Anne Cusick

Occupational Therapy Home Programs for Cerebral Palsy: Double-Blind, Randomized, Controlled Trial

OBJECTIVE: The goal was to assess the effectiveness of an occupational therapy home program (OTHP), compared with no OTHP, with respect to function and parent satisfaction with child function, participation, goal attainment, and quality of upper limb skill in school-aged children with cerebral palsy. METHODS: Thirty-six children with cerebral palsy (mean age: 7.7 years; male: 69%; Gross Motor Function Classification System: level I, 47%; level II, 14%; level III, 16%; level IV, 7%; level V, 16%; spasticity, 85%; dyskinesia, 14%; ataxia, 3%) were randomly and equally assigned to OTHPs for 8 or 4 weeks or to no OTHP. The primary end point was Canadian Occupational Performance Measure scores 8 weeks after baseline. Secondary measures were recorded at 4 and 8 weeks. RESULTS: Eight weeks of OTHP produced statistically significant differences in function and parent satisfaction with function, compared with no OTHP. Parents in the 4-week OTHP group did not discontinue use at 4 weeks, as instructed, and continued for 8 weeks; results demonstrated statistically significant differences, compared with no OTHP. There was no difference in primary or secondary end point measures between intervention groups. CONCLUSION: Pediatricians can advise families that OTHPs developed with a collaborative, evidence-based approach and implemented by parents at home were clinically effective if implemented 17.5 times per month for an average of 16.5 minutes per session.

A comparison of goal attainment scaling and the Canadian occupational performance measure for paediatric rehabilitation research

Purpose: To investigate the relative utility of Canadian Occupational Performance Measure (COPM) (adapted for children) and Goal Attainment Scaling (GAS) as outcome measures for paediatric rehabilitation. Methods: A two-group pre–post design investigated the impact of a 3-month programme. Forty-one children with spastic hemiplegic cerebral palsy (mean 3.9 years; GMPM level 1; 21 boys, 10 girls) were randomized to occupational therapy only and occupational therapy plus one Botulinum Toxin A injection. The latter was considered a ‘proven’ intervention for the purpose of this instrumentation study. Intervention impact was investigated using GAS and COPM. Instrument sensitivity, convergent validity, goal/problem profiles and administration were evaluated. Results: Both instruments were sensitive to within group change and detected significant between group change. Likert scale coding for GAS scores was more sensitive than the traditional weighted GAS or COPM. Different constructs were measured by each instrument. COPM was more time efficient in training, development and administration. Conclusion: Study aim, logistic and resource factors should guide the choice of COPM and/or GAS instruments as both are sensitive to change with a proven intervention and both evaluate different constructs.

Effects of Splinting on Wrist Contracture After Stroke: A Randomized Controlled Trial

Background and Purpose— Splints are commonly applied to the wrist and hand to prevent and treat contracture after stroke. However, there have been few randomized trials of this intervention. We sought to determine whether wearing a hand splint, which positions the wrist in either a neutral or an extended position, reduces wrist contracture in adults with hemiplegia after stroke. Methods— Sixty-three adults who had experienced a stroke within the preceding 8 weeks participated. They were randomized to either a control group (routine therapy) or 1 of 2 intervention groups (routine therapy plus splint in either a neutral or an extended wrist position). Splints were worn overnight for, on average, between 9 and 12 hours, for 4 weeks. The primary outcome, measured by a blinded assessor, was extensibility of the wrist and long finger flexor muscles (angle of wrist extension at a standardized torque). Results— Neither splint appreciably increased extensibility of the wrist and long finger flexor muscles. After 4 weeks, the effect of neutral wrist splinting was to increase wrist extensibility by a mean of 1.4° (95% CI, −5.4° to 8.2°), and splinting the wrist in extension reduced wrist extensibility by a mean of 1.3° (95% CI, −4.9° to 2.4°) compared with the control condition. Conclusions— Splinting the wrist in either the neutral or extended wrist position for 4 weeks did not reduce wrist contracture after stroke. These findings suggest that the practice of routine wrist splinting soon after stroke should be discontinued.

Low-dose/high-concentration localized botulinum toxin A improves upper limb movement and function in children with hemiplegic cerebral palsy.

