Children with Hemiparesis Arm and Movement Project (CHAMP): protocol for a multisite comparative efficacy trial of paediatric constraint-induced movement therapy (CIMT) testing effects of dosage and type of constraint for children with hemiparetic cerebral palsy.

INTRODUCTION: The Children with Hemiparesis Arm and Movement Project (CHAMP) addresses two pressing issues concerning paediatric constraint-induced movement therapy (CIMT): effects of two dosages and two types of constraint on functional outcomes. Systematic reviews conclude that CIMT is one of the most efficacious treatments, but wide variations in treatment protocols, outcome measures and patient characteristics have prevented conclusions about potential effects of dosage levels and constraint methods. METHODS AND ANALYSIS: CHAMP is a multisite comparative efficacy randomised controlled trial of 135 children (2-8 years) with hemiparetic cerebral palsy. The 2×2 factorial design tests two dosage levels-60 hours (3.0 hours/day, 5 days/week × 4 weeks) and 30 hours (2.5 hours/day, 3 days/week × 4 weeks) and two constraint conditions-full-arm, full-time cast and part-time splint, plus usual and customary (UCT) controls, yielding five groups: (1) 60 hours CIMT+full-time cast, (2) 60 hours CIMT+part-time splint, (3) 30 hours CIMT+full-time cast, (4) 30 hours CIMT+part-time splint and (5) UCT. Trained therapists deliver the standardised ACQUIREc protocol for CIMT. Blinded assessments at baseline, end of treatment, and 6 and 12 months post treatment include the Assisting Hand Assessment, and subscales from the Peabody Developmental Motor Scales-2 and modified Quality of Upper Extremity Skills Test. Parents complete the Pediatric Motor Activity Log and Pediatric Evaluation of Disability Inventory. A new Fidelity of Implementation Rehabilitation Measure monitors treatment delivery. Data analyses involve repeated-measures multivariate analysis of co-variance controlling for selected baseline variables. ETHICS AND DISSEMINATION: Ethics boards at site universities approved the study protocol. To promote equipoise, parents of UCT controls are offered ACQUIREc after 6 months. A Data Safety and Monitoring Committee reviews results regularly, including measures of child and family stress. We will disseminate CHAMP results via peer-reviewed publications and presentations to professional and advocacy organisations. TRIAL REGISTRATION NUMBER: NCT01895660; Pre-results.

Behavioral and Physiological Factors Associated With Selective Eating in Children With Autism Spectrum Disorder.

Selective eating is common in children with autism spectrum disorder (ASD), but it is not yet well understood. The objectives of this study were to examine a new definition of selective eating, compare behavioral measures between children with ASD and selective eating and those without selective eating, and determine relationships among behavioral measures and measures of selective eating. Participants were assigned to groups on the basis of number of foods eaten compared with a population-based sample. Results of one-way multivariate analysis of variance indicated no overall effect of group for challenging behaviors, sensory reactivity, or repetitive behaviors. Between-participant tests indicated that scores for compulsive behaviors were significantly lower (p = .036) for the selective eating group. Correlations were moderately strong among variables relating to food intake and behavioral variables, but were not significant between selective eating and behavioral variables. Further research is needed to validate the definition of selective eating and to identify targets for intervention.

A systematic review of sensory processing interventions for children with autism spectrum disorders.

Children with autism spectrum disorders often exhibit co-occurring sensory processing problems and receive interventions that target self-regulation. In current practice, sensory interventions apply different theoretic constructs, focus on different goals, use a variety of sensory modalities, and involve markedly disparate procedures. Previous reviews examined the effects of sensory interventions without acknowledging these inconsistencies. This systematic review examined the research evidence (2000-2012) of two forms of sensory interventions, sensory integration therapy and sensory-based intervention, for children with autism spectrum disorders and concurrent sensory processing problems. A total of 19 studies were reviewed: 5 examined the effects of sensory integration therapy and 14 sensory-based intervention. The studies defined sensory integration therapies as clinic-based interventions that use sensory-rich, child-directed activities to improve a child's adaptive responses to sensory experiences. Two randomized controlled trials found positive effects for sensory integration therapy on child performance using Goal Attainment Scaling (effect sizes ranging from .72 to 1.62); other studies (Levels III-IV) found positive effects on reducing behaviors linked to sensory problems. Sensory-based interventions are characterized as classroom-based interventions that use single-sensory strategies, for example, weighted vests or therapy balls, to influence a child's state of arousal. Few positive effects were found in sensory-based intervention studies. Studies of sensory-based interventions suggest that they may not be effective; however, they did not follow recommended protocols or target sensory processing problems. Although small randomized controlled trials resulted in positive effects for sensory integration therapies, additional rigorous trials using manualized protocols for sensory integration therapy are needed to evaluate effects for children with autism spectrum disorders and sensory processing problems.

