RESEARCH ARTICLE

COMPARISON BETWEEN THE EFFECT OF NEURODEVELOPMENTAL

TREATMENT AND SENSORY INTEGRATION THERAPY ON GROSS
MOTOR FUNCTION IN CHILDREN WITH CEREBRAL PALSY

SHAMSODDINI Alireza Msc

Abstract
Objective
This study was planned to compare the effects of neurodevelopmental treatment
and sensory integration therapy on gross motor function in children with
cerebral palsy

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Materials & Methods
Twenty two children with spastic CP were randomly divided into two
groups. Sensory integrative therapy was given to the first group (n=11), and

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neurodevelopmental treatment was given to the second group (n=11). All
children were evaluated with GMFM-88. Treatment was scheduled for three -
one hour sessions per week for 3 months.
Results
of
Twenty two children with spastic CP (11 diplegia and 11 quadriplegia)
participated in this study. When two groups were compared, a significant
difference was found in lying and rolling (P=0.003), sitting (0.009), crawling
and kneeling (0.02) and standing ability (P=0.04). But there was no significant
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difference in walking, running, and jumping abilities between the two groups
(0.417). Paired t-tests revealed a significant difference between pre and post
test results, with increases in scores of lying and rolling, sitting, crawling and
kneeling, standing in sensory integration therapy (SIT) and neurodevelopmental
treatment (NDT) approaches.
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Master of Occupational
Therapy, Faculty of Medicine,
Conclusion
Baqiyatallah University of Medical
Neurodevelopmental treatment and sensory integration therapy improved gross
Sciences,Tehran,Iran
motor function in children with cerebral palsy in four dimensions (lying and
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rolling, sitting, crawling and kneeling, standing). However, walking, running

and jumping did not significantly improve.
Corresponding Author:
Shamsoddini A. MSC Keywords: Cerebral palsy, Children, Neurodevelopmental treatment, Gross
Baqiyatallah University of Medical motor function, Sensory integration therapy
Sciences, Department of Physical
Medicine and Rehabilitation, Introduction
Tehran, Iran Cerebral palsy (CP) is described a group of permanent disorders of the development
Tel: + 98 21 82483353, of movement and posture, causing activity limitations, which are attributed to
Fax: +98 21 88620843, nonprogressive disturbances that occurred in the developing fetal or infant brain.
Email: alirezaot@bmsu.ac.ir The motor disorder of cerebral palsy is often accompanied by disturbances of
sensation, perception, cognition, communication and behaviour, by epilepsy, and
Received: 4-Apr-2010 by secondary musculoskeletal problems (1, 2). Cp is clinically classified as spastic,
Last Revised: 28- Apr-2010 athetoid, spastic, and hypotonic (3). The primary problem in CP is gross motor
Accepted: 14-June-2010 dysfunction (4). Also, the severity of limitation in gross motor function among

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 COMPARISON BETWEEN THE EFFECT OF NEURODEVELOPMENTAL TREATMENT AND ...

children with CP, the most common physical disability, SID from occupational therapists to reduce the problems
is highly variable (5). Occupational therapy in children of impaired movement and coordination. However,
with CP is performed to avoid abnormal muscle tone and the comparison between these two methods has not
posture, treat muscle and joint deformities, and reduce yet been done. Therefore, this study was conducted to
motor and sensory disorders (6). compare the effect of the sensory integration therapy and
Currently, several approaches are used for the treatment neurodevelopmental treatment on gross motor function
of children with CP, which show promising effects on of the children with CP.
improving motor and functional activities. Among these
approaches, the neurodevelopmental treatment (7, 8, Materials & Methods
9) and sensory integration therapy (10, 11, 12, 13) are Participants
the pioneers for serving children with CP in the field of Twenty two children with spastic CP were selected
occupational therapy. from a population of individuals with CP who had been
The neurodevelopmental treatment approach for CP is followed up at Baqiyatallah Hospital. Inclusion criteria

