Effectiveness of conductive education for cerebral palsy

Evidence Based Review

Evidence Based
Healthcare Advisory

Group

Effectiveness of conductive education for cerebral palsy

Reviewers Zhi-ling Zhang: principal investigator
Amanda Bowens: literature searching
Siiri Bennett: editing and proof reading

Date Report Completed October 2003

Important Note: This evidence-based review summarises information on the efficacy of
conductive education and provides best practice advice. It is not intended to replace
clinical judgement, or be used as a clinical protocol. A reasonable attempt has been
made to find and review papers relevant to the focus of this report. It does not claim to
be exhaustive. This document has been prepared by staff of the ACC, Evidence Based
Healthcare Advisory Group. The content does not necessarily represent the official view
of ACC or represent ACC policy.

Executive Summary

Background: Conductive education or Petö method can be described as an education system
that tries to improve independent function in people (mainly in children) with movement
disorders. The main goal of conductive education is described as to replace dysfunction with
orthofunction (the ability to function as members of society, to participate in the normal
social settings appropriate to their age, kindergarten, school, college or work…). The
theoretical concepts and effectiveness of conductive education have been argued since it was
introduced to the West from Hungary. This evidence-based review summarises the
information around the efficacy of conductive education for children with cerebral palsy from
a systematic literature search.

Search strategy: A range of databases including Pre-MEDLINE, MEDLINE, MEDLINE
Daily Update, CINAHL, CDSR, ACP Journal Club, DARE, CCTR, EMBASE, International
Pharmaceutical Abstracts, and PsycINFO were searched in August 2003 for published papers
about conductive education. A secondary hand search of citations was also conducted.

Selection criteria: All randomised or non-randomised controlled studies that aim at
investigating the effects of conductive education programmes were considered in this review.
Studies without control group were excluded in the review. Therefore, case reports and case
series were not included. The studies with before-and-after (or pre-and-post) design were also
excluded if they did not use a control group.

Main results:

· Two randomised studies and six non-randomised controlled studies were found that
evaluated effectiveness of conductive education programmes. Among them, seven
studies looked at the effectiveness of conductive education programmes for children
with cerebral palsy, and one studied a group of profoundly retarded, multiple-
handicapped children. All included studies have considerable weaknesses e.g. small
sample sizes.

· Overall, all studies included suggest that children involved in conductive education
based programmes made similar progress to children involved in other non-conductive
education based programmes.

· There is no evidence to indicate that conductive education is superior to other
conventional programmes.

· One study reported a deterioration in hip mobility among children who received
conductive education. No other information about harmful effects of conductive
education programmes was found.

· No cost effectiveness studies of conductive education were found.

Conclusions: The present literature does not provide good evidence for the effectiveness of
conductive education. There is no evidence to indicate that conductive education is more
effective than other conventional approaches. The effectiveness of conductive education for
children with cerebral palsy is not clearly established. There is a need for well-designed

ii

randomised controlled studies, with relatively large sample size, clearly defined intervention,
clearly defined study population, adequate period of follow up and well standardised outcome
measures to assess the effectiveness of conductive education for cerebral palsy.

iii

Table of Contents

Title Page.................................................................................................................................... i
Executive Summary .................................................................................................................. i
Table of Contents .................................................................................................................... iv
1. Background........................................................................................................................... 1
2. Objectives .............................................................................................................................. 2
3. Conductive Education.......................................................................................................... 2
4. Methodology ......................................................................................................................... 4

4.1 Criteria for selecting studies for this review .................................................................... 4
4.2 Search strategy and information sources.......................................................................... 5
4.3 Methods of the review...................................................................................................... 6
4.4 Description of Studies ...................................................................................................... 7
5. Results ................................................................................................................................... 7
5.1 Effectiveness of the conductive education programme.................................................... 7
5.2 Safety of the conductive education programme............................................................... 9
5.3 Cost effectiveness............................................................................................................. 9
6. Discussion............................................................................................................................ 10
6.1 Methodological quality................................................................................................... 10
6.2 Effectiveness of the conductive education programme.................................................. 13
6.3 Safety of the conductive education programme............................................................. 14
6.4 Cost effectiveness........................................................................................................... 14
6.5 Limitations of the review ............................................................................................... 14
7. Conclusions ......................................................................................................................... 14
Acknowledgements: ............................................................................................................... 15
References ............................................................................................................................... 15
Appendix 1. Level of evidence in the SIGN system............................................................. 19
Appendix 2. Characteristics of studies with control group ................................................ 20

iv

1. Background

Cerebral palsy refers to a group of chronic conditions affecting body movement and muscle
co-ordination caused by lesions or defect of the brain acquired in pre-natal or early life.
Symptoms of cerebral palsy include difficulties in performing fine motor tasks (e.g. writing),
maintaining balance, communication, feeding, swallowing, walking and involuntary
movements. Some children with cerebral palsy may experience uncontrollable writhing of the
hands, drooling1-3 and learning problems.

Even though cerebral palsy is a group of disorders with similar problems in controlling
movement, the causes of cerebral palsy can be very different. Approximately 70% of cerebral
palsy in children is congenital. Congenital cerebral palsy is present at birth and may not be
detected for months after birth. In most cases, the cause of congenital cerebral palsy is
unknown. However, some factors have been associated with congenital cerebral palsy,
including rubella during pregnancy, low birth weight and severe oxygen shortage in the brain
or trauma to the head during labour and delivery.1-6 In the United States, about 10 to 20 % of
children with cerebral palsy acquire the disorder after birth, as a result of infections (e.g.
meningitis or encephalitis) or head injury from motor vehicle accidents, falls, or child abuse.1-

3

The prevalence of cerebral palsy has generally been estimated at 2 to 2.5 per thousand school-
age children.5,7

There is no standard therapy for children with cerebral palsy. A number of therapeutic
programmes have been designed for children with cerebral palsy, including the
neurodevelopmental treatment (the Bobath approach), early intervention, patterning (the
Doman-Delacato method), family-centred functional therapy and conductive education.3,8-10
Using conductive education-based intervention for cerebral palsy has been reported in several
countries, including the UK, the USA, Canada and Australia.3,11-13

In July 2003, EBHC group was asked by Colleen Shramka, a programme manager in ACC
Healthwise, to review the evidence on conductive education-based interventions for cerebral

1

palsy and other conditions. This evidence-based review reports the findings from a systematic
search and critical appraisal of published studies in relation to the efficacy of conductive
education-based interventions.

