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Does Conductive Education have an impact on the overall development of children with cerebral palsy?

April-Lily Sule

Introduction

Cerebral palsy is an umbrella term that describes disorders that impact a person’s ability to move. It results from damage to the babies’ brain during pregnancy or shortly after birth. Symptoms can range in severity depending upon the area and extent of damage to the brain. It is estimated to affect 1.5- 4 babies, per 1000 births, worldwide (U.S. Department of Health and Human services, 2018). This large population has created a demand for treatment options to improve the well-being of those affected. One of these options is a Hungarian holistic therapy known as Conductive Education which focuses on neuroplasticity. Neuroplasticity is the nervous system’s ability to form new neural connections in the brain (GlowKids, n.d.). This literature review will be investigating the effectiveness of Conductive Education methods as a treatment option for cerebral palsy.

PECOT

The PECOT model assists in refining the question into key components that can easily be identified when looking for relevant literature, while simultaneously identifying the rationale behind these key components (Schneider, Whitehead, LoBiondo-Wood, & Haber, 2013). Using the PECOT model I have formulated this question: Does Conductive Education have an impact on the overall development of children aged 0-12 with cerebral palsy?

The Issue

Cerebral palsy is a significant life-long condition that poses many issues for individuals affected, their families, and the health system. Prevention of this condition is still unknown as 90% of cases occur during intrauterine life which means intervention can only be performed after diagnosis (Balogh & Kozma, 2009). Diagnosing involves evaluating medical history and completing paediatric and neurological examinations (Kenneth, 2019). Research shows that cerebral palsy impacts brain functioning, though exactly how is unknown. It has been reported that similar symptoms related to brain functioning have been expressed in two individuals, one with no visible brain damage and one missing a hemisphere (Balogh & Kozma, 2009), therefore no one testing method is applicable. Cerebral palsy is the most common physical disorder affecting children (Hulton & Pharaoh, 2006) and it causes children to have issues with motor symptoms (61-65% of people), epilepsy (26-28%), mental deficiency (26-28%) and visual disturbances (19-20%) (Balogh & Kozma, 2009). These symptoms can impact on a person’s ability to perform activities of daily living (ADL’s) which can cause a strain on caregivers and parents. These caregivers have an increase in poor physical and psychological health, compared to carers of children without physical disability due to the financial strain and alterations to standard family functioning that caring for a disabled child involves (Raina et al., 2005). In addition, the health system is also impacted with the costs of Physician visits, surgeries, rehabilitation, hospital stays and long-term care. These costs are estimated to cost the U.S health system $1.175 billion (Kenneth, 2019). The impacts on individuals with cerebral palsy is a global issue. Currently cerebral palsy is estimated to affect 7000 New Zealanders (Cerebral palsy Society, 2018). These New Zealanders have a reduced life span, and this depends on their cerebral palsy’s severity. Fifty percent of children with severe cerebral palsy will die before the ages of thirteen due to complications, whereas some people with a milder form may live to sixty (Hulton & Pharaoh, 2006). As cerebral palsy currently has no cure the negative implications on an individual’s quality of life, the families impacted, and the health system needs to be addressed. Therapies like Conductive Education have been designed to help improve these issues.

What is Conductive Education?

The concept of Conductive Education was first invented by a Hungarian called Dr Petö in the 1940’s. His aim was to assist children with a motor dysfunction disorder (like cerebral palsy) to enable them to maximise orthofunction, which is the child’s ability to perform activities of daily living so that the child can function in society regardless of their disability (Darrah, Watkin, Chen & Bonin, 2004). When orthofunction is maximised, the goal would be for the child to attend school independently. With this vision, Petö based Conductive Education on an education model rather than a medical model (Darrah et al., 2004). This allowed for more variation in treatment outcomes including academic, social, communication, and motor coordination skills. These outcomes are achieved through the four elements of Conductive Education; task-orientated learning with structured programmes, facilitating and commenting on motor actions by rhymical speaking or singing, integrating manual abilities into the context of ADL’s, and child-orientated group sessions that facilitate psychosocial learning that increases participation (Blank, Kries, Hesse & Voss, 2008).