Effects of a classroom-embedded occupational therapist-teacher handwriting program for first-grade students.

This study examined the effectiveness of Write Start, a handwriting and writing program cotaught by teachers and occupational therapists for first-grade children. Four classrooms (n = 80) received the Write Start program, and four (n = 58) received standard handwriting and writing instruction. Two teachers and an occupational therapist implemented the 24-session manualized program, which included station teaching and individualized supports. The program emphasized practice in small groups in which the coteaching team provided students with frequent feedback, encouraged self-evaluation, and facilitated peer modeling and peer evaluation. Students who completed the Write Start program improved more in handwriting legibility and speed than the group receiving standard instruction. Writing fluency and written composition were no different between groups at posttest; however, writing fluency was significantly higher for Write Start students at 6-mo follow-up. Write Start students with low legibility at baseline made significant improvements, suggesting that the program may benefit students at risk for handwriting and writing problems.

The professional occupational therapy doctoral degree: why do it?

This article presents a rationale for the development of professional occupational therapy doctorate (OTD) programs. As more universities transition to the entry-level OTD degree, opportunities are becoming available to advance the profession and increase benefits to clients. We analyzed the current health care environment and developed the following proposed outcomes for doctoral-trained practitioners: (1) Demonstrate advanced clinical skills; (2) attain proficiency in outcomes measurement and analysis and synthesis of outcomes data; (3) routinely use standardized evidence-based practice clinical guidelines that translate research into practice; (4) develop, implement, and lead health promotion services; and (5) excel as partners in interprofessional teams.

Effectiveness of a co-taught handwriting program for first grade students.

Our study examined the effects of Write Start, a classroom-embedded handwriting/writing program on handwriting and writing fluency for first grade students, co-taught by occupational therapists and teachers. Two first grade classrooms received the Write Start and two received standard handwriting instruction. This co-taught program included specific feedback during handwriting practice, small group activities, student self-evaluation, and peer supports. The students were evaluated on handwriting legibility, fluency, and written expression at baseline, immediately after the program, and 6 months later. When performance was compared between the two groups, the students in the Write Start program improved significantly more in legibility (d = .57) and fluency (d = .75) than students who received standard instruction. Gains in handwriting speed (d = .18), average legibility (d = .26), and written expression (d = .25) did not differ significantly between the two groups. A co-taught, inclusive handwriting/writing program can promote first grade students' achievement of lower case legibility and writing fluency.

Pilot study of the efficacy of constraint-induced movement therapy for infants and toddlers with cerebral palsy.

The evidence for Constraint-Induced Movement Therapy (CIMT) effectiveness for infants and toddlers with unilateral cerebral palsy is minimal. We performed a pilot study of CIMT using one-month usual care, one-month intervention, and one-month maintenance (return to usual care) phases on five infants (7- to 18-month old). For the CIMT phase, the infants received 2 hr of occupational therapy and 1 hr of parent-implemented home program for five days/week. The infants were casted for the first 23 days, and bimanual therapy was provided for the last three days. Fine motor skills for the more affected arm and gross motor skills improved significantly during the CIMT; these gains were maintained at one-month follow-up. Individual infant data show mixed effects. This pilot study provides initial evidence that CIMT is feasible for infants with unilateral cerebral palsy, and presents preliminary data for CIMT on fine and gross motor performance.

Systematic review of interventions to promote social-emotional development in young children with or at risk for disability.

This systematic review synthesized the research on interventions used by occupational therapy practitioners to promote social-emotional development in young children (birth-5 yr) with or at risk for disabilities. After a comprehensive search of the research literature, 23 studies were reviewed and then synthesized into five themes: (1) touch-based interventions to enhance calming and parent-infant bonding, (2) relationship-based interventions to promote positive caregiver-child interactions, (3) joint attention interventions, (4) naturalistic preschool interventions to promote peer-to-peer engagement, and (5) instruction-based interventions to teach children appropriate social behaviors. The interventions for infants primarily involved coaching parents in specific strategies to promote positive interactions; interventions for preschool-age children typically involved encouraging peer support, instructing children, and applying naturalistic behavioral techniques to develop higher-level social competence. The studies demonstrated low to moderate positive effects for interventions used by occupational therapy practitioners to improve social-emotional development across ages, diagnoses, and settings.