2. Objectives

The aims of this work are to review the efficacy of conductive education-based interventions
for cerebral palsy and other conditions reported, and to provide other relevant information
about the intervention for decision making.

3. Conductive Education

Conductive education or Petö method may be described as an educational system that tries to
improve independent function in people (mainly in children) with movement disorders. The
system was originally designed by Dr Andras Petö in Hungary in the 1940s.14,15 According to
the International Petö Institute in Budapest, Hungary, “Conductive Education is based on the
idea that despite the damage, the nervous system still possesses the capacity to form new
neural connections…this ability can be mobilised with the help of a properly guided, active
learning process.” 16

The International Petö Institute also states that “the objective of conductive education is not to
change directly a certain disability but to integrate and co-ordinate various functions…the
principle is that it is not the environment that has to be changed but it is the motor disordered
person who should be taught to successfully adapt to his or her environment”.16 Conductive
education is therefore considered as a learning process rather than a treatment or therapy.17-19

The main goal of conductive education is described as to replace dysfunction with
orthofunction.8,9,11,12,15 Orthofunction is defined as “the ability to function as members of
society, to participate in the normal social settings appropriate to their age, kindergarten,
school, college or work, without need for wheelchairs, ramps, special furniture, toileting
arrangements, etc.”15 Therefore, it is said that “orthofunction is concerned with the general
adaptive or learning capacity of the individual, while dysfunction refers to ongoing or
increasing difficulty in coping with daily life”.12

2

The following elements are considered as important components in conductive education:10,20

· The conductor:
The conductor is the person who delivers the programme. Originally, conductive
education was practised by conductors only. The conductors generally carry out their
work in groups, and are responsible for all aspects of a child’s education and
development, and most aspects of everyday care.10,21

· The programme:
The programme can be described as a planned learning programme that may include
the activities included in a daily routine.

· The task series:
The task series is the basis of the work session, which prepares children for function
and aims specifically at teaching children to gain the basic control over their
musculature.

· Intention/Rhythmical Intention:
The rhythmical intention is the method by which a child uses speech or inner speech to
express an intention and is followed by movement, which is carried out rhythmically.

· The group:
The basic unit in which the participants may be matched for ability and age. Children
work in groups during all parts of the daily timetable.

The theoretical concepts of conductive education have been questioned by some
authors.10,12,22 For example, Bairstow et al argued that many statements and beliefs of
conductive education “seem never to have been challenged or tested… and many assertions
seem unbelievable; e.g., dysfunction is a personality problem and conductive education is
directed at improving the whole personality”.10

The philosophy of conductive education was introduced to the West by Esther Cotton (an
English physiotherapist who worked for the Spastics Society in the UK) in the 1960s.23 Since
the mid 1980s, interest in conductive education has grown.3 Many conductive education
organisations have been set up since then. In 2002, there were 212 conductive education

3

organisations spread across 16 countries, 7 of them were in New Zealand and located in
Auckland, Christchurch, Lower Hutt, Hamilton and Invercargill.24

4. Methodology

4.1 Criteria for selecting studies for this review

Types of Studies: All randomised or non-randomised controlled studies that aim at
investigating the effects of conductive education programmes were considered in this review.
Studies without control group were excluded in the review. Therefore, case reports and case
series were not included.

The studies with before-and-after (or pre-and-post) design were also excluded if they did not
use a control group. The results from these studies cannot be explained by the effects of
conductive education programme alone since there are other possible alternative explanations
e.g. maturation of children.

The level of evidence for each quantitative study included was determined by a grading
system (see Appendix 1) reported by the Scottish Intercollegiate Guidelines Network
(SIGN).25 Qualitative studies were not included in this review due to the lack of tools or
standards to evaluate the level of evidence from such studies.

Types of Participants: Initially, this work tried to include people with different conditions of
disability (e.g. cerebral palsy, multiple sclerosis, Parkinson’s disease, traumatic brain injury
and stroke) who received conductive education. However, the results from literature searching
showed that most reported controlled studies on conductive education looked at children with
cerebral palsy. The characteristics of participants and the conditions in the studies included
are shown in the Appendix 2.

Types of Interventions: Conductive education programmes or conductive education-based
programmes are both considered as interventions in this review. These programmes were
generally defined by the following key principles of conductive education as described by
Catanese in French’s report26:

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· The programme had a leader or conductor.
· The programme was carried out in a group.
· The programme was designed with task analysed activities.
· The programme used rhythmic intention.

Types of Outcome Measures: As in a previous study,10 changes in the following functional
measurements are considered as main outcomes in this work:

· Mental functioning
· Communication
· Fine motor functioning
· Gross motor functioning
· Personal behaviour
· Interpersonal behaviour
· Self-help behaviour

Parents’ satisfaction was also considered as an outcome in the review.

4.2 Search strategy and information sources

An OVID search strategy was developed to search for studies of conductive education in
August 2003:

1 "conductive education".mp,tw.
2 "andras peto".mp,tw.
3 "conductive learning".mp,tw.
4 "conductive therapy".mp,tw.
5 "conductive pedagogy".mp,tw.
6 or/1-5
7 limit 6 to human
8 limit 7 to english language
9 remove duplicates from 8

This strategy was used to search for all papers reporting the use of conductive education
programmes for different conditions in relation to disability, from a range of available
databases including Pre-MEDLINE, MEDLINE, MEDLINE Daily Update, CINAHL, CDSR,
ACP Journal Club, DARE, CCTR, EMBASE, IPA, AMED and PsycINFO.

