Opening doors to participation of youth with physical disabilities: An intervention study.

BACKGROUND: While participation in leisure activities is beneficial to youth's health, little is known about effective intervention strategies to promote participation. PURPOSE: The aim of this study was to examine the effectiveness of environment-based interventions on participation of youth with physical disabilities. METHOD: Six adolescents ages 14 to 17 years participated in a 12-week intervention aimed at removing environmental barriers and coaching parents. An interrupted time series design was employed and a systematic replication of the intervention effect was examined across three individualized participation goals and across participants (17 goals overall). Goal performance was measured repeatedly using the Canadian Occupational Performance Measure and analyzed using visual inspection and a celeration line approach. FINDINGS: A clinically significant improvement in performance scores (M = 4.5, SD = 1.77) was observed across all 17 goals, and a statistically significant treatment effect was replicated in 13 goals (76%). IMPLICATIONS: Findings support the effectiveness of environment-based interventions in promoting youth participation, but larger studies are required.

Psychometric properties of the Young Children's Participation and Environment Measure.

OBJECTIVE: To evaluate the psychometric properties of the newly developed Young Children's Participation and Environment Measure (YC-PEM). DESIGN: Cross-sectional study. SETTING: Data were collected online and by telephone. PARTICIPANTS: Convenience and snowball sampling methods were used to survey caregivers of children (N=395, comprising children with [n=93] and without [n=302] developmental disabilities and delays) between the ages of 0 and 5 years (mean age±SD, 35.33±20.29 mo) and residing in North America. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The YC-PEM includes 3 participation scales and 1 environment scale. Each scale is assessed across 3 settings: home, daycare/preschool, and community. Data were analyzed to derive estimates of internal consistency, test-retest reliability, and construct validity. RESULTS: Internal consistency ranged from .68 to .96 and .92 to .96 for the participation and environment scales, respectively. Test-retest reliability (2-4 wk) ranged from .31 to .93 for participation scales and from .91 to .94 for the environment scale. One of 3 participation scales and the environment scale demonstrated significant group differences by disability status across all 3 settings, and all 4 scales discriminated between disability groups for the daycare/preschool setting. The participation scales exhibited small to moderate positive associations with functional performance scores. CONCLUSIONS: Results lend initial support for the use of the YC-PEM in research to assess the participation of young children with disabilities and delays in terms of (1) home, daycare/preschool, and community participation patterns; (2) perceived environmental supports and barriers to participation; and (3) activity-specific parent strategies to promote participation.

"Do-Live-Well": a Canadian framework for promoting occupation, health, and well-being.

BACKGROUND: Occupational therapists can bring a unique and valuable perspective to the national dialogue on health promotion. Current approaches have a narrow focus on diet and exercise; a broader focus on occupation has the potential to enrich understanding regarding forces that contribute to health and well-being. PURPOSE: A new "Do-Live-Well" framework will be presented that is grounded in evidence regarding the links between what people do every day and their health and well-being. KEY ISSUES: Elements of the framework include eight different dimensions of experience and five key activity patterns that impact health and well-being outcomes. Personal and social forces that shape activity engagement also affect the links to health and well-being. IMPLICATIONS: The framework is designed to facilitate individual reflection, community advocacy, and system-level dialogue about the impact of day-to-day occupations on the health and well-being of Canadians.

Quality-of-life after brain injury in childhood: time, not severity, is the significant factor.

OBJECTIVE: Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI. METHODS: The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL. RESULTS: The QoL of children with ABI was significantly poorer (p < 0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS. CONCLUSIONS: QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.

Evidence-based practice supports among Canadian occupational therapists.