Evidence and findings

Available literature around the effectiveness of Conductive Education recognises that Conductive Education has beneficial results regarding the development of children with cerebral palsy. This is supported by numerous types of research that illustrates the affects that Conductive Education has on different aspects of child development. One study conducted in Germany involved exposing 64 children aged 3-6 with cerebral palsy to Conductive Education to assess hand motor function. A baseline level was first determined before children began therapy. Therapy followed the elements of Conductive Education with a specific focus on the application of hand motions in relation to ADL’s. This saw an improvement in hand motor function by 25% and the ability to perform ADL’s by 20% from baseline (Blank, et al., 2008). In addition, other research has found similar results with ADL’s being improved from the child’s baseline with the application of the elements of Conductive Education into treatment (Dalvand et al., 2009; Darrah et al., 2004). Specifically, the Darrah et al. (2004) study makes reference to dressing, self-care, and toileting being amongst the most improved ADL’s. Compared to Dalvand et al. (2009) which acknowledges that ADL’s are improved but does not state the specific areas.

Research also acknowledges the affects that Conductive Education has on children’s communication skills. It has been found that children’s speech and vocabulary has improved even despite some words being unfamiliar. A study showed that a group of foreign speaking children with cerebral palsy managed to learn new Hungarian words while being on a Conductive Education exchange program in Hungary (Balogh & Kozma, 2009). This development is thought to have been influenced by the rhymical speaking and singing involved in the therapy. This rhymical singing and speaking corresponds with the actions the child is needing to do, which helps to form new neural connections within the brain. It is also an easy element for parents and caregivers to involve into the child’s care at home to further improve outcomes. The Dalvand et al. (2009) study has also indicated an increase in communication skills. It states that the group environment that is provided in some Conductive Education therapies allowed for children living with cerebral palsy to engage in social interactions with other children experiencing similar symptoms. This allows for improvement in the child’s ability to form relationships and communicate - whether this is verbally, through play, or other methods.

With evidence supporting the effectiveness of Conductive Education, the Ministry of Health and the Ministry of Education provide funding and recommendations for Conductive Education programmes as an option for individuals fitting into their Disability Support Services criteria (Ministry of Health, 2002). These services are accessed through their general practitioner or community nurse who perhaps believes the child may be behind in reaching developmental milestones (Ministry of Health, 2018). However, limitations in research have stopped further government funding from being possible. For example, the Accident Compensation Corporation (ACC) currently doesn’t fund Conductive Education as a rehabilitation option due to their uncertainty around whether Conductive Education is a more effective method for enhancing children’s development than other treatments (ACC, 2016). Research from Blank et al. (2008) and Dalvand et al. (2009) have investigated the effectiveness of Conductive Education against other methods. Blank et al. (2008) research compares the effectiveness of Conductive Education against Special Education in relation to hand motor function and ADL competence. Increases were found in both hand motor function and ADL in the children attending Conductive Education, compared to no improvement in children that attended Special Education. In Dalvand et al. (2009) the effectiveness of the Bobath technique and Conductive education were compared. It was found that both methods improved ADL functioning, however Conductive Education promoted better communication skills and better motor coordination in familiar environments when compared to the Bobath technique.

Even with research comparing and finding favourable outcomes for children undergoing Conductive Education compared with other therapies including Special Education and the Bobath technique (Blank et al., 2008; Dalvand et al., 2009), ACC still disregards this research (ACC, 2016). They believe standardisation of testing and standardised Conductive Education programmes are needed to ensure accuracy of future research. This will allow for results that compare the effectiveness of Conductive Education against other therapies to be valid enough to change current documentation that restrict further funding (ACC, 2016). This statement is reinforced by literature, that recognises their own research was limited by the lack of standardisation and testing methods of Conductive Education programmes that decreased their accuracy, when compared with other therapies (Ludwig, Leggett & Harstall, 2000; Stiller, Marcoux & Olson, 2009).

In addition, considerations around the dates of the research need to be addressed. It was found that the most recent research was completed between 2000 and 2009, which could be considered out of date. This is possibly due to the expanding interest into Conductive Education treatment during this time, thus creating a demand for research to ensure that evidence-based practice is adhered to. Onwards from 2009, limited research around the effectiveness of Conductive Education has occurred which could be a result of the previous research limitations. These limitations suggested a need for the standardisation of the programme, which could be potentially challenging for current researchers or Conductive Educators to establish for future research. Standardisation could compromise Conductive Education as a holistic programme that focuses on ensuring treatment plans are individualised to the child’s needs to optimise the most beneficial effects (Kenneth, 2019).