5

The term “conductive education” was used to search for information from internet sources,
including the websites of:

· The Foundation for Conductive Education in England (http://www.conductive-
education.org.uk)

· The Inter-American Conductive Education Association (http://www.iacea.org)
· The International Petö Institute in Hungary (http://www.peto.hu)
· United Cerebral Palsy in the USA (http://www.ucpa.org)
· HTA institutes e.g. the Alberta Heritage Foundation for Medical Research in Canada

and the Swedish Council on Technology Assessment in Health Care (SBU)

A secondary hand search of citations was also conducted. However, the papers in non-medical
literature databases have not been systematically searched.

4.3 Methods of the review

The reports on conductive education were appraised by the principal investigator using the
Scottish Intercollegiate Guidelines Network (SIGN) grading system25 (see Appendix 1) to
determine the levels of evidence:

1. The type of study was determined by appraising the methodological information
described in each report.

2. For studies with control group, the quality of study was assessed by analysing the
information including the methods of distributing study subjects to different study
groups, blinding, sample size, outcome measurements, period of follow-up, definition
of study population and intervention, criteria of inclusion and exclusion, and potential
bias in the studies.

3. The levels of evidence were determined by considering the quality of study according
to the SIGN system.25

4. An evidence table summarised the information of study type, clinical conditions, study
population, intervention, outcomes and the level of evidence determined.

6

4.4 Description of Studies

Two randomised studies 27,28 and six non-randomised controlled studies were found that
evaluated effectiveness of conductive education programmes.10,13,29-33 Two papers reported
by Heal 13,33 appear to use the same data from one study source.

Among them, seven studies evaluated effectiveness of conductive education programmes for
children with cerebral palsy.10,13,28-33 One study evaluated the effectiveness of conductive
education for a group of profoundly retarded, multiple-handicapped children, including
children with cerebral palsy.27

Even though two studies were found that reported using conductive education for adults with
stroke, multiple sclerosis, Parkinson’s disease and other neurological conditions,34,35 these
two studies were excluded from the review since they were identified as before-and-after
studies. No control group was used in the study designs.

Therefore, all papers included 10,13,27-33evaluated the efficacy of conductive education for
children mainly with cerebral palsy.

The characteristics of each study included are presented in the Appendix 2.

5. Results

5.1 Effectiveness of the conductive education programme

The first published study to evaluate the effects of conductive education was reported by Heal
in the United States in the 1970s.13,33 The study compared an Integrated Management of
Cerebral Palsy (IMCP) programme, which was based on the principles of conductive
education, with conventional training programmes. The results showed that children in the
control group had significantly greater gains on several functional movement variables, while
the intervention group experienced some regression on the measurements. In contrast, the
Intervention group had significantly greater gains on two of seven socialisation variables. The
improvements on cognitive measures in both groups were similar.

7

There are three evaluation studies carried out by a research group in Australia: 28-30

In Reddihough’s study,28 children in the control group were provided with additional
programme time to create equal intensity between randomised intervention and control
groups. The study results from 34 randomised subjects and 32 non-randomised subjects
indicate that children in conductive education-based intervention made similar progress to the
control groups. A few statistically significant differences between intervention and control
groups were noticed in the randomised study subjects. The control group showed a substantial
increase in the score of organisation-behaviour variables while the intervention group showed
a significant decrease. In contrast, the caregivers in the intervention group reported greater
improvement in dressing over 6 months than the caregivers in the control group in this study.

Coleman 29 reported that no main effects were significant between intervention and control
for any measure of videotaped categories including gross motor function, fine motor function,
receptive language, expressive language, grooming and feeding. For the measures of
caregiver ratings, significant improvements over 26 weeks of sessions were reported in
language skills, social interaction and play in both groups. Even though the intervention group
showed a greater improvement than the control group in social interaction from caregiver
ratings, no consistent overall differences between the two groups were detected. No
significant main effects were found from the measures of the questionnaire on resources and
stress (QRS-F scores).

Catanese30compared 17 children who received a conductive education based programme with
17 other children enrolled in traditional early childhood services. The study results showed
that the intervention group “improved in motor performance and parental coping variables”.30
Both the intervention and control groups showed improvement on the cognitive measures,
with the control group had statistically significant greater gains.

Bairstow10 carried out an extensive evaluation study on conductive education in the UK.
During a two-year study period, 19 children enrolled in the Birmingham Institute for
Conductive Education were compared with 17 children who received English special
education programmes in the Greater Manchester area. On the total 47 variables tested, most
results showed similar improvements between intervention and control groups over the study

8

period. Only 8 variables showed statistically significant differences between groups. Among
them, six variables were favourable to the control group, and two variables of adaptive
behaviour were favourable to the intervention group.

Based on the same study subjects as in Bairstow’s study, Hur reported two studies that
evaluated academic performance32 and the skills for independence31by comparing children
who received a conductive education programme in Birmingham with children enrolled in
English special education programmes in the Greater Manchester area. In the first study32,
both intervention and control groups achieved significantly better academic performance in
the second year. However, there were no significant differences of the improvement between
the two groups. A similar pattern was also found in the second study31: both groups presented
significantly better skills for independence as “they were getting old”; however, there were no
significant differences in improvement in skills between the two groups.

Another randomised study27 in UK, based on a very small sample with heterogeneous
conditions, concluded that the teaching programmes based on conductive education principles
were no more effective than traditional individual classroom teaching for profoundly retarded
multiply handicapped children.

5.2 Safety of the conductive education programme

Only one study10 reported a deterioration in hip mobility among children who received
conductive education. No other information about harmful effects of conductive education
programmes was found in the review.

However, Hur reported “…Some mothers in Birmingham were alarmed about the conductors’
advice in relation to the orthopaedic problems of their children…When the mothers tried to
consult fully qualified orthopaedic surgeons, they were forbidden to and told that surgery is
harmful and once surgery has been performed, it is difficult to correct the deformities by
CE…” 31

5.3 Cost effectiveness

No study about cost effectiveness of conductive education was found.