BACKGROUND: Supports for evidence-based practice (EBP) and research utilization are needed for moving evidence into practice. PURPOSE: The purpose of this study was to identify the presence of individual and organizational EBP supports (based on a previous scoping review) and the attitudes toward the supports in a convenience sample of Canadian occupational therapists. METHOD: A cross-sectional survey was used to collect data from members of the Canadian Association of Occupational Therapists. FINDINGS: Data from 368 clinicians (21%) indicated that although factors that have been shown to support EBP, such as student supervision and participation in research and mentoring, were not common practice, attitudes toward these EBP supports were positive. IMPLICATIONS: EBP supports, although viewed favourably by clinicians, have yet to be integrated fully into clinical practice. These findings provide researchers with an opportunity to design studies to support clinicians who view EBP in a positive light in integrating evidence into their practice.

Promoting an occupational perspective in public health.

BACKGROUND: Although the value of occupation for health and well-being is fundamental to the occupational therapy profession, this view is not well recognized in the field of public health. PURPOSE: In this article, we argue that occupational therapists have a unique and valuable perspective to bring to the field of public health, particularly with respect to the importance of occupational engagement in promoting the health and well-being of Canadians. KEY ISSUES: There are many compelling reasons for public health advocacy, including the need to increase awareness of the health benefits and risks of occupational engagement for individuals and communities. Challenges that lie ahead, however, include issues related to terminology, the complexity of occupation, the need to consider multidimensional outcomes, and diversity of evidence. IMPLICATIONS: To move forward, the profession of occupational therapy in Canada needs to position health promotion messaging in a way that clearly captures the complexity and value of occupation and resonates with Canadians of all ages and abilities.

Renegotiating environments to achieve participation: A metasynthesis of qualitative chronic disease research.

BACKGROUND: Qualitative studies describe environmental influences on participation in adults with chronic disease, but translating these findings into practice can be difficult. PURPOSE: This study sought to synthesize qualitative research findings regarding the influence of environmental factors on participation among adults with chronic disease. METHODS: Searching revealed 31 I articles that describe the link between environment and participation for adults with osteoarthritis, rheumatoid arthritis, diabetes mellitus, heart disease, cancer, chronic obstructive pulmonary disease, and/or depression. Study findings were analyzed using metasynthesis methods to identify themes. FINDINGS: For adults with chronic disease, renegotiating their environments and occupations to achieve, maintain, or rework their participation involves understanding support processes, being ordinary and able, navigating systems, and navigating physical environments. IMPLICATIONS: Key areas that occupational therapy interventions can target are facilitating constructive collaboration between client and support person, fostering connections with others, recognizing cultural pressure to be ordinary and able, and advocating for supportive policy and practice.

Administration of the Canadian Occupational Performance Measure: effect on practice.

BACKGROUND: The Canadian Occupational Performance Measure (COPM) is recommended as a systematic approach to identify issues and determine client progress in occupational therapy, yet little empirical evidence is available that supports this practice. PURPOSE: To determine if COPM administration was associated with changes in eight dimensions of occupational therapy practice. METHODS: Twenty-four occupational therapists on eight geriatric rehabilitation sites completed a before-and-after study with a repeated baseline. The eight practice dimensions were assessed after three months of usual care (no COPM use) and after three months of intervention (COPM use) using chart stimulated recall (CSR) interviews and chart audit. FINDINGS: Mean practice scores for CSR interviews indicated a statistically significant practice improvement (p < .0001) across the eight dimensions, including knowledge of client perspective, clinical decision making, clinician ability to articulate outcomes, and documentation. Chart audit indicated that COPM use resulted in identifying more occupation-focused issues. IMPLICATIONS: COPM administration could improve occupational therapy practice.

Context therapy: a new intervention approach for children with cerebral palsy.

AIM: To describe the development of context therapy, a new intervention approach designed for a randomized controlled trial. METHOD: Therapists were trained to change task and environmental factors to achieve parent-identified functional goals for children with cerebral palsy. Therapists did not provide any remediation strategies to change the abilities of the child. Theoretical constructs were developed using dynamic systems theory and the principles of family-centered care. A primary therapist model was used. A three-step intervention strategy was developed. RESULTS: Therapists adhered to the treatment protocol. Parents participated in the development of both functional goals and intervention strategies. INTERPRETATION: A therapy approach focusing on changing the task and the environment rather than children's impairments can be a viable treatment strategy and merits further investigation. The detailed description of the context therapy approach allows replication by both researchers and clinicians. Such intervention descriptions are an important methodological consideration in rehabilitation research.

