EFFICACY OF LCYRA® ARM SPLINTS: AN INTERNATIONAL CLASSIFICATION OF FUNCTIONING ... · SPLINTS: AN...
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CATHERINE ELLIOTT B.Sc. (Occupational Therapy)
THE UNIVERSITY OF WESTERN AUSTRALIA This thesis is presented in fulfilment of requirements for the degree of Doctor
of Philosophy at the University of Western Australia April, 2005.
Preface
Abstract This thesis consists of five experimental studies from seven data collection periods.
The first two studies quantitatively analyse children with and without cerebral palsy
using upper limb three dimensional (3D) motion analysis. Upper limb angular
kinematics and sub-structures were measured and analysed, both of which were
utilised during subsequent studies. The final three studies assess the efficacy of
lycra® arm splints using clinical assessments, 3D dimensional upper limb kinematics
and 3D sub-structures.
Study 1 analysed 3D movement sub-structures in children with and without cerebral
palsy. The objective of this study was to provide normative 3D data on movement
sub-structures (absolute jerk, normalised jerk, percentage of jerk and time in primary
and secondary movements, peak velocity, peak velocity as a percentage of distance
in the primary movement, path directness, movement time, task displacement and
task distance). The aim of the study was to quantitatively analyse movement sub-
structures in children with and without cerebral palsy during four functional tasks
taken from the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne
Assessment - Randall, Johnson & Reddihough, 1999). Movement substructures
showed a significant difference in children with and without cerebral palsy and
demonstrated that motion analysis, and particularly movement sub-structures can
precisely quantify movement deficits.
Study 2 reported 3D angular kinematics together with data from the Melbourne
Assessment (Randall et al., 1999) in children with and without cerebral palsy. The
primary objective of this study was to establish normative 3D angular kinematic data
and to further confirm the validity of the Melbourne Assessment (Randall et al.,
1999). The first aim of this study was to quantitatively analyse 3D trunk and upper
limb (shoulder, elbow and wrist) angular kinematics in children with and without
cerebral palsy during five functional tasks taken from the Melbourne Assessment
(Randall et al., 1999). The second aim of the study was to review the operational
performance standards of the Melbourne Assessment (Randall et al., 1999). This
was done by comparing the scoring criteria for range of motion from the Melbourne
Assessment with 3D angular kinematics of children with no known neurological
impairment, as well as by comparing the total percentage scores of these children on
the Melbourne Assessment with the expected mean of 100%. Results demonstrated
significant difference in the mean score of children with no known neurological
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condition and the expected mean of 100% on the Melbourne Assessment.
Inconsistencies were also established in the scoring criteria for range of motion and
the actual performance of children with no known neurological condition measured
by 3D motion analysis. Results demonstrated significant differences in angular
kinematics in children with and without cerebral palsy, while the methodology
developed in this study provided improved insight into the movement of the upper
limb and trunk during functional tasks.
Study 3 reported a randomised controlled trial of lycra® arm splints in children with
cerebral palsy across all levels of the International Classification of Functioning
Disability and Health (ICF). Active and passive range of motion and the Melbourne
Assessment were used to measure change at the level of impairment. The
Functional Independence Measure for Children assessed change at the level of
activity and the Goal Attainment Scale was employed at the participation level. The
ICF Checklist provided a functional profile of the children in the study as well as
identifying environmental and contextual factors that may have impacted on the
outcome of the study. The parental, teacher and child questionnaire were used to
collect data from the point of view of the family, child and teacher about the efficacy
of lycra® splints at all levels of the ICF. Lycra® arm splints were shown to have a
statistically significant impact at the level of participation, whereas no significant
difference was seen at the level of impairment and activity.
Study 4 reported a randomised controlled trial of the effects of lycra® arm splints on
3D movement sub-structures during functional tasks in children with cerebral palsy.
The purpose of this study was to measure changes in movement sub-structures and
quality of upper limb movements in children with cerebral palsy at baseline, initial
splint application, 3 months after lycra® splint wear, on immediate splint removal
following this 3 months and 3 months post splint wear. Three-dimensional upper limb
and trunk kinematic data were recorded using a seven camera Vicon motion analysis
system. Movement substructures during tasks taken from the Melbourne
Assessment were analysed from 3D movements of the wrist joint centre. A full
Melbourne Assessment was also completed across all treatment conditions. A
significant difference was established between baseline and 3 months after lycra®
splint wear for the movement substructures; movement time, percentage of time and
distance in primary movement, jerk index, normalised jerk and percentage of jerk in
primary and secondary movements. These substructures moved closer to the motor
behaviour of children without cerebral palsy at 3 months after lycra® splint wear.