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the most widespread and clinically accepted to target were as follows: a diagnosis of spastic CP (patient’s
the central nervous and neuromuscular systems and diagnosis of CP confirmed by an expert pediatrician and

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‘teaches’ the brain to improve motor performance skills a neurologist), no other severe abnormalities such as
and to achieve ‘as near normal function as possible’, seizure, no participation in other therapeutic programs
in view of the specific lesion in the central nervous except for occupational therapy, age between 2 and 6
system. The main purpose of this approach is to correct years, and referral to the occupational therapy clinic of
abnormal postural tone and to facilitate more normal the children with disabilities, Baqiyatallah Hospital, for
of
movement patterns for performing performance skills a 12-week course of treatment. Our exclusion criteria
(14, 15). On the other hand, sensory integration therapy were (a) receipt of medical procedures likely to affect
(SIT) is one of the rehabilitative approaches that was motor function such as botulinum toxin injections, (b)
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originally developed by A. Jean Ayres in the 1970s. The orthopedic remedial surgery, (c) mental retardation or
principles of SIT are used by occupational therapists learning disability
in developing treatment approaches for children with
sensory processing difficulties, including CP. The SIT Instrumentation
approach attempts to facilitate the normal development GMFM
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and improves the child ability to process and integrate Gross Motor Function Measure (GMFM) was used to
sensory information. It is proposed that this will allow evaluate the gross motor function of the patients. GMFM
improved functional capabilities in motor function (6). is the first evaluative measure of motor function designed
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Some studies have shown that the NDT approach is for quantifying changes in the gross motor abilities of
effective in improving measures of motor performance children with cerebral palsy (22). The measure is widely
in children with CP, especially in gross motor ability, used internationally, and is now the standard outcome
postural control, and stability (16, 17, 18, 19, 20). In assessment tool for clinical intervention in cerebral
contrast, other investigators have found that the SIT is palsy. In children with CP, GMFM has been shown to
one of the methods for promoting motor activity skills be sensitive to changes during the periods of therapy
and improving measures of motor performance in (24, 25, 26). This clinical measure consists of 88 items
children with CP because a child with cerebral palsy grouped into 5 gross motor function dimensions; lying
may experience sensory integration dysfunction as a and rolling (17 items), sitting (20 items), crawling and
result of central nervous system damage, or sensory kneeling (14 items), standing (13 items), and walking,
integration dysfunction might develop secondary to the running, and jumping (24 items). The 88 items of the
limited sensory experiences that these children have as GMFM are measured by child observation and scored
a result of their limited motor abilities (6, 21, 22). So, on a 4-point ordinal scale (0=does not initiate, 1=initiates
children with cerebral palsy frequently receive NDT and <10% of activity, 2=partially completes 10% to <100%

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of activity, and 3=completes activity). Scores for each improves balance and steady movement by training (29,
dimension are expressed as a percentage of the maximum 30). Also, in a research by shamsoddini and hollisaz, the
score for that dimension. The total score is obtained by result showed that SIT intervention had a significantly
averaging the percentage scores across the 5 dimensions. positive effect on gross motor function in children with
The entire GMFM is administered without mobility aids diplegic spastic CP (6).
or orthoses (27). Also, In Iran, this test has been used
to assess gross motor function in children with cerebral Procedures
palsy (6, 37). There is evidence to back up the reliability Ethical approval was granted to the study and informed
and validity of GMFM scores (23, 27). written consents were signed by all parents. Gross
motor abilities of the subjects were first evaluated in
NDT five dimensions (Lying and rolling; Sitting; Crawling
The NDT approach for CP is the most widespread and kneeling; Standing; Walking, running and jumping).
and clinically accepted to target the central nervous Participants were then randomly divided into two

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and neuromuscular systems and teaches the brain to experimental groups. There were 11 children in each
improve motor performance skills and to achieve as group. In one group, children were treated by NDT and

