ORIGINAL ARTICLE

Effects of Neurodevelopmental Therapy on Gross Motor Function in

Children with Cerebral Palsy
How to Cite This Article: labaf S, Shamsoddini A, Hollisaz MT, Sobhani V, Shakibaee A . Effects of Neurodevelopmental Therapy on Gross Motor
Function in Children with Cerebral Palsy. Iran J Child Neurol. Spring 2015;9(1):36-41.

Abstract
Sina Labaf MSc1, Objective
Alireza Shamsoddini PhD 2, Neurodevelopmental treatments are an advanced therapeutic approach
Mohammad Taghi Hollisaz MD 3, practiced by experienced occupational therapists for the rehabilitation
Vahid Sobhani MD 4, of children with cerebral palsy. The primary challenge in children with
Abolfazl Shakibaee PhD 2 cerebral palsy is gross motor dysfunction. We studied the effects of
neurodevelopmental therapy on gross motor function in children with
cerebral palsy.
Materials & Methods
In a quasi-experimental design, 28 children with cerebral palsy were randomly
divided into two groups. Neurodevelopmental therapy was given to a first
group (n=15) with a mean age of 4.9 years; and a second group with a mean
age 4.4 years (n=13) who were the control group. All children were evaluated
with the Gross Motor Function Measure. Treatments were scheduled for three
1. Occupational therapist, Ebnesina - one-hour sessions per week for 3 months.
Rehabilitation Clinic, Consulting Unit,
Tehran, Iran.
Results
2. Department of Exercise Physiology, We obtained statistically significant differences in the values between the
Exercise Physiology Research Center, baseline and post treatment in two groups. The groups were significantly
Baqiyatallah University Medical
different in laying and rolling (P=0.000), sitting (0.002), crawling and kneeling
Sciences, Tehran, Iran,
3. Department of physical medicine (0.004), and standing abilities (P=0.005). However, there were no significant
and Rehabilitation, faculty of differences in walking, running, and jumping abilities between the two groups
Medicine, Baqiyatallah University of (0.090).
Medical Sciences, Tehran, Iran.
4. Exercise Physiology Research Conclusion
Center, Baqiyatallah University We concluded that the neurodevelopmental treatment improved gross motor
Medical Sciences, Tehran, Iran. function in children with cerebral palsy in four dimensions (laying and rolling,
Corresponding Author:
sitting, crawling and kneeling, and standing). However, walking, running, and
Shamsoddini A. PhD jumping did not improve significantly.
Exercise Physiology Research Center,
Keywords: Cerebral palsy; Children; Gross motor function; Neurodevelopmental
Baqiyatallah University Medical
Sciences, Tehran, Iran, treatment; Rehabilitation
Tel: + 982182482402,
Fax: +982188600030,
Introduction
Mobile: 09121503604
Email: [email protected] In children with cerebral palsy (CP), lesions of the central nervous system (CNS)
could cause motor-sensory impairments that progressively deteriorate over time
Received: 29-Apr-2014 (1). CP occurs in every 2/1000 and up to 2.5/1000 live births (2).The primary
Last Revised: 31-Sep-2014 challenge for CP is gross motor dysfunction (GMD) (3, 4). In addition, the severity
Accepted: 1-Oct-2014 of limitation in gross motor function (GMF) among children with CP, the most
common physical disability is highly variable (4, 5).The motor problems of CP arise

36 Iran J Child Neurol. 2015 Spring Vol 9 No 2

 Effects of Neurodevelopmental Therapy on Gross Motor Function in Children with Cerebral Palsy