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Lycra® arm splints when worn as part of a goal directed training program for 3
months made a significant, positive difference to some movement sub-structures in
children with cerebral palsy. This research demonstrated that movement sub-
structures (including movement time) can be quantified and are amenable to change
with intervention.
Study 5 reported a randomised controlled trial of the effects of lycra® arm splints on
angular kinematics (thorax, shoulder and elbow) during functional tasks in children
with cerebral palsy. Sixteen children with cerebral palsy (hypertonia) were assessed
using 3D motion analysis at baseline, initial splint application, after 3 months of
lycra® splint wear, on immediate splint removal following this 3 months and 3
months post splint wear. For some of the tasks wearing a lycra® splint had a
positive effect on angular kinematics (thorax, elbow and shoulder) in children with
cerebral palsy. These effects were only observable after 3 months of splint wear and
following a period of goal directed training. The benefits of the splint on angular
kinematics were only apparent when worn for the 3 month period, as minimum
evidence was established for the short-term (1hour) and long term (3 month post
splint wear) carry-over effects.
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Acknowledgements I would like to acknowledge my two supervisors, Dr Jacque Alderson and Professor
Bruce Elliott. It has been a fantastic opportunity and an amazing learning experience
working with you both. Thanks and acknowledgment to Professor Peter Hamer for
his support in the modification of the 2D jerk analysis software. I would also like to
thank Si Reid, the fabulous biomechanist who taught me so much about 3D motion
analysis and managed to bridge the gap between clinical and hard science. Thank-
you also to all the staff in the school of Human Movement and Exercise Science for
all the help along the way.
I would like to acknowledge and thank all the children and their families who
participated in the study. All their time and energy spent during the assessment
sessions and at home carrying out the program was integral to the success of this
research. I would also like to thank Princess Margaret Hospital for Children,
especially the Department of Development Medicine and Rehabilitation, Physical and
Occupational therapy for their ongoing support of this research.
I would like to thanks to my parents Carol and John Newton-Smith for their tireless
support with the thesis especially the editing and referencing. Thank-you, to my
husband, Craig Elliott for making everything beautiful and believing in me. Without
your ongoing support in every way I would have never been able to make it through
this process. Thank-you also to all of our friends and family who have put up with us
both through the thesis and helped in so many ways to make the journey fun!
I would also like to acknowledge the Occupational Therapy Board of Western
Australia for their financial assistance with the project.
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Table of Contents
Abstract ……………………………………………………………………………………….i
Acknowledgements ….……………………………………………………………………..iv
Table of Contents …………………………………………………………………………...v
List of Tables ………….……………………………………………………………….…..viii
List of Figures ………………………………………………………………………………..x
Chapter 1:
The Problem
1.1 Introduction ………………………………………………………………………....1
1.2 Aims …………………………..………………………………………….................5
1.3 Overview of thesis structure ………………………………………………………6
1.4 Definition of key terms ……………………………………………………………..7
1.5 Delimitations and Limitations ……………………………………..………………8
Chapter 2:
Review of the related literature
2.0 Introduction ………………………………………………………………………….9
2.1 Upper limb splinting in cerebral palsy …………………………...……………….9
2.2 Evidence based practice review: Upper limb splinting …………………….....15
2.3 Measurement tools ………………………………..……………………………...20
2.4 Variables of interest at the impairment level …………………………………..42
2.5 Conclusion ………………………………………………………………………...48
Chapter 3:
Three dimensional quantification of movement variables during function in children
with and without cerebral palsy
Abstract ……………………………………………………………………………………..50
Introduction ………………………………………………………………………………...51
Methods …………………………………………………………………………………….54
Data Analysis ………………………………………………………………………….......59
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Results …………….………………………………………………………………………..59
Discussion ………………………………………………………………………………….65
Chapter 4:
Application of the Melbourne Assessment and 3D upper limb motion analysis in
