intervention, and the
GMFM had high reliability and validity (Alireza, 2010). However, it did not further report
reliability and validity of the results obtained. For instance, reliability measures the consistency
of the results, or being able to obtain the same results if the study was repeated (Richardson,
2010). The results from this study may not be reliable due to the small sample size, which
increases the difficulty in reproducing the same outcome. There are no concerns regarding the
chosen outcome measures nor the validity of the studys results. The study used the GMFM to
measure gross motor skills, which was the intended purpose of the research.
What Confounding Factors could Contribute to or Influence the Study Outcomes?
A confounding factor is that participants in the study were allowed to be receiving other
occupational therapy services outside of the study. Therefore, if some children were receiving
additional therapy services, improvements measured in the study may have been attributed to
those additional services rather than the studys intervention itself. Additionally, it is unknown
whether or not certain participants parents may have been reinforcing therapeutic strategies at
home, which could have enhanced improvements in motor skills for those children. Finally, a
childs overall temperament and motivation can impact his or her progress in treatment.
Strengths, Weaknesses, and Author Limitations

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What are the Major Strengths of this Study?

One of the strengths of this study is that the GMFM, a criterion reference test, was
conducted before and after the interventions to assess the childrens gross motor abilities.
Results from the GMFM have shown to be both valid and reliable (Russell, 2002). Providing a
pre- and post- evaluation of the children provides quantifiable data to determine whether the
children did indeed improve from their baseline after receiving specific interventions. Another
strength is that all the occupational therapists that participated in the research had at least 8 years
of experience. Having more years of experience provides a higher confidence level that the
therapists are proficient in their skills and expertise to carry out the intended therapeutic
intervention. Finally, the 22 children were randomly assigned to one of the two intervention
groups. This helped to make the groups relatively even, ultimately allowing results to be
attributed to the different treatments rather than differences in group characteristics.
Author Limitations and Major Weaknesses of the Study
The author did not specify any limitations of his study. However, one of the weaknesses
of this study was that it had a small sample size. The study had 22 children, and they were all
recruited solely from one hospital. Because of the lack of diversity in the sample, results are not
representative or generalizable, and it becomes questionable whether the outcomes would be
reproducible in future research. In addition, there were two experimental groups, but no control
group was assigned. The research data reported improvements in gross motor skills after
receiving specific interventions. However, without a control group, it is difficult to determine
whether the participants would have shown improvements even without intervention. Finally,
another limitation and a confounding factor as mentioned previously was that participants were
allowed to receive additional occupational therapy services while the study was being conducted.

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This was a major limiting factor because improvements in childrens motor skills may have been
attributed to other occupational therapy interventions they received outside of the study.
Clinical Application
How would you use this Article as a Therapist?
A therapist can use this article when considering the use of NDT or SIT when treating
children with cerebral palsy. For example, the results from this study showed that NDT and SIT
improved the childrens motor functions in lying and rolling, sitting, crawling and kneeling, and
standing. However, only NDT showed significant improvement in the higher level motor skills
such as walking, running and jumping. Therefore, therapists may consider using one of these
treatments depending on which motor skills they are trying to address with a child. Additionally,
a therapist could use this article by implementing either NDT or SIT to improve certain motor
skills that would serve as precursors to motor transitions. For example, a child must have both
sitting and kneeling skills before being able to successfully transition from sitting to kneeling.
By addressing these foundational motor skills, a therapist could work toward facilitating better
motor transitions in children with spastic CP as a long-term goal. Overall, one must also keep in
mind that the researcher mentioned that this was the first study to compare the two intervention
strategies. Therefore, more research would be needed to conclude with more confidence the
effects of NDT compared to SIT.
How does this Article Support/not Support Participation in Occupation and the Field of
Occupational Therapy?
This article supports the use of NDT in occupational therapy because as mentioned, NDT
is a widely used and accepted treatment method for children with cerebral palsy (Alireza, 2010).
These gross motor skills support participation in occupation because childrens main occupation

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is play. Therefore, by improving their gross motor skills, they can engage in physical play and
practice their balance, coordination and strength. In addition, improvement in these functional
abilities is also important for a childs socialization and participation with their peers at school
during recess. Finally, this article supports participation in occupation and the field of
occupational therapy because it showed improvements in certain physical positions and motor
skills that are precursors to effective motor transitions. Having effective motor transitions allows
a child to efficiently move in and out of different positions, facilitating more independence and
participation in daily activities.

References

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Alireza, S. (2010). Comparison between the effect of neurodevelopmental treatment and sensory
integration therapy on gross motor function in children with cerebral palsy. Iranian
Journal of Child Neurology, 4(1), 31-38. Retrieved from
http://www.sid.ir/en/VEWSSID/J_pdf/108320100106.pdf
Carlsen, P. N. (1975). Comparison of two occupational therapy approaches for treating the
young cerebral palsied child. American Journal of Occupational Therapy, 29(5), 267
272. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/50014
Ketelaar, M., Vermeer, A., Hart, H., van Petegem-van Beek, E., & Helders, P. J. M. (2001).
Effects of a functional therapy program on motor abilities of children with cerebral palsy.
Journal of the American Physical Therapy Association, 81(9), 15341545. Retrieved
from http://www.ncbi.nlm.nih.gov/pubmed/11688590\
MacDermid, J. C., & Law, M. (2014). Evaluating the evidence. In M. Law & J. C. MacDermid
(Eds.), Evidence-based rehabilitation: A guide to practice (3rd ed., pp. 129-156).
Thorofare, NJ: Slack.
Richardson, P. K. (2010). Use of standardized tests in pediatric practice. In J. Case-Smith & J. C.
OBrien (Eds.), Occupational therapy for children (pp. 216-242). Maryland Heights,
MO: Mosby.
Russell, D. J., Rosenbaum, P. L., Avery, L. M., & Lane, M. (2002). Gross motor function
measure (GMFM-66 and GMFM-88) users manual. London: Mac Keith Press.