Recommendations

Findings from this literature review are critical for Conductive Education to advance forward as a more known therapy for cerebral palsy. Recommendations to help advocate for Conductive Educations effectiveness includes a global standardisation of Conductive Education programmes. This would promote more research to be conducted as standards around testing would be developed. Standardisation would allow effectiveness of Conductive Education to be measured more specifically against an established testing criteria. This can assist in the credibility of future research, as the lack of standardisation has been a research limitation (Ludwig et al., 2000; Stiller et al., 2009). With research being more credible the effectiveness of Conductive Education on the development of children with cerebral palsy can be better understood. In addition, with testing criteria being established, Conductive Education can be compared to other therapy options to investigate what treatment is most effective in aiding the development of children with cerebral palsy. If research finds Conductive Education to be more effective than Special Education and the Bobath technique, as previously thought (Blank et al., 2008; Dalvand et al., 2009), more government funding can be established (ACC, 2016). However, these standardisations to the Conductive Education programme would need to be adaptable to incorporate the variations in disabilities caused by cerebral palsy. Another recommendation would be for different Conductive Education therapies to be created that would correspond to the already established types of cerebral palsy. If these established groups of cerebral palsy were created to reflect the child’s symptoms (Balogh & Kozma, 2009), matching the Conductive Education programmes to these groupings; perhaps more beneficial and quantifiable effects of Conductive Education will emerge.

Conductive Education is funded through the governments Disability Support Services, which can be accessible through community nurses. These nurses complete assessments which investigate whether that child is meeting developmental milestones in correlation to their age. It is recommended for these assessments to be comprehensive, as early intervention is key to help limit the implication that the developmental delay has on the child. Additional implications of failure of early detection can decrease life expectancy or cause death through respiratory complications (Holmes et al., 2013; Hulton & Pharoah, 2006). These critical assessments are not limited to community nurses, all nurses need to be familiar with developmental assessments in anticipation for encounters. If nurses fail to complete these assessments accurately then there could be a delay in that particular child getting appropriate treatment. For children with mild symptoms of cerebral palsy recognising these symptoms can be challenging. This reinforces the need for accuracy of assessment, as symptoms may not be recognised until the age of five, which can be problematic (Kenneth, 2019). There is opportunity for earlier intervention before the age of five as cerebral palsy occurs in intrauterine life or shortly after birth (Balogh & Kozma, 2009). In addition, if the nurse recognises that there is a delay in that child’s development, the nurse needs to be able to demonstrate nursing knowledge around the appropriate actions to follow and give an indication of the process that family can expect. When giving this nursing education, Conductive Education can be discussed as a proposed holistic therapy if applicable to the family. This education should incorporate the known benefits of treatment as supported by literature, different sources of information should be used to help ensure comprehension. With the potential increase in research due to standardisation, the familiarity of Conductive Education amongst nurses will increase. This will create further awareness for families whose children have been identified with a delay in reaching their developmental milestones by the nurse. With nurses having an awareness of the elements of Conductive Education, nurses can incorporate parts into their own practice. This may include using rhymical singing or speaking when providing personal care to help benefit a child with cerebral palsy.

With the recommended increase in awareness of Conductive Education through nurses and the potential improved government funding influenced by the proposed standardisation, these recommendations have an ability to help further reduce the effects of cerebral palsy. These recommendations allow Conductive Education to be more accessible as more families will be aware of the therapy and have more available financial resources from the government to fund the treatment required. Nurses will also be equipped with the correct knowledge around Conductive Education, the benefits, how to implement elements into personal practice, and the referral process for families to access the appropriate services. These factors will increase the number of participants that allows for an increase in numbers of those benefiting from Conductive Education. These children attending Conductive Education that are affected by cerebral palsy will increase their ability to perform ADL’s, such as dressing and toileting, motor coordination (Blank et al., 2008; Dalvand et al., 2009; Darrrah et al., 2004) and Communication skills (Balogh & Kozma, 2009; Dalvand et al., 2009).