fundamentally from CNS dysfunction, which interferes months by the parents and controlled by an occupational
in the development of normal postural control against therapist. No statistically significant differences in
gravity and impedes normal motor development (5, 6, physical and clinical characteristics of both groups were
7).Occupational therapy in children with CP is performed found before treatment (p>0.05).A convenience sample
to avoid abnormal muscle tone and posture, to treat muscle was used. Ethical approval was granted for the study
and joint deformities, and to reduce motor and sensory and informed consent statements were signed by all the
disorders (8, 9).This approach for neurodevelopmental parents. One standardized validated measure of function
treatment for CP is the most widespread and is clinically was used as follows: the GMFM (GMFM-88) is a clinical
accepted for targeting the CNS and the neuromuscular measure designed to assesses gross motor abilities of
system. In view of the specific lesions in the CNS that children with CP in five dimensions: (1) Lie and Roll, (2)
‘teaches’ the brain to improve motor performance skills Sit, (3) Crawl and Kneel, (4) Stand, and (5) Walk, Run,
and achieve ‘as near normal function as possible’ (10). and Jump (13). In children with CP, the GMFM has been
The primary purpose of this approach is to correct shown to be sensitive to change during periods of therapy
abnormal postural tone and to facilitate more normal (9, 14, 15, 16).Assessments before and after treatment
movement patterns for performing performance skills were completed by an occupational therapist. The
(11, 12).Although Neurodevelopment Therapy (NDT) treatment group that participated in the study underwent
is widely used by pediatric therapists in the treatment neurodevelopment treatments. In each session, exercises
of children with CP, there is little research evidence included patients sustaining themselves on their
regarding its efficacy in Iran. The purpose of this article forearms and hands, sitting, crawling, semi-kneeling,
is to present the basics of NDT for the rehabilitation of and in standing positions supported by the occupational
children with cerebral palsy. therapist until tone reduction was achieved. Balance and
corrective reactions were developed by using a CP ball
Materials & Methods and tilt board after the children had acquired the skill
A total of 28 children with diplegic CP were selected of maintaining exercise positions. Ambulation training,
from a population of individuals with CP who had been appropriate to the motor development level (crawling,
followed up at Ebnesina Rehabilitation Clinic. Our creeping, walking while in a semi-kneeling position, and
inclusion criteria were as follows: a diagnosis of cerebral walking between parallel bars) was given. Additionally,
palsy (patient’s diagnosis of CP confirmed by an expert for this study, the NDT programme included passive
pediatrician neurologist), no other severe abnormalities stretching of the lower limb muscles (e.g. hamstrings,
such as seizure, no participation in other therapeutic gastrocsoleus), followed by techniques of reducing
programs except for occupational therapy, between 2–6 spasticity and facilitating more normal patterns of
years of age, and referred to the occupational therapy movement while working on motor functions (10).
clinic of children with disabilities for a 3 month course of The control group underwent the exercises (stretching,
therapy. Our exclusion criteria were as follows: receipt of passive range of motion, and active range of motion) at
medical procedures likely to affect motor function such as home with their parents. The duration of the treatment
botulinum toxin injections, orthopedic remedial surgery, for the two groups was three days a week for 3 months
mental retardation, or a learning disability. Participants with each session being one hour.
were divided into a treatment group (15 subjects) and a Statistical analysis: The normal distribution of variables
control group (13 subjects).The GMF of patient’s were was assessed with the Kolmogrov-Smirnov test. An
evaluated according to Gross Motor Function Measure independent sample t-test used for comparison of scores
(GMFM). The treatment group received and participated between the two groups. The pre-NDT and post-NDT
in neurodevelopment treatment for 3 months. In this intervention mean scores for each group were analyzed
study, the control group received home exercise, which using a paired-sample t-test to determine whether there
included routine movement therapy (stretching, passive were any significant differences. Statistical analysis was
range of motion, and active range of motion) for 3 performed with SPSS (version 17.0), with P-values less

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 Effects of Neurodevelopmental Therapy on Gross Motor Function in Children with Cerebral Palsy

than 0.05 considered statistically significant. laying and rolling (P=0.000), sitting (P=0.002), crawling
and kneeling (P=0.004), and standing abilities (P=0.005).
Results However, there were no significant differences in
A total of 28 children completed the entire duration walking, running, and jumping abilities between the
of treatment for 3 months. A total of 15 subjects two groups (0.090) (Table2). The paired t-test used for
participated in the treatment group (7 girls, 8 boys; age before and after measurements for the treatment group
range 2–6 years; mean age 4.9 years) and 13 subjects in (NDT) revealed significant differences in GMFM-88
the control group(7 girls, 6 boys; age range 2–5.5 years; scores in laying and rolling, sitting, crawling, standing,
mean age 4.4years). Table 1 provides the mean, standard and walking abilities (P> 0.05) (Table3). Nevertheless,
deviation (SD), minimum and maximum scores for the in the control group, the paired-sample t-test revealed
GMFM-88, pre-treatment and post-treatment measures GMF significantly improved after intervention only in
for both groups. The independent simple t-test showed the rolling position (p<0.05). According to our results,
significant improvements in GMFM scores between the as initially hypothesized, NDT intervention had a
two groups following neurodevelopment treatment in significantly positive effect on GMF in children with CP.