The objective was to determine the effects of low‐dose, high‐concentration, dual localized botulinum toxin A (BTX‐A) injections on upper limb movement quality and function. Study design was an evaluator‐blinded, randomized, controlled trial. Forty‐two children (31 males, 11 females; range 2–8y, mean 4y [SD 1.6]) with hemiplegic cerebral palsy (Gross Motor Function Classification System level I) participated. All received occupational therapy. The treatment group (n=21) received one injection series (mean muscles injected 6 [SD 1.05]; total dose 82–220 units, mean 139 [SD 37.48]; dilution 100 units/0.5ml). Primary outcome of Quality of Upper Extremity Skills Test (QUEST) at 6 months was not significant (p=0.318). Secondary outcomes were average treatment effects at 1, 3, and 6 months, which favoured the treatment group: QUEST (p<0.001); Canadian Occupational Performance Measure (performance, p=0.002; satisfaction p=0.007); parent Goal Attainment Scaling (GAS; p=0.001), therapist GAS (p<0.001); Pediatric Evaluation of Disability Inventory (PEDI) functional skills (p=0.030); Ashworth (p<0.001). PEDI caregiver assistance was not significant (p=0.140). Therapy alone is effective, but at 1 and 3 months movement quality is better where BTX‐A is also used. Moreover, function is better at 1, 3, and 6 months, suggesting BTX‐A enhances therapy outcomes beyond the pharmacological effect. One‐ and 3‐month Ashworth and QUEST scores suggest precise needle placement accuracy.

Adapting the Canadian Occupational Performance Measure for use in a paediatric clinical trial.

Background. The Canadian Occupational Performance Measure (COPM) is a commonly used outcome measure in rehabilitation. In this study it was adapted for very young children by deleting paid/unpaid work and household management categories and having parents act as proxies to rate child performance and their own satisfaction. Purpose. To assess the internal consistency reliability, content and construct validity, responsiveness, and impact of half scores (20 not 10-point scale) of the adapted COPM. Method. Parent proxies of subjects aged 2 – 8 (mean 3.9) years with spastic hemiplegic cerebral palsy (n = 41) participating in a clinical trial. There was a total of 214 occupational performance problems for analysis and an additional 56 which had used half score ratings. Internal consistency reliability and construct validity were evaluated using Cronbach alpha statistic. Proxy views explored content validity. Responsiveness was evaluated using pre-post intervention scores and a comparison with Goal Attainment Scaling scores which were assumed to be a suitable benchmark measure. The effect of half scores was assessed by two-sample t-tests. Results. The COPM adaptations did not have a negative impact on internal consistency reliability as this was acceptable for performance (0.73) and satisfaction (0.83). The high Cronbach alpha scores indicated good construct validity. Content of occupations and rating approach was considered valid by proxies. Use of half scores did not result in significantly different performance ratings, but mean satisfaction ratings were significantly higher when half scores were used (p = 0.0001). This suggests that half scores may provide more precise proxy satisfaction ratings, but at the cost of rigour as internal consistency with satisfaction half scores was lower (0.63 vs. 0.82). Responsiveness to change in clinical status was demonstrated by significant pre-post scores and moderate correlations with goal attainment scores. Conclusion. The adapted COPM is a psychometrically robust tool and the use of half scores is not recommended.

Consensus research priorities for cerebral palsy: a Delphi survey of consumers, researchers, and clinicians

Aim  Research funds for cerebral palsy are scarce and competition for them is strong. This study aimed to identify questions for future research that were agreed to be a high priority.

Repeat injection of botulinum toxin A is safe and effective for upper limb movement and function in children with cerebral palsy.

The efficacy of repeated botulinum toxin A (BTX‐A) injections in two and three dose regimes, together with occupational therapy, on upper limb movement and function, was studied using an evaluator blinded, randomized, controlled two‐group trial. Forty‐two children (31 males, 11 females; range 2–8y, mean 4y [SD 1y 7mo]) with hemiplegic cerebral palsy (Gross Motor Function Classification System Level I) longitudinally participated for 30 months, with the first 6 months reported earlier (Lowe et al. 2006). The BTX‐A group (n=21) received three injections (0, 6, and 18mo), while the delayed group had two (6 and 18mo; dose 0.5‐2.1 units/kg, mean 1.5 [SD 0.18]; dilution 100 units/0.5ml). At 30 months, no difference existed between groups on any standardized measures. First and second injections showed significant treatment effect sizes, on Quality of Upper Extremity Skills Test (5.5 p=0.01: 4.5 p=0.03); parent Goal Attainment Scaling (GAS; 3.5 p=0.02: 3.9 p=0.01; therapist GAS 7.8 p=0.00: 4.0 p=0.03); Canadian Occupational Performance Measure (performance 0.4 p=0.05: 0.4 p=0.02; satisfaction 0.4 p=0.05: 0.37 p=0.08); and Pediatric Evaluation of Disability Inventory functional skills (1.8 p=0.00: 2.3 p=0.04). BTX‐A was not linked to adverse events, suggesting repeated upper limb injections in children with hemiplegia receiving occupational therapy were safe and effective for improvement of movement and function.