Focus on function: a cluster, randomized controlled trial comparing child- versus context-focused intervention for young children with cerebral palsy.

AIM: This study evaluated the efficacy of a child-focused versus context-focused intervention in improving performance of functional tasks and mobility in young children with cerebral palsy. METHOD: A randomized controlled trial cluster research design enrolled 128 children (49 females, 79 males; age range 12 mo to 5 y 11 mo; mean age 3 y 6 mo, SD -1 y 5 mo) who were diagnosed with cerebral palsy. Children across levels I to V on the Gross Motor Classification System (GMFCS) were included in the study. Children were excluded if there were planned surgical or medication changes during the intervention period. Therapists from 19 children's rehabilitation centers were block randomized (by occupational therapist or physical therapist) to a treatment arm. Children from consenting families followed their therapists into their assigned group. Children received child-focused (n=71) or context-focused intervention (n=57) over 6 months, returning to their regular therapy schedule and approach between 6 and 9 months. The primary outcome measure was the Pediatric Evaluation of Disability Inventory (PEDI). Secondary outcome measures included the Gross Motor Function Measure (GMFM-66), range of motion of hip abduction, popliteal angle and ankle dorsiflexion, the Assessment of Preschool Children's Participation (APCP), and the Family Empowerment Scale (FES). Outcome evaluators were masked to group assignment and completed assessments at baseline, 6 months, and 9 months. RESULTS: Ten children did not complete the full intervention, six in the child group and four in context group. GMFCS levels for children in the study were level I (n=37), level II (n=23), level III (n=21), level IV (n=21), and level V (n=26). There were no significant differences at baseline between the treatment groups for GMFCS level, parental education, or parental income. For the PEDI, there was no significant difference between the treatment groups, except for a small effect (p<0.03) on the Caregiver Assistance Mobility subscale between baseline and 9 months. The mean scores of both groups changed significantly on the Functional Skills Scales (p<0.001) and Caregiver Assistance Scales (p<0.02) of the PEDI after the 6-month intervention. There was no additional statistically significant change on the PEDI during the follow-up period from 6 to 9 months. A subgroup effect was found for age (p<0.001), with children younger than 3 years changing significantly more than older children. GMFCS level at baseline did not influence the amount of change on the PEDI scales. There were no significant differences between the treatment groups on the GMFM, range of motion measures, APCP or FES assessments. For the GMFM, there was a significant change over time from baseline to 6 months (p<0.001) and no significant change between 6 and 9 months. There was no adverse side effect as range of motion did not decrease in either group. Hip abduction increased significantly (p<0.01) at the 9-month assessment for both groups. For the APCP, significant changes for both treatment groups were found between baseline and 6 months for play intensity (p<0.04), physical activity intensity and diversity (p<0.001), and total score intensity (p<0.01). INTERPRETATION: This study shows that child- or context-focused therapy approaches are equally effective and that frequency of intervention may be a critical component of successful intervention. Further evaluation is required to identify the various 'dose-response' relations of amount of treatment and changes in functional abilities.

Parent perspectives to inform development of measures of children's participation and environment.