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near normal function as possible (7, 8, 9). This program in the other group, children received SIT. Duration of
includes passive stretching of lower limb muscles (e.g. the treatment for the two groups were three days a week
hamstrings, gastrosoleus), followed by techniques of for 3 months, each session being 1.5 hour and was then
reducing spasticity and facilitating more normal patterns re-evaluated by the GMFM again after the interventions.
of movements while working on motor functions. These All of patients were treated by occupational therapists
of
treatment outcomes are supposed to be achieved through with at least 8 years of experience. The treatment was
physical handling of the child during movement, giving conducted in one rehabilitation centre for all participants
the child more normal sensorimotor experiences. As in the two groups.
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the child gains postural control, the therapist gradually Statistical analysis was performed with SPSS (version
withdraws support. Handling techniques and treatment 17). Normal distribution of variables was assessed with
activities undergo continual changes as they are adapted the Kolmogrov-smirnov test. Independent sample t-test
to the responses of a particular child (28). was used for comparison of scores between two groups.
The pre and post intervention mean scores for each group
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SIT were analyzed using a paired-sample t-test, to determine

SIT is a treatment approach that was originally developed whether there were any significant differences. P-values
by Jean Ayres (10). It helps children with CP to achieve less than 0.05 were considered statistically significant.
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their optimal level of sensory and motor functioning (10,

11, 13). It is typically given by an occupational therapist Results
with training and expertise in sensory integration. SIT A total of 22 children based on the inclusion criteria
is an active therapy, and the activities usually involve were enrolled in the study and completed the course
visual-motor co-ordination training, ocular-pursuit of the treatment for 3 months. Information on sample
training, moving ball and pegboard activities, turning left characteristics including sex, type and distribution of CP
and right side and awareness of the body parts through are listed in Table 1. The SIT and the NDT group had a
touch (6, 21, 22). It is a process occurring in the brain that mean age of 3.6 years and 3.1 years, respectively. Pre-
enables children to make sense of the world by receiving, and post-treatment mean, standard deviation, minimum
registering, modulating, organizing and interpreting and maximum scores for the GMFM-88 are given in
the information that comes to their brains from their Table 2.
senses. SIT helps to overcome problems experienced The independent simple t-test showed significant
by many children in absorbing and processing sensory improvements in GMFM-88 scores in both groups
information. Encouraging these abilities ultimately in lying and rolling (P=0.003), sitting (P=0.009),

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 COMPARISON BETWEEN THE EFFECT OF NEURODEVELOPMENTAL TREATMENT AND ...

crawling and kneeling (P=0.02) and standing positions significant difference was observed in walking, running
following SIT and NDT (P=0.04). However, there were and jumping abilities before and after SIT intervention
no significant improvements in walking, running and (P> 0.05) (Table 4).
jumping (P=0.417) (Table 3). The paired t-test, used The Student t-test revealed significant changes in children
for comparing the values before and after intervention who received NDT in GMFM-88 scores of lying and
in the SIT group, revealed significant changes in rolling, sitting, crawling and kneeling, standing, and
GMFM-88 scores of lying and rolling, sitting, crawling walking, running and jumping before and after NDT
and kneeling, and standing (P> 0.05). However, no intervention (P< 0.05) (Table 4).

Table 1. Characteristics of the samples

Diplegia Quadriplegia

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Group n Male Female

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Male Female Male Female

SIT 11 6 5 3 2 3 3
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NDT 11 8 3 4 2 4 1

Total 22 14 8 7 4 7 4
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Table 2. Descriptive statistics in the SIT and NDT groups

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GMFM-88*

Group Assessment
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Mean SD** Min*** Max****

After treatment 102.1 10.7 75 122

SIT
Before treatment 117.6 9.1 103 148

After treatment 99.6 9.6 81 120

NDT
Before treatment 102.7 8.9 104 152

GMFM*, Gross Motor Function Measure; SD**, Standard Deviation; Min***, Minimum Max****, Maximum

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Table 3. Comparison of differences between groups