children with and without cerebral palsy
Abstract ………………………………………………………………………….………….69
Introduction ………………………………………………………………………………...70
Methods …………………………………………………………………………………….73
Data Analysis ………………………………………………………………………………77
Results ………………………………………………………………………….................81
Discussion …………………………………………………….……………………...........97
Chapter 5:
A randomised controlled trial of lycra® arm splints in children with cerebral palsy
across all levels of the International Classification of Functioning Disability and
Health
Abstract …………………………………………………………………….……………..101
Introduction …………………………………………………………………………........102
Methods …………………………………………………………………………...……...107
Data analysis …………………………………………………………….…..…………...112
Results ………………………………………………………………………...................115
Discussion …………………………………………………………………………..........122
Chapter 6:
A randomised controlled trial of the effects of lycra® arm splints on children on
movement substructures during functional tasks in children with cerebral palsy
Abstract …………………………………………………………………………………...127
Introduction …………………………………………………………………………........128
Methods ………………………………………………………………………….............134
Data Analysis ………………………………………………………………..…………...140
Results ……………………………………………………………………….…………...142
Discussion ……………………………………...………………………………………...150
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Chapter 7:
A randomised controlled trial of the effects of lycra® arm splints on trunk and upper
limb angular kinematics in children with cerebral palsy
Abstract …………………………………………………………………………..............156
Introduction …………………………………………………………………………........157
Methods …………………………………………………...……………………………...162
Data Analysis ………………………………………………………………………….....170
Results …………………………………………………………………………………....174
Discussion ……………………………………………………………………………......186
Chapter 8:
Synthesis of results………………………………............………………………….......192
References: References……………………………………………………………………….………..196
Appendices: Appendix A: (Information and Informed Consent Documents
for children with cerebral palsy) …………………………………...……………………227
Appendix B: (Information and Informed Consent Documents
for children without cerebral palsy) …………………………………………………….230
Appendix C: (Abbreviations, Greek letter and symbols) …………………….…….234
Appendix D: Glossary of key terms ………………………………………………….236
Appendix E: Melbourne Assessment score sheet …………………………………239
Appendix F: Sample scoring criteria for the Melbourne Assessment ……..……..241
Appendix G: Advertorials ……………………………………………………………...243
Appendix H: Residual analysis …………………………………………………..…..244
Appendix I: Sites / Resources Searched …………………………………………..245
Appendix J: A Pilot Study to Investigate Goals, Outcomes and
Influence of Environmental Factors from the
perspective of the Family, Child and Occupational
Therapist during a Lycra® Arm Splint Program ………………………………...…….246
Appendix K: Repeatability of a 3D Upper Limb Kinematic Model ……………..…254
Appendix L: A pilot study to investigate the intra-subject
repeatability of upper limb 3D motion analysis
within a test day for children with and without
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cerebral palsy …………………………………………………………………………….255
Appendix M: Parent, Child and Teacher Questionnaire …………………………...258
Appendix N: Goal Directed Training …………………………………………………260
Appendix O: Technical Proficiency Checklist ……………………………………….261
Appendix P: Coding of questionnaire ………………………………………………..262
Appendix Q: Example of Goal Attainment Scale……………………………………265 Appendix R: ICF Checklist ……………………………………………………………268
Appendix S: WeeFIM Instrument Rating Scale …………………………………….283
Appendix T: The Goal Attainment Score ……………………………………………284
Appendix U: Intra-rater reliability of the Melbourne Assessment of Unilateral
Upper Limb Function ……………………………………………………………………..285
List of Tables Chapter 2:
2.0 Study designs of relevant articles ……………………………..........................17
Chapter 3:
3.1 Descriptive data of participants who have cerebral palsy …………………...54
3.2 Mean data for all movement tasks for children with
and without cerebral palsy ………………………………………….……………60
3.3A Mean descriptive data, for the task reach forwards for children
with and without cerebral palsy ..……………………...………………………...61
3.3B Mean descriptive data, for the task reach forwards to an
elevated position for children with and without cerebral palsy ….……….…..61
3.3C Mean descriptive data, for the task reach sideways to an
elevated position for children with and without cerebral palsy …………..…..61
3.3D Mean descriptive data, for the task hand to mouth and down,
for children with and without cerebral palsy ………………………………..….62
Chapter 4:
4.1 Conversions of Vicon Body Builder Data ..……………………………………..80