Table 1. Descriptive statistics in the treatment and control groups

GMFM 88
Group
Assessment Mean SD Min Max

After treatment 90.1 11.62 66 124

Treatment (NDT)
Before treatment 112.6 10.41 105 132

After treatment 86.3 7.93 75 103

Control
Before treatment 88.2 7.36 80 109
GMFM, Gross Motor Function Measure; Min, Minimum; Max, Maximum

Table 2. Gross Motor Function Measure in five positions–Independent simple t-test

Ability Group Mean SD P

Control 23.2 13.8

Lying and Rolling
treatment 21 8.8 0.000

Control 34.3 8.5

Sitting
treatment 25.9 8.1 0.002

Control 20.7 5.2

Crawling
treatment 20 6.2 0.004

Control 19.7 4.5

Standing
treatment 17 9.2 0.005

Walking, running and Control 5 4

jumping treatment 4.3 4.4 0.090

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 Effects of Neurodevelopmental Therapy on Gross Motor Function in Children with Cerebral Palsy

Table 3. Pre and Post Gross Motor Function Measure in the treatment group (NDT)

GMFM Score
Ability SD P
Pre Post

Lying and Rolling 19.5 32.2 9.7 0.001

Sitting 32.2 36.7 4.9 0.04

Crawling 19.8 23.7 3.8 0.002

Standing 17.8 19.7 1.2 0.010

Walking, running and jump-

4.9 6.3 1.5 0.04
ing

Discussion improved motor skills functionality (18). In this study,

Occupational therapy and neuro-rehabilitation the data demonstrates in all of GMFs, that the NDT
approaches are important components in the treatment approach was statistically more significant than for the
of children with CP (17). Improvement of GMF is one of control group from the pre test to post test, because
the most important goals of treatment for children with the NDT approach includes of improvements of GMF
CP. The primary aim of neurodevelopmental therapy and postural stability. In addition, it may be that the
is to promote GMF for children with CP. In this study, treatment effects are most obvious in the postural set
the focus was on neurodevelopmental therapy, which used for GMF and caused improved developmental
was administered for 3 months in children with spastic ability (19). Akbari et al, a pre- and post-design study,
cerebral palsy (distribution of diplegia and quadriplegia), showed that for GMF of subjects assessed with GMFM,
and their GMF as measured with the GMFM. The the results indicated that a functional therapy program
results of the present study showed significant was effective in increasing GMF and improving daily
improvement in rolling and laying, sitting, crawling, and activities in children with CP (20). Tsorlakis et al
standing abilities in children with spastic diplegia and evaluated the effect of neurodevelopmental treatment
quadriplegia after application of NDT using GMFM. on these functions in children CP. They used GMFM
The GMFM reflects the motor developmental sequence to measure the treatment effects and reported significant
from birth to 5 years and necessarily includes activities improvements for GMF from the GMFM total scores
that precede or that are prerequisites for the achievement (21). Also, Arndt et al evaluated the efficacy of a
of standing and walking. However, in the second group, neurodevelopmental treatment based sequenced trunk
which received no neurodevelopmental treatments, activation protocol for changes in the GMF of infants
there was only significant improvement in rolling with posture and movement dysfunction, their results
ability. Ketelaar et al showed significant differences in showed that the NDT-based protocol group made
rolling, sitting, and kneeling after neurodevelopmental significantly more progress than the control group from
intervention (6). These results were consistent with the pretest to posttest (22).
present study in that we show positive changes in laying To mention the limitations of study, although GMFM
and rolling, sitting, crawling, kneeling, and standing provides a great deal of data, it is complex and time
after NDT intervention. Shamsoddini also reported consuming for staff to gather and analyze. Another
that use of the neurodevelopmental approach for the limitation has been the interpretation of the GMFM
treatment of children with CP will lead to improvements total score. In conclusion, our findings show that
in GMF (10). Fetters and Kluzik reported that the use neurodevelopmental treatments may be effective in
of neurodevelopmental treatment for children with CP improving in GMF after intervention in children with

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 Effects of Neurodevelopmental Therapy on Gross Motor Function in Children with Cerebral Palsy