9

6. Discussion

6.1 Methodological quality

All studies included have considerable weaknesses in study design. The methodological
quality of the studies is discussed as follows:

· Sample size, study power and statistical analysis: In this review, the largest sample
(66 children) was found in Reddihough’s study.28 However, the researchers were only
able to include 34 children for randomisation. The other 32 children were included in a
non-randomised study. Therefore, the sample size for each different study design
(randomised and non-randomised) was still small. Sample sizes in the other six
studies10,13,29-32ranged from 20 to 36 children. A extremely small sample of 10 children
was included in the study by Cottam.27

Study power was not reported in all studies. The small sample sizes in the studies may
not have enough power to detect effects of intervention, especially to detect the changes
in the children with severe disabilities. There may be a high risk of making type II error
for all studies.

Statistical analysis was used in all included studies. Statistical significance was reported
for some measures in some studies.10,13,28-32 However, the clinical significance was not
clearly discussed for all studies.

· Randomisation: The methods for randomisation were not reported in the two
studies27,28 that indicated the study subjects were “randomly assigned” to conductive
education group or control group. These two studies27,28 could be either true
randomised or quasi-randomised controlled studies.

Even though randomisation was used in Cottam’s study,27 the sample size of this study
was extremely small. In addition, one study subject in the intervention group was
replaced during the study period. Such a change could have a significant impact on the
random allocation. This study also included children with very different clinical
diagnoses. The level of evidence from this study was therefore graded as “2-” instead of
“1-”.

10

· Matching: In most studies,10,13,27,28,30-32 study subjects in intervention and control
groups were matched by different variables. Matching may reduce the effects that were
related to the variables involved in the match, but it still would not be able to produce
two completely comparable groups for intervention and control. For example, in
Bairstow’s study,10 ten children with severe handicap were allocated in the conductive
education group while only six were allocated in the control group after matching.

· Study population, inclusion and exclusion criteria: The included studies did not
clearly define the populations from which the study subjects were sampled. It is unclear
whether the study subjects could represent children with cerebral palsy in the general
population. Some study subjects were selected from previously existing
programmes29or special education schools.10,27 The potential impacts on study results
from previous exposure to conductive education or other treatments could not be
excluded. Each study included male and female subjects whose age varied from 1 to 14
years old approximately.

Apart from Cottam’s study27in which only some of the cases could be considered as
cerebral palsy, all study subjects included had a diagnosis of cerebral palsy. However,
the diagnosis of cerebral palsy covers a group of disorders of impairments and
disabilities, and therefore does not ensure the homogeneity of the sample studied. The
heterogeneous nature of cerebral palsy may create potential confounding factors in the
studies.

Inclusion and exclusion criteria were not stated in two studies.27,29 In general, children
receiving conductive education are required to be able to understand simple instructions.
As such, only some children with cerebral palsy are suitable to receive conductive
education. Children with severe visual or hearing impairment were excluded from the
studies.27,28,36 Biarstow estimated that about 65% of children with cerebral palsy were
not suitable to receive conductive education and argued that conductive education
“might not be appropriate for the majority of children with cerebral palsy”.21,36

· Conductive education programmes: It is generally agreed that conductive education
programmes outside Hungary have been modified significantly to fit the education and
social structures in other countries.3,29,30,37 In Bairstow’s report,10 the conductive

11

education programme was clearly described. The conductive education interventions in
other studies were not described in details.13,27-30

The study periods were well reported in each study and ranged from six months to two
years. The intensity of conductive education programmes varied considerably, ranging
from 25 minutes per day in Cottam’s study27 to 13.5 hours per day in Heal’s study.13
One study30 did not report any information about programme intensity. Three studies of
the same group of children in the UK10,32,38 reported that the averages of physical
programme and academic programme duration in the conductive education group were
14 hours and 4 hours per week respectively. In contrast, averages of physical
programme and academic programme duration in the English special education school
(control group) were 3.3 hours and 8 hours per week. For non-randomised study
subjects in Reddihough’s study,28 mean programme time of conductive education was
3.2 hours per week compared with 2.2 hours per week in the control group. The
intensity of conductive education may be higher than in conventional programmes.
Such differences may need to be taken into account in evaluating the effectiveness of
conductive education.

Follow-up: Since conductive education is considered a learning process and the main
goal of the education is described as to replace dysfunction with orthofunction,
8,9,11,12,15,17-19 it would be important to evaluate the long-term outcomes by an
appropriate period of follow up after conductive education intervention. All included
studies reported the outcomes at the point when interventions were ended. Long term
effects observed after conductive education have not been studied.

· Outcome measures: Different assessment tools were used in the studies and make
comparisons of studies difficult. The Eau Claire Functional Motor Abilities Test
(ECFMAT) was used in Heal’s study.13 The Vulpe Assessment Battery (VAB) and the
questionnaire on resources and stress (QRS-F) were used in the three Australian
studies.28-30 Bairstow10 used a battery of 47 tests to measure outcomes. The
Comprehensive Reading Test (CRT) and the Basic Mathematical Test (BMT) were used
in Hur’s study32to measure academic performance. The Vineland Adaptive Behaviour

12

Scales were used in Hur’s later study31 to assess the skills of independence. “A
specifically designed assessment schedule” was used in Cottam’s study27.

Blinded method was used to assess part of outcomes in some studies,13,29,30 but it was
not used for others.10,27,28,31,32 The scores of some measures were rated by the
caregivers. Therefore, there may be some measurement bias in the studies.28-30

6.2 Effectiveness of the conductive education programme

The available controlled studies do not provide good evidence for the effectiveness of
conductive education programmes. All studies have considerable weaknesses as discussed in
section 6.1. A randomised controlled study, with evidence level “1-”, concluded that children
involved in conductive education-based programmes made similar progress to children
involved in traditional programmes.28

Statistically significant differences of some measures between intervention and control groups
were reported in some studies.10,13,28-30 Among these statistically significant results, some of
them were favourable to the conductive education group, but others were favourable to the
control group. There is no clear pattern that can be concluded from the results. The clinical
significance of these statistically significant results is unknown. In addition, compared with
the total numbers of variables tested in each study, the variables with the statistically
significant differences were relatively few. For example, in Bairstow’s study,10 only 8 of 47
variables tested showed statistically significant differences between the intervention and
control groups. Among them, 6 variables were favourable to the control group while 2
variables were favourable to conductive education. These results need to be interpreted
cautiously.

