Margaret Wallen

Conceptualising a modified system for classification of in‐hand manipulation

Occupational therapists consider in-hand manipulation (IHM) to be an important component of fine motor skills and to be related to handwriting and self-care proficiency. These relationships have not been well explored nor has the impact of intervention including IHM skill enhancement on proficiency in motor tasks. We propose that the existing conceptualisation of IHM may contribute to a dearth of evidence in this area. This paper closely examines the existing classification systems of IHM. We propose an adaptation of Exners classification system which contains more discrete categories of IHM movements and includes: finger-to-palm translation to achieve stabilisation, palm-to-finger translation, simple shift, complex shift, simple rotation and complex rotation. Further research to test this modified classified system and to explore evidence for IHM intervention is warranted.

REACH: study protocol of a randomised trial of rehabilitation very early in congenital hemiplegia

Objectives Congenital hemiplegia is the most common form of cerebral palsy (CP). Children with unilateral CP show signs of upper limb asymmetry by 8 months corrected age (ca) but are frequently not referred to therapy until after 12 months ca. This study compares the efficacy of infant-friendly modified constraint-induced movement therapy (Baby mCIMT) to infant friendly bimanual therapy (Baby BIM) on upper limb, cognitive and neuroplasticity outcomes in a multisite randomised comparison trial. Methods and analysis 150 infants (75 in each group), aged between 3 and 6 months ca, with asymmetric brain injury and clinical signs of upper extremity asymmetry will be recruited. Children will be randomised centrally to receive equal doses of either Baby mCIMT or Baby BIM. Baby mCIMT comprises restraint of the unimpaired hand using a simple restraint (eg, glove, sock), combined with intensive parent implemented practice focusing on active use of the impaired hand in a play-based context. In contrast, Baby BIM promotes active play requiring both hands in a play-based context. Both interventions will be delivered by parents at home with monthly home visits and interim telecommunication support by study therapists. Assessments will be conducted at study entry; at 6, 12 months ca immediately postintervention (primary outcome) and 24 months ca (retention). The primary outcome will be the Mini-Assisting Hand Assessment. Secondary outcomes include the Bayley Scale for Infant and Toddler Development (cognitive and motor domains) and the Hand Assessment of Infants. A subset of children will undertake MRI scans at 24 months ca to evaluate brain lesion severity and brain (re)organisation after intervention. Ethics and dissemination Full ethical approvals for this study have been obtained from the relevant sites. The findings will be disseminated in peer-reviewed publications. Trial registration number Australian and New Zealand Clinical Trials Registry: ACTRN12615000180516, Pre results.

Eye-gaze control technology for children, adolescents and adults with cerebral palsy with significant physical disability: findings from a systematic review

ABSTRACT Purpose: The primary objective of this systematic review was to examine the effectiveness of eye-gaze control technology for facilitating communication across different social contexts for people with cerebral palsy and significant physical disability. Methods: Systematic review. Results: The search identified 756 potentially eligible articles, of which two, low level articles were eligible. One study reported positive results for achieving communication goals for children with cerebral palsy. The second concluded that eye-gaze control technology resulted in greater quality of life and less depression for adults with late stage amyotrophic lateral sclerosis when compared to non-users. Discussion: Research regarding the effectiveness of eye-gaze control technology used to access a laptop, tablet or computer on communication outcomes, participation, quality of life and self-esteem in children, adolescents and adults with cerebral palsy and significant physical disability is sparse. A scoping review to fully identify issues to inform clinical practice and future research is required.

Grading and quantification of upper extremity function in children with spasticity

The World Health Organizations International Classification of Functioning, Disability and Health (ICF) provides an ideal framework within which to conceptualize grading and quantification of upper extremity function for children with spasticity. In this article the authors provide an overview of assessments and classification tools used to (1) understand upper extremity function associated with spasticity and the factors that contribute to dysfunction, (2) guide the selection of appropriate interventions, (3) identify specific muscles to target using surgical interventions and botulinum toxin-A injections, and (4) measure the outcomes of upper extremity interventions. Assessments of upper extremity function are briefly described and categorized as to whether they (1) measure childrens best ability or actual performance in daily life, (2) are clinician administered or are a child/proxy report, (3) assist in planning intervention and/or measuring outcomes, and (4) evaluate unimanual or bimanual ability. In addition, measures of spasticity and hypertonicity, and classifications of static and dynamic upper extremity postures are summarized.