Systematic review of interventions used in occupational therapy to promote motor performance for children ages birth-5 years.

We examined the research evidence for interventions used in occupational therapy to promote the motor performance of young children ages 0-5 yr. We identified 24 trials, Levels I-III, that met our review criteria. The studies fell into three categories: (1) developmental interventions for infants (ages 0-3 yr), (2) interventions for young children with or at risk for cerebral palsy (CP), and (3) visual-motor interventions for preschool children (ages 3-5 yr). Developmental interventions showed low positive short-term effects with limited evidence for long-term effects, and findings on the benefits of neurodevelopmental treatment were inconclusive. Interventions using specific protocols for children with CP resulted in positive effects. Visual-motor interventions for children with developmental delays (ages 3-5 yr) resulted in short-term effects on children's visual-motor performance. Of the intervention approaches used in occupational therapy, those that embed behavioral and learning principles appear to show positive effects.

Importance of tissue morphology relative to patient reports of symptoms and functional limitations resulting from median nerve pathology.

Significant data exist for the personal, environmental, and occupational risk factors for carpal tunnel syndrome. Few data, however, explain the interrelationship of tissue morphology to these factors among patients with clinical presentation of median nerve pathology. Therefore, our primary objective was to examine the relationship of various risk factors that may be predictive of subjective reports of symptoms or functional deficits accounting for median nerve morphology. Using diagnostic ultrasonography, we observed real-time median nerve morphology among 88 participants with varying reports of symptoms or functional limitations resulting from median nerve pathology. Body mass index, educational level, and nerve morphology were the primary predictive factors. Monitoring median nerve morphology with ultrasonography may provide valuable information for clinicians treating patients with symptoms of median nerve pathology. Sonographic measurements may be a useful clinical tool for improving treatment planning and provision, documenting patient status, or measuring clinical outcomes of prevention and rehabilitation interventions.

Constraint-induced movement therapy (CIMT) for young children with cerebral palsy: effects of therapeutic dosage.

OBJECTIVE: To compare effects of 2 dosage levels of constraint-induced movement therapy (CIMT) for children with hemiplegic cerebral palsy (CP). We hypothesized that high-dosage CIMT would produce larger benefits than moderate-dosage. METHODS: Three sites enrolled a total of 18 children (6 children per site from 3-6 years) with unilateral CP. Children were randomly assigned to CIMT for 21 days for either 6 hours/day (high-dosage=126 hours) or 3 hours/day (moderate-dosage=63 hours); both groups wore a long-arm cast. Evaluators (blind to dosage) assessed children 1-week prior, then 1-week and 1-month after treatment with the Assisting Hand Assessment (AHA), The Quality of Upper Extremity Skills Test (QUEST) Dissociated Movement and Grasp sections, the Shriners Hospital Upper Extremity Evaluation (SHUEE), and the Pediatric Motor Activity Log (PMAL). RESULTS: All children responded well to casting and received the full intended dosage. Both groups showed statistically significant gains on the AHA, QUEST, SHUEE, and PMAL. Effect sizes ranged from 0.36-0.79. Overall, both groups showed comparable improvements at 1-week and 1-month post-treatment. CONCLUSIONS: Pediatric CIMT at both moderate and high dosages produced positive effects across multiple reliable, valid outcome measures. The findings refuted the hypothesis of differential dosage benefits. Future research should address long-term effects, enroll larger and more diverse samples, and assess lower dosages to ascertain a minimal-efficacy threshold.

Effect of a coteaching handwriting program for first graders: one-group pretest-posttest design.

We examined the effects of a cotaught handwriting and writing program on first-grade students grouped by low, average, and high baseline legibility. The program's aim was to increase legibility, handwriting speed, writing fluency, and written expression in students with diverse learning needs. Thirty-six first-grade students in two classrooms participated in a 12-wk handwriting and writing program cotaught by teachers and an occupational therapist. Students were assessed at pretest, posttest, and 6-mo follow-up using the Evaluation Tool of Children's Handwriting-Manuscript (ETCH-M) and the Woodcock-Johnson Writing Fluency and Writing Samples tests. Students made large gains in ETCH-M legibility (η² = .74), speed (η²s = .52-.65), Writing Fluency (η² = .58), and Writing Samples (η² = .59). Students with initially low legibility improved most in legibility; progress on the other tests was similar across low-, average-, and high-performing groups. This program appeared to benefit first-grade students with diverse learning needs and to increase handwriting legibility and speed and writing fluency.