Overall, the controlled studies included in this review suggest that children involved in
conductive education-based programmes made similar progress to children involved in other
non-conductive education-based programmes. Taking methodological weaknesses (see
section 6.1) of each study into account, there is no evidence to indicate that conductive
education is more effective than other conventional programmes. The effectiveness of
conductive education for children with cerebral palsy is not clearly established.

13

6.3 Safety of the conductive education programme

Even though a deterioration in hip mobility among children receiving conductive education
was reported in one study,10 this finding has not been repeated in other studies. Therefore,
available studies may not strongly indicate that safety is a main issue of conductive education
programmes. Parents should seek appropriate medical advice for the conditions of their
children.

6.4 Cost effectiveness

The cost effectiveness of conductive education cannot be directly discussed in this report as
no cost effectiveness studies were found.

However, the high intensity of conductive education could lead to high costs. There have been
a very small number of visits to conductive education providers in the 2002/2003 financial
year, the gross cost per visit in ACC data was about $4,050 to $4,252 for the “education
support-teacher aide” and $1,012 to $9,483 for “training for independent living”.

6.5 Limitations of the review

The number of controlled studies evaluating the effects of conductive education is limited.
These available studies vary in the intervention described, patient population, outcome
measures and study design. Therefore, this review only tries to address a broad research
question about the general effectiveness of conductive education.

A reasonable attempt, including hand searching of citations, has been made to find published
reports from relevant medical literature databases and internet sources, but no attempt was
made to identify unpublished studies and studies published in the languages other than
English. Papers in non-medical literature databases may be missed. Publication bias has not
been discussed in this review. Qualitative studies were not included.

7. Conclusions

Implications for practice: The present literature does not provide good evidence for the
effectiveness of conductive education. There is no evidence to indicate that conductive

14

education is more effective than other conventional approaches. The effectiveness of
conductive education for children with cerebral palsy is not clearly established.

Implications for research: There is a need for well-designed randomised controlled studies,
with relatively large sample size, clearly defined intervention of conductive education, clearly
defined study population, adequate period of follow up and well standardised outcome
measures.

Implications for Purchasing and Policy Decisions: There appears to be no evidence to
indicate that conductive education is more effective than conventional programmes or
treatments. Decision making around the purchasing conductive education needs to consider a
range of other factors such as the cost, suitability and accessibility of the intervention.

Acknowledgements:

We thank Dr Phillipa Clark and Dr Rosemary Marks in Auckland Starship Hospital, Dr Kevin
Morris in ACC for their advice and comments on this work, Helen Brodie and Janice Keys in
ACC for their help in obtaining related materials used in this report.

References

1. National Institute of Neurological Disorders and Stroke. Cerebral Palsy--hope through
research. On http://www.ninds.nih.gov 2003.

2. United Cerebral Palsy. Cerebral Palsy--Facts & Figures. On http://www.ucpa.org 2003.
3. Ludwig S, Leggett P, Harstall C. Conductive education for children with cerebral palsy.

Alberta Heritage Foundation for Medical Research 2000.
4. Clark SL, Hankins G. Temporal and demographic trends in cerebral palsy - Fact and

fiction. American Journal of Obstetrics & Gynecology 2003;188(3):628-633.
5. Robertson CMT, Svenson LW, Joffres MR. Prevalence of cerebral palsy in Alberta.

Canadian Journal of Neurological Sciences 1998;25(SUPPL. 2):117-122.
6. Liu JM, Li S, Lin Q, Li Z. Prevalence of cerebral palsy in China. International Journal of

Epidemiology. 1999;28(5):949-54.
7. Murphy CC, Yeargin-Allsopp M, Decoufle P, Drews CD. Prevalence of cerebral palsy

among ten-year-old children in metropolitan Atlanta, 1985 through 1987. Journal of
Pediatrics 1993;123(5):S13-S19.

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8. Hedges K. The Bobath and Conductive Education approaches to cerebral palsy treatment-
management and education models. New Zealand Journal of Physiotherapy
1988;16(1):6-12.

9. Chu SKH. The application of contemporary treatment approaches in occupational therapy
for children with cerebral palsy. British Journal of Occupational Therapy
1989;52(9):343-8.

10. Bairstow P, Cochrane R, Hur J. Evaluation of Conductive Education for children with
cerebral palsy. HMSO publication, London 1993.

11. Brown H et al. Conductive education in the UK: present and future challenges. British
Journal of Therapy & Rehabilitation 1998;5(6):330-3.

12. Bochner S, Center Y, Chapparo C, Donelly M. Implementing conductive education in
Australia: A question of programme transplantation. Educational Psychology
1996;16(2):181-192.

13. Heal LW. Evaluation of an integrated approach to the management of cerebral palsy.
Exceptional Children 1974;40(6):452-453.

14. Llewellyn A, Owens M, Hogan K. Conductive education: The case for further research.
Early Development & Parenting 1997;6(2):89-91.

15. Sutton A. Developments in Hungary. In P. Cottam & A. Sutton (Eds), Conductive
Education: A system for overcoming motor disorder. London: Billing & Sons Limited,
1986.

16. International Peto Institute. The principle and aim of conductive education. On
http://www.petoinstitute.org 2003.

17. Sutton A. Problems of theory. In P. Cottam & A. Sutton (Eds), Conductive Education: A
system for overcoming motor disorder. London: Billing & Sons Limited, 1986.

18. Inter-American Conductive Education Association. What is Conductive Education. On
http://www.iacea.org 2003.

19. The Foundation for Conductive Education. What is Conductive Education. On
http://www.conductive-education.org.uk 2003.

