Natasha Lannin

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.

Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis

Objective: A systematic review and meta-analysis of randomized controlled trials to determine if motivational interviewing leads to increased physical activity, cardiorespiratory fitness or functional exercise capacity in people with chronic health conditions. Data sources: Seven electronic databases (MEDLINE, PsychINFO, EMBASE, AMED, CINHAL, SPORTDiscus and the Cochrane Central Register of Controlled trials) were searched from inception until January 2014. Trial selection: Two reviewers independently examined publications for inclusion. Trials were included if participants were adults (>18 years), had a chronic health condition, used motivational interviewing as the intervention and examined physical activity, cardiorespiratory fitness or functional exercise capacity. Data extraction: Two reviewers independently extracted data. Risk of bias within trials was assessed using the Physiotherapy Evidence Database Scale. Data synthesis: Meta-analyses were conducted with standardized mean differences and 95% confidence intervals (CIs) were calculated. The Grades of Recommendation, Assessment, Development and Evaluation approach was used to evaluate the quality of the evidence. Results: Eleven publications (of ten trials) were included. There was moderate level evidence that motivational interviewing had a small effect in increasing physical activity levels in people with chronic health conditions relative to comparison groups (standardized mean differences = 0.19, 95% CI 0.06 to 0.32, p = 0.004). Sensitivity analysis based on trials that confirmed treatment fidelity produced a larger effect. No conclusive evidence was observed for cardiorespiratory fitness or functional exercise capacity. Conclusion: The addition of motivational interviewing to usual care may lead to modest improvements in physical activity for people with chronic health conditions.

Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: international consensus statement

Upper limb spasticity affecting elbow, wrist, and finger flexors can be safely and effectively reduced with injections of botulinum toxin type‐A (BoNT‐A). It has been best studied in adults in the context of post‐stroke spasticity. The clinical benefits include reduction in pain and deformity, improvement in washing and dressing the upper limb, and a reduction in caregiver burden (Class I evidence, recommendation level A). Some patients show improvement in function performed by active movement of the affected upper limb (Class III evidence, recommendation C), but predicting and measuring this is difficult, and further research is needed. An individually based approach to treatment and outcome measurement is preferred (Class IV, recommendation U). More research is needed to resolve many unknown issues of assessment and treatment, using research methods appropriate to the question.

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.

Is hand splinting effective for adults following stroke? A systematic review and methodological critique of published research

Background: Upper limb hemiplegia after stroke is common and disabling. Hand splints are widely used to prevent contracture and reduce spasticity. Objective: To assess the effectiveness of hand splinting on the hemiplegic upper extremity following stroke. Search strategy: A search was conducted of the Cochrane Central Register of Controlled Trials; the electronic databases MEDLINE, EMBASE, CINAHL, PEDro, SCI, SSCI; websites of professional associations; reference lists in trial reports and other relevant articles. Selection criteria: Studies of the effect of upper extremity splinting on motor control, functional abilities, contracture, spasticity, or pain in the hand or wrist. Data collection and analysis: Validity of studies was assessed systematically and a content analysis was conducted of the methodologies used. Methodological quality of randomized trials was rated by two independent assessors using the PEDro scale. Results: Nineteen studies were appraised for content. Of these, most (63%) were reports of case series. Four studies (21%) were randomized controlled trials. Methodological scores of trials ranged from 2 to 8 (maximum possible score 10). One trial of nominally ‘medium’ quality reported that in‘atable arm splinting makes no difference to hand function (mean difference on Fugl-Meyer Assessment –0.12, 95% confidence interval (CI) –9.8 to 9.6). The remaining trials investigated effects of thermoplastic splints; one trial of ‘high quality’ reported no difference in contracture formation in the wrist and finger ‘exor muscles after wearing a hand splint which positioned the wrist in the traditional functional position for 12 hours each night for four weeks (mean difference in range of movement after four weeks was 1°, 95% CI –3.7° to 6.1°; power >80%). All remaining trials were of poor methodological quality. Limited research and lack of a no-splint control group in all trials to date limit the usefulness of these results. Reviewers conclusion: There is insufficient evidence to either support or refute the effectiveness of hand splinting for adults following stroke.

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.

Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke

Purpose: The upper limb items of the Motor Assessment Scale (MAS) have been shown to be a sensitive, valid and reliable measure of upper limb function for adults following stroke, however the validity and reliability of summing these items into an independent subscale has not yet been evaluated. The stability, internal consistency and construct validity of the upper limb MAS subscale (UL-MAS) was assessed in this study. Method: Twenty-seven inpatients following stroke (mean age = 67 years, range = 40 – 80) were sampled from an acute, inpatient rehabilitation setting. Patients were evaluated with ‘Upper Arm Function’, ‘Hand Movements’, and ‘Advanced Hand Activities’ items of the MAS by masked physiotherapists who had received standardized training in administration of the MAS. Results: All items were explained by one factor on confirmatory factor analysis and correlated significantly with one another and with the composite (summed total) score. Internal consistency analysis produced a Cronbachs alpha of 0.83 which did not benefit from removal of any items. Conclusions: The acceptable internal consistency score obtained verifies the validity and reliability of using the UL-MAS as an independent scale. This study has also verified the construct validity of the UL-MAS subscale and provides a valuable extension of previous work, which together demonstrates the value of the UL-MAS as a responsive, valid and reliable measure of upper limb function in adults following stroke. The UL-MAS produced a single, composite score that could be interpreted as a total score for upper limb function in this population.

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.

Functional Electrical Stimulation Improves Activity After Stroke: A Systematic Review With Meta-Analysis

OBJECTIVE To investigate the effect of functional electrical stimulation (FES) in improving activity and to investigate whether FES is more effective than training alone. DATA SOURCES Cochrane Central Register of Controlled Trials, Ovid Medline, EBSCO Cumulative Index to Nursing and Allied Health Literature, Ovid EMBASE, Physiotherapy Evidence Database (PEDro), and Occupational Therapy Systematic Evaluation of Effectiveness. STUDY SELECTION Randomized and controlled trials up to June 22, 2014, were included following predetermined search and selection criteria. DATA EXTRACTION Data extraction occurred by 2 people independently using a predetermined data collection form. Methodologic quality was assessed by 2 reviewers using the PEDro methodologic rating scale. Meta-analysis was conducted separately for the 2 research objectives. DATA SYNTHESIS Eighteen trials (19 comparisons) were eligible for inclusion in the review. FES had a moderate effect on activity (standardized mean difference [SMD], .40; 95% confidence interval [CI], .09-.72) compared with no or placebo intervention. FES had a moderate effect on activity (SMD, .56; 95% CI, .29-.92) compared with training alone. When subgroup analyses were performed, FES had a large effect on upper-limb activity (SMD, 0.69; 95% CI, 0.33-1.05) and a small effect on walking speed (mean difference, .08m/s; 95% CI, .02-.15) compared with control groups. CONCLUSIONS FES appears to moderately improve activity compared with both no intervention and training alone. These findings suggest that FES should be used in stroke rehabilitation to improve the ability to perform activities.