With these enhancements to the children’s abilities, children can become more independent with their care. This will assist in decreasing the work-load of carers, thus reducing the negative physical and psychological effects on the caregiver’s health. In addition, lessening the severity of the child’s needs addresses the national financial issue of care through the reduction of the severity of the child’s care needs. This can help to reduce the child’s need for hospital admissions and the use of support workers, overall limiting the government’s spending on health care for children affected by cerebral palsy.

Conclusion

This review has identified that research on Conductive Education suggests that the holistic Hungarian therapy has a tendency to be effective in the therapy of children with cerebral palsy. Research has identified that children attending Conduction Education sessions have improvements in ADL functioning, communication skills and overall motor functioning. This has a flow on effect to improve the lives of parents/caregivers and additionally reduce hospital admissions through the improved well-being of the child. Though it is suggested that Conductive Education is effective in the therapy of children with cerebral palsy, with limited research, it is uncertain whether Conductive Education is the most effective method of addressing these issues created by cerebral palsy. Through recognising these limitations, it was recommended for standardisation of the programme, as without standardisation there will not be an increase in research awareness and therefore future improvement of the lives of children living with cerebral palsy.

References

ACC. (2016). Evidence update: Conductive Education in children with cerebral palsy. Retrieved from https://www.acc.co.nz/assets/research/cerebral-palsy-education-review.pdf

Balogh, E., & Kozma, I. (2009). Conductive Education for children with neurological disease. Ideggyógyászati Szemle official Journal, 62(1-2), 12-22. Retrieved from ResearchGate

Blank, R., Kries, R., Hesse, S., & Voss, H. (2008). Conductive Education for children with cerebral palsy: Effects on hand motor functions relevant to activities of daily living. Archives of Physical Medicine and Rehabilitation, 89(1), 251-259. DOI: 10.1016/j.apmr.2007.08.138

Cerebral palsy Society. (2018). About cerebral palsy. Retrieved from https://cerebralpalsy.org.nz/

Dalvand, H., Dehghan, L., Feizy, A., Amirsalai, S., & Bagheri, H. (2009). Effects of the Bobath technique, Conductive Education and education to parents in activities of daily living in children with cerebral palsy in Iran. Hong Kong Journal of Occupational Therapy, 19(1), 14-19. Retrieved from ResearchGate

Darrah, J., Watkin, B., Chen, L., & Bonin, C. (2004). Conductive Education intervention for children with cerebral palsy: An AACPDM evidence report. Developmental Medicine and Child Neurology, 46(1), 187-203. DOI: 10.1017/S00121162204000337

GlowKids. (n.d.). Conductive Education. Retrieved from http://www.glowkids.org.nz/conductive-education

Holmes, L., Joshi, A., Lorenz, Z., Miller, F., Dabney, K., Conner, J., & Karatas, A. (2013). Paediatric cerebral palsy life expectancy: Has survival improved over time. Paediatrics and Therapeutics, 3(1), 1-6. DOI: 10.4172/2161-0665.1000146

Hulton, J., & Pharoah, P. (2006). Life expectancy in severe cerebral palsy. Archives of Diseases in Childhood, 91(3), 254-258. DOI: 10.1136%2Fadc.2005.075002

Kenneth, A. (2019). My child at cerebral palsy. Retrieved from https://www.cerebralpalsy.org/

Ludwig, S., Leggett, P., & Harstall, C. (2000). Conductive Education for children with cerebral palsy. Retrieved from ResearchGate

Ministry of Health. (2002). DSS Child Development Services. Retrieved from https://www.health.govt.nz/system/files/documents/pages/service-specification-child-development-services.pdf

Ministry of Health. (2018). Disability services. Retrieved from https://www.health.govt.nz/your-health/services-and-support/disability-services

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Schneider, Z., Whitehead, D., Lobiondo-wood, G., & Haber, J. (2013). Nursing and Midwifery research methods and appraisal for evidence-based practice (4^th ed.). Sydney, Australia: Elsevier.

Stiller, C., Marcoux, P., & Olson R. (2009). The effects of Conductive Education, intensive therapy and Special Education services on motor skill in children with cerebral palsy. Physical and Occupational Therapy in Paediatrics, 23(3), 31-50. DOI: 10.1080/j006v23n03_03

U.S. Department of Health and Human Services (2018). Centre for Disease Control and Prevention. Retrieved from https://www.cdc.gov/ncbddd/cp/facts.html