20. The Foundation for Conductive Education. Elements of conductive education. On
http://www.conductive-education.org.uk 2003.

21. Bairstow P. Evaluation of conductive education: The selection process. Educational &
Child Psychology 1992;9(1):57-63.

22. Oliver M. Conductive education: if it wasn't so sad it would be funny. Disabil Handicap
Society 1989;4(2):197-200.

23. Sutton A. Developments outside Hungary. In P. Cottam & A. Sutton (Eds), Conductive
Education: A system for overcoming motor disorder. London: Billing & Sons Limited,
1986.

16

24. The Foundation for Conductive Education. CE world survey: preliminary report. On
http://www.conductive-education.org.uk 2003.

25. SIGN. Grading system for recommendations in evidence-based clinical guidelines--report
of a review of the system for grading recommendations in SIGN guidelines: Scottish
Intercollegiate Guidelines Network (SIGN), 2000.

26. French L, Nommensen A. Conductive education evaluated: Future directions. Australian
Occupational Therapy Journal 1992;39(4):17-24.

27. Cottam P, McCartney E, Cullen C. The effectiveness of conductive education principles
with profoundly retarded multiply handicapped children. British Journal of Disorders
of Communication 1985;20(1):45-60.

28. Reddihough DS, King J, Coleman G, Catanese T. Efficacy of programmes based on
Conductive Education for young children with cerebral palsy. Developmental
Medicine & Child Neurology 1998;40(11):763-770.

29. Coleman GJ, King JA, Ressighough DS. A pilot evaluation of conductive education-based
intervention for children with cerebral palsy: The Tongala Project. Journal of
Paediatrics & Child Health 1995;31(5):412-417.

30. Catanese AA, Coleman GJ, King JA, Reddihough DS. Evaluation of an early childhood
programme based on principles of conductive education: The Yooralla Project. Journal
of Paediatrics & Child Health 1995;31(5):418-422.

31. Hur JJ-A. Skills for independence for children with cerebral palsy: A comparative
longitudinal study. International Journal of Disability, Development & Education
1997;44(3):263-274.

32. Hur J, Cochrane R. Academic performance of children with cerebral palsy: A comparative
study of conductive education and British special education programmes. British
Journal of Developmental Disabilities 1995;41(1):33-41.

33. Heal L. The comparison of intact groups using the analysis of covariance. Journal of
special education 1976;10:427-436.

34. Bandyopadhyay S et al. Conductive education-based physiotherapy in Parkinson's disease.
British Journal of Therapy & Rehabilitation 2002;9(5):176-9.

35. Cott C, Wright F. An evaluation of a conductive education program for adults with
neurological disability. Physiotherapy Canada 2001;53(3):182-9.

36. Bairstow P, Cochrane R, Rusk I. Selection of children with cerebral palsy for conductive
education and the characteristics of children judged suitable and unsuitable.
Developmental Medicine & Child Neurology 1991;33(11):984-992.

37. Darrah J, Watkins B, Chen L, Bonin C. Effects of Conductive Educatio Intervention for
Children with a Diagnosis of Cerebral Palsy: A AACPDM Evidence Report.
Document of American Academy for Cerebral Palsy and Developmental Medicine
(AACPDM) 2003.

17

38. Hur J, Cochrane R. Maternal stress and level of satisfaction with treatment for children
undergoing conductive education. International Journal of Special Education
1995;10(2):54-62.

18

1++ Appendix 1. Level of ev
1+
1- High quality meta analyses, systematic review
2++ Well conducted meta analyses, systematic rev
Meta analyses, systematic reviews, or RCTs w
2+ High quality systematic reviews of case-cont
2- High quality case-control or cohort studies w
the relationship is causal
3 Well conducted case control or cohort studies
4 that the relationship is causal
Case control or cohort studies with a high risk
not causal
Non-analytic studies, e.g. case reports, case s
Expert opinion

19

vidence in the SIGN system

ws of RCTs, or RCTs with a very low risk of bias
views, or RCTs with a low risk of bias
with a high risk of bias
trol or cohort studies
with a very low risk of confounding or bias and a high probability that
s with a low risk of confounding or bias and a moderate probability
k of confounding or bias and a significant risk that the relationship is
series

9

Appendix 2. Characteristics

Study Methods Participants Inter

Heal 197413,33 · Non - · 25 children with cerebral · Interventi
randomised palsy, aged 6 to 14 years children (
The study was old female, a
supported by a controlled yrs) parti
grant from the · Criteria for enrollment in Integrated
Bureau of study intervention group of Cerebr
Education for included: (a)non- programm
the ambulatory (b)between conductiv
Handicapped, the ages of 5 and 13 principles
US office of (c)able to understand integrated
Education, simple instructions day progr
Department of developm
Health, · Children in the control movemen
Education and group were matched to and acade
Welfare. the extent possible with
the intervention subjects · Control g
Reddihough · Part A: on their (a)description of children (
199828 randomised cerebral palsy female, a
controlled involvement yrs) recei
The study was study (b)chronological age (c) conventio
funded by mental age (d) motor programm
Australian · Part B: non- ability (e)hand skills
randomised (f)dressing abilities and · Period of
controlled (g) speech characteristics about one
1971 to th
· Sixty-nine children were 1972)
originally assessed, but 3
withdrew. A total 66 · Interventi
children (41 boys, 25 education
girls) with a definite with inpu
diagnosis of cerebral Hungaria
palsy were included. conducto
programm
intention