CP. There were a number of issues arising from this 7. Mayston M. People with cerebral palsy: effects of and
study, which suggest directions for future investigations. perspectives for therapy. Neural Plasticity 2001; 8: 51–
However, it is clear that further studies are needed to 69.
support the results of this study through replication and 8. Mintaze Kerem G. Rehabilitation of children with
to investigate other issues related to the effectiveness of cerebral palsy from a physiotherapist’s perspective. Acta
the treatment. Orthop Traumatol Turc. 2009; 34(2): 173-80.
9. Shamsoddini AR and Hollisaz MT. effect of Sensory
Acknowledgements integration therapy on Gross motor Function in Children
The authors would like to acknowledge the generous with cerebral palsy. Iran J Child Neurology 2009; 8(1)
assistance of the staff of the ebnesina rehabilitation 43-48.
Clinic, Tehran, Iran.
10. Shamsoddini AR. Comparison Between the effect of
neurodevelopmental treatment and sensory integration
Author Contribution
therapy on gross motor function in children with cerebral
1- Sina Labaf: Data collection, Interpretation of data
palsy. Iran J Child Neurology 2010; 4(1): 31-38.
2- Alireza Shamsoddini: Concept/design, Interpretation
of data and Study supervision, writing the article 11. Case-Smith J. Occupational therapy for children. 6th ed.
3- Mohammad Taghi Hollisaz: Concept/design, Study St Louis MO: Mosby; 2010. P. 325-372.
supervision and Fund raising, Article writing supervision. 12. Mintaze Kerem G. Rehabilitation of children with
4- Vahid Sobhani and Abolfazl Shakibaee, Editing and cerebral palsy from a physiotherapist’s perspective. Acta
Revise of article. Orthop Traumatol Turc. 2009; 34(2): 173-80.
All authors approved final version of the paper. 13. Russell D, Rosenbaum P, Gowland C, Hardy S, Lane
Conflict of Interest: None M, Plews N, et al. Manual for the Gross Motor Function
Measure. Children’s Developmental Rehabilitation
References Programme at Chedoke-McMaster University Ontario
1. Miller F. Cerebral palsy. Springer Science-Business 1993; 67-73.
Media: New York; 2005. p. 523-666. 14. Alotaibi M, Long T, Kennedy E, Bavishi S. The efficacy
2. Stanley FJ, Blair E, Alberman E. Cerebral Palsies: of GMFM-88 and GMFM-66 to detect changes in gross
Epidemiology & Causal Pathways. London, England: motor function in children with cerebral palsy (CP): a
Mac Keith Press 2000; 29-41. literature review. Disabil Rehabil. 2014; 36(8):617-27.
3. Scherzer AL, Tscharnuter I. Early Diagnosis and Therapy 15. Ko IH, Kim JH, Lee BH. Relationship between Lower
in Cerebral Palsy: A Primer on Infant Development Limb Muscle Structure and Function in Cerebral Palsy. J
Problems. 2nd Ed. New York: Marcel Dekker Inc; Phys Ther Sci. 2014 Jan; 26(1):63-6.
1990.P.87-101. 16. Song CS. Relationships between Physical and Cognitive
4. Hutton JL, Cooke T, Pharoah PO. Life expectancy in Functioning and Activities of Daily Living in Children
children with cerebral palsy. British Medical Journal with Cerebral Palsy. J Phys Ther Sci. 2013; 25(5):619-22.
1994; 13: 430-435. 17. Shamsoddini A, Amirsalari S, Hollisaz MT, Rahimniya
5. Bulter C and Arrah J. Effects of neurodevelopmental A, Khatibi-Aghda A. Management of Spasticity in
treatment (NDT) for cerebral palsy: an AACPDM Children with Cerebral Palsy. Iran J Pediatr 2014; 24(4):
evidence repoet. Dev Med Child Neurol. 2001; 43(11): 345-351.
778- 90. 18. Fetters L, Kluzik J. The effects of neurodevelopmental
6. Ketelaar M, Vermeer A, Hart H, van Petegem-van Beek treatment versus practice on the reaching of children with
E, Helders PJM. Effects of a functional therapy program spastic cerebral palsy. Physical Therapy 1996; 76(4):346-
on motor abilities of children with cerebral palsy. Phys 58.
Ther 2001; 81: 1534–1545. 19. Mayston M. People with cerebral palsy: effects of and

40 Iran J Child Neurol. 2015 Spring Vol 9 No 2

 Effects of Neurodevelopmental Therapy on Gross Motor Function in Children with Cerebral Palsy

perspectives for therapy. Neural Plasticity 2001; 8: 51–

69.
20. Akbari A, Javad zadeh M, Shahraki S, Jahanshahi J.
the effects of functional therapy on motor development
in children with cerebral palsy. Iran J Child Neurology
2009; 8(4) 23-32.
21. Tsorlakis N, Evaggelinou C, Grouios G, Tsorbatzoudis
C. Effect of intensive neurodevelopmental treatment in
gross motor function of children with cerebral palsy.
Dev Med Child Neurol 2004; 46(11):740-5.
22. Arndt SW, Chandler LS, Sweeney JK, Sharkey
MA, McElroy JJ. Effects of a neurodevelopmental
treatment-based trunk protocol for infants with posture
and movement dysfunction. Pediatr Phys Ther. 2008;
20(1):11-22.

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