OBJECTIVE: To obtain parents' perspectives on children's participation and environment to inform the development of new measures. DESIGN: Descriptive design using qualitative methods with focus groups and semistructured interviews. SETTING: Focus groups and interviews with parents of children with disabilities were held on campus, in the home, and at community agencies; interviews with parents of children without disabilities were conducted in their homes. PARTICIPANTS: Parents (N=42): parents of children with disabilities (n=25) from the United States (n=14) and Canada (n=11) and parents of children without disabilities (n=17) from the United States. Most children (93%) were aged 5 to 16 years. Children with disabilities had diagnoses characterized by psychosocial, learning, attention, and sensory-processing difficulties. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Not applicable. RESULTS: Parents described common life activities and environmental factors that were similar to and expanded on categories currently reported in the literature. Differences identified among parents mainly focused on impairments and challenges of children with disabilities and concerns related to activities and programs designed for them. Parents spontaneously talked about participation and environmental factors together. Their descriptions consistently included information about features of the physical and social environment and other factors that influenced their child's participation, such as demands of the activity, parent strategies, and the child's age, preferences, and abilities. Parents' standards and expectations for their child's participation often varied depending on the specific setting, activity, and situation. CONCLUSIONS: Findings have informed the development of a parent-report measure that explicitly links participation and environmental factors specific to home, school, and community settings. Having 1 measure to assess participation and environment rather than using distinct tools to assess each construct separately should situate the child's participation in real-life contexts.

The experience of participation in everyday occupations for adults with obesity.

BACKGROUND: Participation in occupations of everyday life, such as self-care, work, and leisure, contribute to health and well-being. Obesity has been shown to influence health-related quality of life, but it is unclear how obesity influences participation in specific occupations. PURPOSE: To describe the lived experience of adults with class III obesity and the associated impact on participation in occupations of daily living. METHODS: Ten adults enrolled in an obesity treatment program were interviewed. Data were interpreted using descriptive phenomenological methods. FINDINGS: Participants underscored the tensions, barriers, and coping strategies across and within specific occupations. Although participation across occupations of daily living was described, the quality and diversity of occupations was influenced by real and perceived barriers within the environment. IMPLICATIONS: Participation in daily occupations is limited for persons with class III obesity. Intervention approaches should address health-related concerns and consider environmental adaptations that facilitate meaningful engagement in everyday life.

Advocacy in occupational therapy: exploring clinicians' reasons and experiences of advocacy.

BACKGROUND: Occupational therapy literature encourages therapists to advocate, yet any member of the team could advocate with/for people with disabilities. There is a need to determine why occupational therapists provide these services and how they learn to advocate. PURPOSE: The objective of this article is to understand the meaning of advocacy for occupational therapists by exploring their reasons for advocating. METHODS: Interpretive phenomenology and the social model of disability were used to interview 13 occupational therapists about their advocacy experiences. Data analysis was completed using a Gadamerian-based approach. FINDINGS: Occupational therapists advocate for a number of reasons; some relate to themselves, some relate to clients, and others relate to both. Learning about advocacy may be understood as taking place on a continuum of time. IMPLICATIONS: The occupational therapist's unique reason for advocating is to facilitate the client's occupational performance. A new definition of advocacy is presented based on study findings.

A scoping review of the use of theory in studies of knowledge translation.

BACKGROUND: Advancing the science of knowledge translation (KT) in occupational therapy is critical. Explicit application of theory can advance this science; yet, how theory is applied and the degree to which it can guide research remain poorly defined. PURPOSE: To understand how theory is applied within KT research. METHODS: A scoping review was conducted to examine and summarize the extent, range, and nature of the application of three specific KT theories: Diffusion of Innovations, Promoting Action on Research Implementation in Health Services framework, and Theory of Planned Behaviour. FINDINGS: Theory use was seen most frequently in medicine and nursing. Only 3 of 90 articles were in rehabilitation. Five approaches to theory application were found, the most common being the use of to predict success of KT (57/90). IMPLICATIONS: In-depth study of the importance and methods of theory application in KT research is needed, in particular in occupational therapy.

Exploring postinjury living environments for children and youth with acquired brain injury.