20

s of studies with control group

rvention Outcomes Comments and
Level of
ion group: 10 · Control group showed significantly Evidence
(5 male, 5 · greater gains on several functional
average age 9.29 · movement variables, while intervention · The severity of
icipated in an group experienced some regression on the disorders in
d Management · the measures. the children is
ral Palsy (IMCP) · Intervention group had significantly unclear.
me, based on greater gains on two out of seven
ve education socialisation variables. · Small sample
s. “The carefully Both groups made comparable gains on size
d, 13.5 hour-per- cognitive measures.
ram stressed the · Potential
ment of functional Results based on the analyses of 17 selection bias.
nt, socialisation, matched pairs in Part A; and 13
emic skills.” matched pairs in Part B. · No detailed
The outcome was measured for motor, information
group: 15 cognitive, language, organisational about
(10 male, 5 behaviours and activity of daily living treatments used
average age 9.24 skills. in control
ived group
onal training
mes · Blinded
methods were
f intervention: used in the
e year (spring of assessment
he spring of
· Evidence level
ion: conductive 2-
n programme
ut from · The method of
an-trained randomisation
or, repetitive was not stated
me, rhythmical in the Part A.

and task series · It is unknown
what
population the

0

National Health study Children with severe · Control: a
and Medical visual or hearing approach
Research impairment were meeting t
Council Project excluded. therapeut
Grant.
· Age range 12 to 36 · Study per
months (average: 22
months 3 weeks) Total mean nu
hours:
· Part A: 34 children (17
each in intervention and · Part A: 7
control group) hours/chi
interventi
· Part B: 32 children (15 in hours (2.9
intervention and 17 in hours/chi
control group) control gr

· The groups were closely · Part B: 86
matched. hours/chi
interventi
hours (2.2
hours/chi
control

Coleman · Non- · Initially 26 children were · Conducti
199529(Tongala randomised
Project) controlled enrolled in the study, but based pro
study
The Myer and six withdrew during the children w
Stegley
Foundations evaluation period. five prog
provided
financial · The final study group the princi
support for the
study. consisted of 20 children conductiv

(10 male, 10 female), “which o

ranging in age from 19 to five morn

69 months, with an five morn

average age of 45 months. fortnight”

· Control g

21

a treatment · In both randomised and non-randomised · children were
h based on controlled studies, children involved in · drawn from for
conductive education based · study.
the child’s programmes made similar progress to ·
tic objectives children involved in traditional Traditional
riod; 6 months programmes (control group). programmes
(controls) were
umber of therapy Few measurements were of statistical not well
significance in Part A; described.
5.6 hours (2.8
ild/week) in the · The control group showed a substantial Relatively
ion group; 79.8 increase in score of organisation- short term of
9 behaviour variables while the the intervention
ild/week) in the intervention group showed a substantial (six months)
roup decrease following treatment (P<0.05)
6 hours (3.2 Possible
ild/week) in the · The caregivers in the intervention group selection bias
ion group; 59 reported greater improvement in in the Part B
2 dressing over the 6 months than the study.
ild/week) in the caregivers in the control group(P<0.05)
Control group
· in the Part A
· was provided
with additional
ive education Videotaped items: · programme
ogramme: 11 time.
were enrolled in · No main effects were significant ·
grammes based on between intervention and control for No blinded
iples of any of the videotaped categories (gross · method used.
ve education, motor, fine motor, receptive language, ·
operated between expressive language, grooming and Evidence level:
nings a week and feeding) (P>0.05). Part A: 1-
nings a Part B: 2-
”. For caregiver ratings:
No inclusion or
group: 9 children exclusion
criteria were
stated.

The severity of
the disorders in
the children is
unclear.

Small sample
size

Blinded

1

· All children had diagnosis in the con
of cerebral palsy: seven involved

with spastic diplegia, based ear

eleven with spastic programm

quadriplegia, one with traditiona

hemiplegia and one with therapy a

athetoid cerebral palsy. education

· Measurem

in pre and

at 26 wee

tools used

included

Assessme

(VAB) an

on resour

(QRS-F)

· Programm

weeks

Catanese · Non - · 34 children (18 male, 16 · Interventi
199530 randomised
controlled female), aged 4 yrs to 7 children w
“The research study
was funded by a yrs 1 months, with a the Yoora
donation from
the Brockhoff definite diagnosis of based on
Foundation
with support cerebral palsy. education
from the
Yooralla · Each child received in · Control g
Society of
Victoria” conductive education was children i

matched with a control received

child. physiothe

· “Each ch

conductiv

group wa

closely as

control ch

type and

physical d

cognitive

matching

· The grou

in terms o

22

ntrol group were method was

in four centre- · Significant improvements over sessions used in the

rly intervention for both groups were obtained for assessment

mes using more receptive language, expressive · Self-selection

al approaches to language, social interaction and play. to intervention

and special (P<0.05) or control.

n. · Intervention group showed greater · Relative short

ments were taken improvement than control group in term of

d post treatment social interaction (P<0.01). intervention

eks. Assessment · No consistent overall differences · Matching was

d in the study between the intervention and control not used

Vulpe groups were obtained. · Evidence level
ent Battery 2-

nd questionnaire QRS-F scores

rces and coping

mes lasted for 26 · No significant main effects were

obtained.

ion group: 17 · The intervention group improved in · No mention of
were enrolled in motor performance and parental coping exclusion and
alla programme variables. inclusion
criteria.
conductive · Both intervention and control group
n. showed improvement on the cognitive · Small sample
measures, with the control group had size
group: 17 statistically significant greater gains.
in control group · Blinded
“an individual · Caregiver ratings: control children had method was
erapy program” improved more over time than did the used in the
children in the intervention for social assessment
hild in the interaction and play; while children in
ve education the intervention were rated to have · Intervention
as matched as improved more for toileting. group may
s possible with a have had
hild using age, exposure to
severity of other
disability and conductive
e ability as the education
g variables” programme
prior to the
ups were similar study.
of “associated

2

intellectu

but more

severe ce

located in

group tha

interventi

1)

· Measurem

at beginn

weeks. A

used in th

Vulpe As

Battery (V

questionn

resources

(QRS-F)

· Programm

weeks

Bairstow 1993 · Non- · In total, 36 children were · Interventi
10 randomised
selected: (a) having a children w
controlled
form of cerebral palsy (b) Hungaria
study
birth dates between 1 were enro