Multicenter randomized controlled trial of pediatric constraint-induced movement therapy: 6-month follow-up.

OBJECTIVE: Pediatric constraint-induced movement therapy (CIMT) is a promising intervention for children with unilateral cerebral palsy (CP). This multisite randomized controlled trial (RCT) tested the hypothesis that 6 hr versus 3 hr per day for 21 days would produce larger maintenance of gains 6 mo posttreatment. METHOD: Three sites recruited 18 children (6 per site) ages 3-6 yr with unilateral CP. Children were randomly assigned 3 to 6 hr/day of CIMT for 21 days and wore a cast on the unaffected extremity the first 18 days. Occupational therapists applied a standardized pediatric CIMT protocol. Evaluators blinded to condition administered the ASsisted Hand Assessment and the Quality of Upper Extremity Skills Test, and parents completed the Pediatric Motor Activity Log pre- and posttreatment (1 wk, 1 mo, and 6 mo). RESULTS: Both CIMT dosage groups showed significant gains on all five assessments with no significant group differences at 6 mo follow-up. Effect sizes (n = 15) comparing preintervention to postintervention measures (partial η2) ranged from .33 to .80. CONCLUSION: The first multisite RCT of pediatric CIMT confirmed the maintenance of positive effects at 6 mo follow-up across multiple functional performance measures. The hypothesis that maintenance of effects would differ for children who received 6 versus 3 hr/day of CIMT (126 vs. 63 total hr) was not supported.

Perceptions of the use of critical thinking teaching methods.

OBJECTIVE: To identify the perceived level of competence in teaching and assessing critical thinking skills and the difficulties facing radiologic science program directors in implementing student-centered teaching methods. METHODS: A total of 692 program directors received an invitation to complete an electronic survey soliciting information regarding the importance of critical thinking skills, their confidence in applying teaching methods and assessing student performance, and perceived obstacles. Statistical analysis included descriptive data, correlation coefficients, and ANOVA. RESULTS: Responses were received from 317 participants indicating program directors perceive critical thinking to be an essential element in the education of the student; however, they identified several areas for improvement. A high correlation was identified between the program directors' perceived level of skill and their confidence in critical thinking, and between their perceived level of skill and ability to assess the students' critical thinking. Key barriers to implementing critical thinking teaching strategies were identified. CONCLUSION: Program directors value the importance of implementing critical thinking teaching methods and perceive a need for professional development in critical thinking educational methods. Regardless of the type of educational institution in which the academic program is located, the level of education held by the program director was a significant factor regarding perceived confidence in the ability to model critical thinking skills and the ability to assess student critical thinking skills.

Therapeutic effects of horseback riding therapy on gross motor function in children with cerebral palsy: a systematic review.

PURPOSE: This systematic review examined the efficacy of hippotherapy or therapeutic horseback riding (THR) on motor outcomes in children with cerebral palsy (CP). METHODS: Databases were searched for clinical trials of hippotherapy or THR for children with CP. RESULTS: Nine articles were included in this review. Although the current level of evidence is weak, our synthesis found that children with spastic CP, Gross Motor Function Classification System (GMFCS) levels I-III, aged 4 years and above are likely to have significant improvements on gross motor function as a result of hippotherapy and THR. Evidence indicates that 45-min sessions, once weekly for 8-10 weeks, result in significant effects. CONCLUSIONS: The current literature on hippotherapy and THR is limited. Large randomized controlled trials using specified protocols are needed to more conclusively determine the effects on children with CP. From the current evidence, it appears that hippotherapy and THR have positive effects on gross motor function in children with CP.

Diagnostic accuracy of ultrasonography vs. electromyography in carpal tunnel syndrome: a systematic review of literature.

A plethora of research investigates sonography vs. electrodiagnostic testing (EDX) for diagnosis of carpal tunnel syndrome (CTS). Through database searches, hand searches and communication with authors, 582 abstracts published from 1999 to 2009 were identified. A comprehensive systematic review process resulted in inclusion of 23 studies. Significant methodologic discrepancies among the studies limited the ability to complete a meta-analysis to identify specific diagnostic thresholds. Instead, the data were reviewed to provide implications for clinical utility of sonography as a screening tool as a compliment to EDX and to suggest continued and future research. The largest cross-sectional area of the median nerve within the carpal tunnel region has high potential for clinical screening, especially in individuals with severe CTS. Identifying swelling of the nerve through comparative measurements, qualitative analysis and Doppler techniques all require further investigation. Screening protocols may be enhanced through exploration of sonography in patients with mild CTS and false-negative EDX.