OBJECTIVES: To explore and describe the extent to which children and youth (10-18y) with acquired brain injury in Ontario are living in environments considered inappropriate, to describe the nature of services and supports in those environments, and to determine appropriate living environments for children and youth with acquired brain injury. DESIGN: A mixed-methods approach with a case-study design was used in which the living environment represented the case. This article reports on the qualitative component. SETTING: Community agencies and service providers. PARTICIPANTS: Forty-four service providers across a wide range of profit and nonprofit services for children and youth with acquired brain injury throughout the province of Ontario. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Semistructured in-depth interviews with participants. RESULTS: Seven major themes emerged from the data: kids go home, a continuum of appropriateness, show me the way home, same chapter different story, cracking the acquired brain injury code, who said care was fair, and coping, and managing and advocating: new dimensions for families. Important service recommendations were also reported. CONCLUSIONS: Most children and youth with acquired brain injury are living at home. The level of appropriateness of the environment for children and youth after acquired brain injury can depend on multiple interrelated factors including type and severity of acquired brain injury, existing services and service delivery, acquired brain injury knowledge, and family's ability to cope and manage.

The participation of children and youth with disabilities in activities outside of school: A scoping review

BACKGROUND: Participation in occupations is vital for learning and development. Children with disabilities are at risk for decreased participation. PURPOSE: The purpose of this study is to examine peer-reviewed literature about the participation-based experiences of children and youth with disabilities in activities outside of formal preschool and school academics. METHOD: A scoping review was conducted to examine research studies published between 1990 and 2012. Studies included participants from 2 to 18 years who had at least one physical or intellectual/cognitive disability. FINDINGS: Forty-nine articles discussing 32 studies and three systematic reviews met the inclusion criteria. Perceptions of and influences on participation were important emerging themes about direct impacts on patterns of participation. A child or youth's level of functioning, activity level, level of enjoyment, and contextual factors were found to influence their level of successful participation. IMPLICATIONS: Occupational therapists can use the findings from this review to consider supports and barriers within interventions to enhance participation in meaningful life situations.

"My child doesn't have a brain injury, he only has a concussion".

OBJECTIVE: The term "concussion" is frequently used in clinical records to describe a traumatic head injury; however, there are no standard definitions of this term, particularly in how it is used with children. The goals of this study were to examine the clinical correlates of the concussion diagnosis and to identify the factors that lead to the use of this term in a regional pediatric center. METHODS: Medical data were prospectively collected from 434 children with traumatic brain injury who were admitted to a Canadian children's hospital. A proportional hazards regression was used to examine the association of the concussion diagnosis and the times until discharge and school return. A classification-tree analysis modeled the clinical correlates of patients who received a concussion diagnosis. RESULTS: The concussion label was significantly more likely to be applied to children with mild Glasgow Coma Scale scores of 13 to 15 (P = .03). The concussion label was strongly predictive of earlier hospital discharge (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.2-1.9; P = .003) and earlier return to school (OR: 2.4 [95% CI: 1.6-3.7]; P < .001). A diagnosis of a concussion was significantly more likely when the computed-tomography results were normal and the child had lost consciousness. CONCLUSIONS: Children with mild traumatic brain injuries have an increased frequency of receiving the concussion label, although the label may also be applied to children with more-severe injuries. The concussion diagnosis is associated with important clinical outcomes. Its typical use in hospital settings likely refers to an impact-related mild brain injury, in the absence of indicators other than a loss of consciousness. Clinicians may use the concussion label because it is less alarming to parents than the term mild brain injury, with the intent of implying that the injury is transient with no significant long-term health consequences.

Development of hand function among children with cerebral palsy: growth curve analysis for ages 16 to 70 months.

This study documents the development of hand and upper-extremity function in young children who have cerebral palsy (CP) with upper-extremity involvement using longitudinal data. Assessments of hand function and the quality of upper-extremity movement were conducted on 29 males and 22 females (mean age 36.2 months, SD 10.6; age range 16 to 60 months at baseline) and on four other occasions over 10 months. Linear mixed effects modeling was used to estimate average developmental curves and the degree of individual differences in the patterns of development which were conditional on the body-site distribution of CP and severity of impairments. Results indicate that hand function in this clinical population develops differently from overall upper-extremity skills with declines in function in upper-extremity skills being more common and pronounced among older children. However, there is substantial interindividual variation. Distribution of CP and severity of impairments were significant predictors of development. Results are discussed in terms of their clinical implications.