Weighted vests did not improve competing behaviours or joint attention of 2 year olds with Autism Spectrum Disorder (ASD)

Difficulties ‘withdrawing’ an intervention based on learning may be the reason for this. The design was strengthened by inclusion of a one-month follow-up. Performance variability during baseline phase may have warranted additional observations; however the Single-Case Experimental Design (SCED) Scale recommendations were met (Tate et al., 2008). Participants received seven to nine, one hour CO-OP treatment sessions. The dynamic nature of assessment and intervention occurring within the same therapy session may artificially inflate the observed performance capacity of each participant depending on the degree of prompting and facilitation being provided by the CO-OP therapist. A greater separation between intervention and assessment may yield more rigorous data during intervention phases. Use of independent ratings of client-selected goals as the primary outcome measure demonstrates ecological validity and consistency with stroke guidelines (National Stroke Foundation, 2010). Although difficulties using this method were acknowledged by the authors, the integral nature of goal setting as part of the CO-OP necessitates measurement of goal attainment as an indicator of treatment outcome. Functional performance (PQRS) improved on all goals during the CO-OP intervention phase; exceeding 2SD band on 4/9 goals immediately post-intervention, and 8/9 goals at one month follow-up. Although fewer than half the set goals demonstrated statistically significant change immediately post-intervention, participants rated a clinically significant change in performance satisfaction for 8/9 goals. Satisfaction with improving performance may be evident even before performance has achieved maximal outcome, and may contribute to increased motivation. This study adds to current evidence supporting global cognitive strategy approaches such as CO-OP, challenging occupational therapists to think beyond the traditional dichotomy of remedial vs. functional retraining in neurorehabilitation (Kennedy et al., 2008). The strategies integral to CO-OP and other similar cognitive strategy approaches appear to be beneficial for clients with occupational performance difficulties due to either cognitive or motor impairments, and may in fact promote a more integrated approach to occupational therapy intervention rather than “retraining” individual impairment areas.

Comparison of the properties of the Handwriting Speed Test (HST) and Detailed Assessment of Speed of Handwriting (DASH): An exploratory study

ABSTRACT Background: Handwriting speed is an important component of students’ ability to adequately express their ideas, knowledge and creativity in a timely and effective manner. Aims: Psychometric properties of the Handwriting Speed Test (HST) and Detailed Assessment of Speed of Handwriting (DASH) and accuracy of the norms for identifying current Australian students with handwriting speed difficulties were examined. Methods: An exploratory, cross-sectional study was conducted involving students, with and without handwriting difficulties, in Years 3–12 (mean age: 12.0 yrs, SD = 3.0 yrs; range = 7 to 18 yrs) in New South Wales (NSW; Australia). Participants were recruited through occupational therapists and schools. Students completed the HST and all DASH subtests. Results: Thirty-two students with, and 139 students without, handwriting difficulties participated. Intra-rater and inter-rater reliability were found to be excellent; sensitivity was low and specificity high for the HST and DASH. No significant differences were found between test scores and normative data for students without handwriting difficulties (year/age groups with n > 10). Conclusions: The HST and DASH are reliable assessments of handwriting speed. Further research is required into discriminant validity of the HST and DASH and need for updated norms.

Can goal setting be isolated from activity-focused intervention in cerebral palsy?

SIR–The systematic review by Carlberg and L€ owing was particularly thought-provoking and addressed a critical and contemporary issue in paediatric rehabilitation. We would like to offer some perspectives on this publication. The aim of the review was to identify if the process of goal setting could influence treatment outcome of activity-focused interventions measured by standardized assessment. The authors reported that ‘. . . none of the studies was designed specifically to determine the effect of goal setting per se,’ and it was ‘. . . difficult to separate the effect of the goal setting from the effect of intervention . . .’ as goal setting was integral to guiding the activity-focused interventions being examined. Intuitively, it is plausible that involving families in goal setting focuses attention on priority activities and may influence parents to engage with their child to focus on mastery of goals. Important and clinically useful information would result from understanding whether goal setting influences treatment outcome. As the authors didn’t find studies evaluating the effects of goal setting per se, they recommended that studies are needed which ‘. . . specifically assess the effect of goal setting on treatment outcome . . .’ Two options are possible when contemplating the highest level of evidence that would isolate goal setting as an intervention. In the first, participants would be randomized to a group participating in goal setting and no intervention, or a comparison group receiving no intervention. This option is unlikely to be palatable to participants, researchers, or ethics bodies. In the other option, participants could be randomized to goal setting and activityfocused intervention or activity-focused intervention alone to isolate goal setting as the independent variable. Activityfocused intervention, however, is reliant on goal setting to direct and focus the nature and course of intervention. Consequently, neither option is feasible, which illustrates why Carlberg and L€ owing did not locate studies evaluating goal setting per se. Another more feasible option exists, albeit providing lower level evidence. Randomized controlled trials (RCTs) with a non-treatment control group, where outcome measurement included goal attainment, would provide information of the effects of goal setting. Failure of such control groups to achieve a meaningful treatment effect in the presence of a significant between-group difference would provide evidence that goal setting alone may not influence outcomes. If, on the other hand, the control group achieved clinically meaningful outcomes, evidence may exist in support of goal setting alone influencing outcomes. Two RCTs illustrate this option, both of which were included in Carlberg and L€ owing’s review. Wallen et al.’s four-group RCT evaluated the effects of botulinum toxin-A injections, with and without occupational therapy, to the upper limbs of children with cerebral palsy. The no-treatment group failed to reach average goal achievement using Goal Attainment Scaling (GAS) at either 3or 6-month endpoints. The control group in Novak et al.’s study of home programme implementation failed to achieve any change on the GAS over the course of the study. Results from these studies suggest goal setting alone may not be sufficient to effect meaningful change. Carlberg and L€ owing concluded that their review did not ‘. . . provide support for a positive effect of goal setting . . .’ These words are reminiscent of Braithwaite’s six dangerous words in evidence-based medicine: ‘There is no evidence to suggest . . .’ The conclusion that the review failed to find support for a positive effect of goal setting could mean that the evidence reviewed was inconclusive or that the evidence suggested that goal setting did not affect outcome. The conclusion reported by Carlberg and L€ owing is not strictly incorrect but it is ambiguous and potentially, though unintentionally, misleading. Rather than failing to find support for goal setting, Carlberg and L€ owing didn’t actually find a study which addressed the review question. Alternatively, accurately reporting that they did not locate any studies which addressed the review question would have been precise, unambiguous, and clearly identified the status of available evidence. Such a conclusion provokes consideration of the intricacies of conducting research that would isolate goal setting as the independent variable in studies of activity-focused intervention. Goal setting is inherently intertwined with many current and evidence-based, activity-focused interventions for children with cerebral palsy.