The study was January 1983 and 31 conductiv
supported by
the Department August 1986 (c) not programm
of Education
and Science in suffering from profound Birmingh
UK.
mental handicap, Conducti

blindness, autism, · Control g
continuous ill health, children f

continuous fits or Manchest

medication that could were “clo

seriously affect ability to with inter

participate in the on a num

programme. variables”

selected b

Hungaria

receive tr

special ed

programm

23

ual disability”, · Intervention
children with and control
· treatments
erebral palsy were · were not
n the control · clearly
an in the described in
ion group (5 vs · On most of the 47 tested functional and · detail.
· physical variables, the two groups · No information
ments were taken · showed similar improvement over time. · about drop-
ning and 26 outs.
Assessment tools · Only 8 tested variables showed · Relatively
he study included · statistical differences between groups · short term
ssessment intervention
Control group progressed better than the Evidence level:
VAB) and intervention group on the 6 tested 2-
naire on variables of Object Transfer 1, Postural
s and coping Independence, Position Changing Small sample
Independence, Form Discrimination, size
mes lasted for 26 Activities of Daily Living and hip Potential
mobility. selection bias
ion group: 19 Drop-out in
were selected by On hip mobility, there was a slight both
an conductors and improvement for control group, but a intervention
olled in a substantial deterioration for intervention and control
ve education group. groups and
me at the follow up have
ham Institute for Intervention group progressed better not been
ive Education. than the control group in two variables discussed
group: 17 of adaptive behaviour: interpersonal and Blinded
from the Greater play method was
ter area, who not used in the
osely matched assessment
rvention group Evidence level:
mber of 2-
”, were also
by the same
an conductors to
raditional English
ducation
mes.

3

· The child

on a total

including

functioni

communi

motor fun

motor fun

personal

interperso

and self-h

at before

study per

· The study

year to Ja

interventi

intensity

in physic

and 4hr/w

Hur 199532 programm

· Non- · 36 children with cerebral · Interventi
randomised
palsy aged 5 to 6.5 years (10 male,
controlled
old at the first assessment enrolled i
study
(they were the same as education

those that participated in Birmingh
Bairstow study10)
· Control: 1
male, 12

enrolled i

for the ph

handicapp

Greater M

· The two g

similar in

· The child

assessed

specially

Reading a

Mathema

individua

24

dren were tested

l of 47 variables,

g mental

ng,

ication, fine

nctioning, gross

nctioning,

behaviour,

onal behaviour

help behaviour,

and after the

riod.

y lasted for two

anuary 1990. In

ion groups,

was 14 hr/week

cal programme,

week in academic

me

ion: 19 children · There were no significant differences of · Small sample

, 9 female) were improvements between the two groups size

in a conductive in Reading and Mathematics · Potential
n programme in selection bias
ham. · There were significant differences
across time for both Reading and · Drop-out and
17 children (5 Mathematics: both intervention and follow up have

female) were control group performed significantly not been

in special schools better in the second year. discussed

hysically · Blinded
ped in the method was
Manchester area.
not used in the
groups were
assessment
n age, IQ.
dren were · Evidence level:
2-
twice using

designed

and

atical tests on an

al basis with an

4

Hur 1997 31 · Non- · 36 children with cerebral interval o
randomised palsy aged 3.5 to 4.5
years old at the first · The study
controlled assessment of their skills years to J
for independence (they interventi
study were the same as those intensity
that participated in in physic
Bairstow study10) and 4hr/w
programm

· Interventi
(10 male,
enrolled i
education
Birmingh

· Control: 1
male, 12
enrolled i
for the ph
handicapp
Greater M

· The two g
similar in

· Skills for
were mea
Vineland
Behaviou
teachers’
parents w
using the
Profile 2;
three occ
1991, 199

· The prog
for two y
1990. In i
groups, in
hr/week
programm
in academ

25

of one year. · Measures on both teachers’ and parents’ · Small sample
· responses indicated that there was no · size
y lasted for two significant difference of improvement ·
January 1990. In between the two groups in their skills Potential
ion groups, for independence. · selection bias

was 14 hr/week Both groups performed significantly Drop-out has
cal programme, better “as they were getting older”. not been
week in academic discussed
me ·
Blinded
ion: 19 children method was
, 9 female) were not used in the
in a conductive assessment
n programme in
ham. Evidence level:
2-
17 children (5
female) were
in special schools
hysically
ped in the
Manchester area.

groups were
n age, IQ

r independence
asured with the
d Adaptive
ur Scales via
’ responses;
were interviewed
e Developmental
; once a year on
casions (1990,
92).

grammes lasted
year to January

intervention
ntensity was 14
in physical
me, and 4hr/week
mic programme

5

Cottam 198527 · Controlled · 14 children from a special · Interventi
study
school, who were programm
· Randomised
considered to be programm

profoundly retarded programm

multiply handicapped, principles

were assessed. They meet education

the criteria of (a) over the · Control g
age of four years, and (b) similar pr

regular attended at the not based

school over the past six education

months · The funct
· Four children were before an

excluded for the interventi

following reasons: (1) motor, co

severe visual handicap (2) and langu

inability to remain seated · The prog
at a table even with for 25 mi
restraint (3) the scores on
assessment were too near for 22 mo

the test ceiling

· The ten remaining

children were grouped as

closely as possible on the

basis of the scores

achieved on the

assessment into five

matched pairs

· “one of each pair was

randomly assigned to the

experiment group, the

other to the control

group”

· One subject in experience

group was replaced with a

“closely matched”

formerly excluded subject

26

ion group: · Teaching programmes based on · Very small

mes (drinking conductive education principles were no sample size

me and feeding more effective with profoundly retarded · The method of

me) based on multiply handicapped children than randomisation

s of conductive more traditional, individual classroom was not stated

n teaching (Wilcoxon Matched-Pairs · Heterogeneous
group completed Signed Ranks Test, P>0.05) conditions of

rogrammes but handicaps

d on conductive · The impact of
n principles the

tions were tested replacement in

nd after intervention

ion, including group has not

ognitive, social, been discussed

uage skills · Blinded

grammes lasted method was

inutes each day not used in the

onth period assessment

· Evidence level:
2-

6