Mean ± SD
Group p
Before After

SIT 39±3.3 48±4.1

lying and rolling 0.003
NDT 35±3.6 47±3.9

SIT 43±4.1 52±4.3

sitting 0.009
NDT 46±4.2 55±4.7

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SIT 20±2.3 26±2.5
crawling and kneeling 0.02
NDT 22±2.5 28±2.8

standing
SIT

NDT SI
15±1.7

17±1.9
18±2.1

31±3.2
0.04
of
SIT 29±2.8 31±2.3
walking and running and jumping 0.417
NDT 31±2.9 32±3.1
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Table 4. Pre and Post GMFM-88 scores between the NDT and SIT groups
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Lying & Crawling & Walking & running &

Sitting Standing
rolling kneeling jumping
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Before 39±3.3* 43±4.1 20±2.3 15±1.7 29±2.8

GMFM scores in SIT
After 48±4.1 52±4.3 26±2.5 18±2.1 31±2.3

P Value 0.000 0.001 0.003 0.001 0.842

Before 35±3.6 46±4.2 22±2.5 17±1.9 31±2.9

GMFM scores in NDT
After 47±3.9 55±4.7 28±2.8 31±3.2 32±3.1

P Value 0.000 0.000 0.004 0.002 0.03

*Value is Means ± Standard Deviation

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Discussion and also pre and post-treatment scores of both types of

Improvement of gross motor function is one of the most treatments showed a significant improvement in gross
important aims of treating children with CP. Mainly, motor function over the 3 months of treatment with SIT
the aim of SIT and NDT is also to promote gross motor and NDT. However, this effect might be anticipated as
function for children with cerebral palsy. In this study, SIT and NDT focus on preparing, practicing, and gaining
two interventions, which were administered for 3 months new functional skills (35). Published literature shows that
in children with spasticity - distribution of diplegia and sensory integration therapy programs have been used to
quadriplegia- significantly improved their gross motor facilitate motor functions. Each type of treatment (SIT
function as measured with the GMFM-88. or NDT) might be expected to yield different changes
To the best of our knowledge, this is the first study that in motor performance. The SIT approach tries to
has compared neurodevelopmental treatment and sensory facilitate normal development and to improve the child’s
integration therapy on gross motor function of children ability to process and integrate sensory information
with cerebral palsy. Various occupational therapy (visual, perceptual, proprioceptive, auditory, etc) (36).

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methods have been applied to obtain normal motor Furthermore, one important aspect of choosing the SIT
development, to prevent postural abnormalities, sensory approach is that the motivation of the child plays a crucial

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defenses, gross motor dysfunction and deformities and role in the selection of the activities (37). In our study,
to increase functional capacity in children with cerebral comparison between pre and post intervention values
palsy (6, 16, 19, 21, 30). of walking, running and jumping showed no significant
According to the results, after comparing the two difference in NDT or SIT approaches (36). Also, in a
groups of children with CP for gross motor function, before-after study by Akbari et al. in which gross motor
of
four dimensions of gross motor function, i.e. lying and function of the subjects was assessed using GMFM, the
rolling, sitting, crawling and kneeling, and standing, results showed that a functional therapy program might
significantly improved following sensory integration be effective in increasing gross motor function and
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therapy and neurodevelopmental treatment. However, improving daily activities in children with cerebral palsy
walking, running and jumping showed no significant (38).
improvement between two groups. In a research by In conclusion, this study showed that neuro-
Ketelaar et al., a significant difference was noticed in developmental treatment and sensory integration
rolling and sitting and kneeling after neurodevelopmental therapy improved gross motor function. Four
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intervention (32). These results were consistent with our dimensions of gross motor function, including lying
study showing significant changes in lying and rolling, and rolling, sitting, crawling and kneeling, and
sitting, crawling and kneeling and standing after NDT standing, significantly improved after intervention.
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intervention. In another study, Fetters and kluzik reported However, walking, running and jumping did not
that use of neurodevelopmental approach for treating improve significantly.
children with cp caused improvement of motor functions
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