Eyes on communication: trialling eye-gaze control technology in young children with dyskinetic cerebral palsy

ABSTRACT Purpose: This study aims to identify eye-gaze control technology outcomes, parent perception of the technology and support received, and gauge the feasibility of available measures. Methods: Five children with dyskinetic cerebral palsy, mean age 4 years, 4 months (1 year, 0 months); n = 4 males; trialled two eye-gaze control technology systems, each for six weeks. Parents completed pre- and post-questionnaires. Results: Parents found the 6-week home-based trial period to be the right length. Written guidelines and instructions about set-up, calibration, and play and learning activities were perceived as important. Children demonstrated improvements in goal achievement and performance. Parents found questionnaires on quality of life, participation, behaviours involved in mastering a skill and communication outcomes challenging to complete resulting in substantial missing data. Conclusion: Eye-gaze control technology warrants further investigation for young children with dyskinetic cerebral palsy in a large international study.

A magic-themed upper limb intervention for children with unilateral cerebral palsy: The perspectives of parents

ABSTRACT Aim: To explore parent’s perspective of their child’s participation in a magic-themed intervention called Amazing Magic Club (AMC), and to further our understanding of motivated engagement and the impact of themed group-based interventions for children with unilateral cerebral palsy (CP). Methods: Twenty-nine parents of children with unilateral CP completed semi-structured interviews. The child participants (n = 28) attended one of three AMCs; average age of the children was 10y 6mo (SD 2y 2mo). The parent interviews were analysed using thematic analysis. Results: The three themes are: “It’s okay to be me”, the magic effect and “I can do it”. Parents observed their children to belong and learn about their abilities. The importance of the magicians and the performance is described. Parents observed their children to have increased self-belief and a new willingness to attempt difficult tasks. Discussion: AMC appears to capture intrinsic motivation for children with unilateral CP to complete challenging tasks.

Meta-synthesis of qualitative studies concluded that the social environment was the most influential environmental factor to impact participation of youths with disabilities.

Objective: To systematically integrate multiple qualitative studies to describe perceptions of school-aged youths with disabilities of the impact of the environment and environmental modification on participation in home, school and community. Design: Meta-synthesis (unspecified theoretical framework). Methods: CINAHL, ERIC, ISI, Medline, PsycInfo and PubMed, and reference lists were searched (dates unspecified) using relevant terms related to children/youth, disability, environment and participation. Eligible studies included youth aged 3–21 years with a disability (e.g. Autism Spectrum Disorder, deafness, chronic illness; excluding learning disability), were completed in a western country and addressed participation in home, school or community and at least one ICF-defined environmental component. Following the search, an iterative process identified 15 eligible qualitative studies with conceptual congruence; study information was extracted and quality appraised. The results sections were read line by line and data extracted according to specified rules to generate an initial code list based on a subset of the articles. Constant comparison was used to code remaining articles and identify additional codes. All methods were conducted by two or more reviewers. Main findings: Included articles were interviews of youth aged 6–21 years; youth mostly had cerebral palsy or spina bifida. Study quality was predominantly moderate. Meta-synthesis suggested that three themes (all related to the social environment) influenced participation: (i) adult and peer understanding of individual abilities and needs – providing appropriately timed emotional, cognitive or physical support; (ii) decisions about accommodations – implications around whether decisions were made by youth, a professional or collaboratively; and (iii) quality of services and policies – individualised, flexible and timely services were perceived as most helpful. A framework to explain the influence of the environment on participation was constructed, which proposed that interaction across the themes and youths’ own strategies (cognitive, interpersonal, physical/object strategies) supported high or low participation. Youth based their perceptions of quality of participation on engagement alongside peers and in meaningful roles along the following continuum from high participation to low: doing what everyone else is doing, fringe participation, waiting or watching, and doing something different. Authors’ conclusions: Aspects of the social environment emerged, from the perspective of youths with disabilities, as the environmental factor most influencing participation. Participation is enhanced when others understand and respond to youths’ abilities and needs, when youth are involved in decisions about environmental accommodations, and services and policies are individualised. Contact details of original author: kramerj@bu.edu