A systematic review of upper extremity casting for children and adults with central nervous system motor disorders

Objective: To summarize evidence on the use of upper extremity casting designed to achieve reductions in contracture, tone, pain, function, oedema or spasticity in the elbow, wrist or hand of adults and children with neurological conditions. Data sources: A search was conducted of the Cochrane Database of Systematic Reviews; the electronic databases MEDLINE, EMBASE, CINAHL, PEDro, OT-Seeker; Google Scholar; reference lists of retrieved trial reports and review articles. Review methods: Two independent reviewers determined whether retrieved study abstracts met inclusion criteria: human subjects; >50% of participants children or adults described as having brain injury, cerebral palsy or stroke. Methodological quality of randomized controlled trials was rated using the PEDro scale (1—10 highest). Results: Thirty-one papers were retrieved and 23 studies appraised: three were randomized controlled trials and four were systematic reviews. Over three-quarters of the studies, excluding systematic reviews, were lower level evidence (n = 4 level V; n = 4 level IV; n = 1 level III). Methodological quality of randomized controlled trials was high (PEDro 8, 8 and 9) and there were modest positive short-term outcomes for two trials, although they did not include no-stretch comparison conditions. Safety issues typically included pain or skin breakdown; two adverse events were not cast related. Conclusion: While theoretical rationales suggest upper limb casting should be effective there is insufficient high-quality evidence regarding impact or long-term effects to either support or abandon this practice. High variability in casting protocols indicates little consistency or consensus in practice. As maximum or low-load stretch are rationales for cast application, the absence of no-stretch conditions in existing trials is a major weakness in current evidence.

Effect of rater training on reliability of Melbourne Assessment of unilateral upper limb function scores

The aim of this study was to explore the effect of rater training on interrater reliability, internal consistency, standard error of measurement, and rater familiarity for the Melbourne Assessment of Unilateral Upper Limb Function. Twenty‐four participants (raters) were randomly assigned to either‘trained’(n=12) or‘untrained’(n=12) interventions; they then scored the same nine video recordings of children completing the instrument. The age range of the children was 5 years 5 months to 12 years; there were six males, three females, all with spastic cerebral palsy (five with quadriparesis and four with hemiparesis); Gross Motor Function Classification System levels were I (n=3), II (n=3), III (n=1), and IV (n=2). All participants were novice occupational therapists and had no previous experience of using the instrument. A significant difference in perceived test familiarity was found after scoring but not before: trained raters scored higher. A significant difference in total scores for all cases was found and in eight of 16 individual item total raw scores. Again, trained raters scored higher. Interrater reliability was high in both groups, except item 6 (untrained). Internal consistency was high in both groups, except items 6 and 9 (untrained). We conclude that training for novice users increases familiarity and results in raters’perceiving higher levels of performance in some items. The Melbourne Assessment has high reliability even for novice users.

Functional assessments utilised in emergency departments: a systematic review

BACKGROUND functional assessment is an important component of the management of older adults in the emergency department (ED) as the function level has been identified as a predictor of adverse events including ED re-presentation. A systematic review (SR) of all functional assessments utilised in EDs has not been undertaken making assessment selection, on the basis of evidence, difficult for staff. OBJECTIVE this SR: (i) identified functional assessments that have been utilised in ED settings, (ii) examined what psychometric properties analysis has been completed and (iii) established recommendations for practice. METHODS electronic database searching was completed utilising key search terms. Articles were reviewed using pre-determined inclusion criteria. Each study was appraised using quality criteria for aspects of validity and reliability in addition to clinical utility, interpretability and responsiveness. Recommendations for practice were determined on the basis of the extent of psychometric data generated in ED settings and whether or not the assessment was specifically developed for ED use. RESULTS a total of 332 articles were identified of which 43 articles utilising 14 functional assessments were retained. Psychometric testing was scarce. Functional assessment has been reported internationally and only with older adults. Following appraisal four assessments [the Identification of Seniors at Risk (ISAR), Triage Risk Stratification Tool (TRST), Older Adult Resources and Services (OARS) and Functional Status Assessment of Seniors in Emergency Departments (FSAS-ED)] were recommended for practice with moderate reservations. CONCLUSION the ISAR or TRST are suitable for fast screening, whereas the OARS or FSAS-ED are more suitable for a comprehensive understanding of functional performance. Further research is warranted and recommendations for ED assessment may change as more becomes known about psychometric properties and clinical applications of other assessments.