4.2 Percentage scores on the Melbourne Assessment for
each sub-population ……………………………………………………………...82
4.3A Melbourne Assessment Task: Reach forwards,
maximum angle ……...……………………………………………………………84
4.3B Melbourne Assessment Task: Reach forwards,
to an elevated position, maximum angle ……………………………………….84
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4.3C Melbourne Assessment Task: Reach sideways
to elevated position, maximum angle ……………………………………..……85
4.3D Melbourne Assessment Task: Pronation / supination,
maximum angle ……..………………………………………………………….…85
4.3E Melbourne Assessment Task: Hand to mouth and down,
maximum angle ………………..………………………………………………….86
4.4A Total range of movement, for the task, reach forwards ..……………………..89
4.4B Total range of movement for the task,
reach forwards to an elevated position……………….…………………………90
4.4C Total range of movement for the task,
reach sideways to an elevated position…………………………………………91
4.4D Total range of movement for the task,
pronation / supination ……………………………………………………..……...92
4.4E Total range of movement for the task,
hand to mouth and down ……...………………………..……………………….93
Chapter 5:
5.1 Themes for Questionnaire using the ICF Framework ……………………....114
5.2 Passive range of motion across all treatment conditions …………………...115
5.3 Active range of motion across all treatment conditions ……………………..115
5.4 Intervention, actual splint wearing regime,
as identified by parents and teachers ………………………………………...121 5.5 Environmental factors …………………………………………………………..122
Chapter 6:
6.1 Descriptive details of participants in the study …………………………….....135
6.2 Descriptive statistics of sub-movements, across all treatment conditions ………………………..……..………………..142
Chapter 7:
7.1 Descriptive details of the sample of children in the study …………….…….163
7.2 Conversions of Vicon Body Builder Data ……………………………………..174
7.3 Maximum and total range of elbow extension (degrees) across
all treatment conditions …………………………………………………...…….175
7.4 Maximum and total range of elbow pronation (degrees) across
all treatment conditions …………………………………………………………179 7.5 Maximum and total range of elbow supination (degrees) across
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all treatment conditions …………………………………………………………180
7.6 Maximum and total range of shoulder flexion (degrees) across
all treatment conditions …………………………………………………………181
7.7 Maximum and total range of shoulder abduction (degrees) across
all treatment conditions …………………………..……………………………..182 7.8 Maximum and total range of thorax flexion (degrees) across
all treatment conditions …………………………………………………………183 7.9 Maximum and total range of lateral thorax flexion (degrees) across
all treatment conditions …………………………………………………………184 7.10 Maximum and total range of lateral thorax rotation (degrees) across
all treatment conditions …………………………………………………………185
List of Figures Chapter 1:
1.0 Interaction of concepts …………………………………………….……………....1
Chapter 2:
2.0 Supination-extension lycra® arm splint ………………………………….……..14
Chapter 3:
3.1 Static calibration marker set, represented photographically
and by the reconstructed marker and joint centre positions
in Vicon Workstation (the wrist joint centre is represented in red) ………… 56
3.2 Figure includes wrist joint centre velocity, acceleration, jerk
and 3D trajectory used to identify the primary movement …………………....58 3.3 Three-dimensional trajectories of the wrist joint centre for children,
with cerebral palsy (A) and for children without cerebral palsy (B) ….………63
3.4A Acceleration and jerk trace for a child without cerebral palsy,
during the task reach sideways to an elevated target ………………...………64
3.4B Acceleration and jerk trace for a child with cerebral palsy,
during the task reach sideways to an elevated target ……………………...…65
3.5 Typical velocity and acceleration curve for a child
without cerebral palsy……………………………………………..……………...68
3.6 Typical velocity and acceleration curve for a child
with cerebral palsy ……………………………………………………………...68
Chapter 4:
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4.1 Room set up…………………………………………………………………..……75
4.2 The figure on the left is a participant with the static marker
set, the figure on the right is a polygon animation of the participant
with the markers represented by white circles ………………..………….……76
4.3 A static ‘pointer’ trial using the standardised rod to point at
the medial and lateral epicondyle landmarks ……………………………..…..76
4.4 Upper arm model, left figure representing markers,
right figure representing joint centre and coordinate
system………………………………………………………………………………78
4.5 Shoulder wing segment …………………………………………………..……...79
4.6A Upper limb and thorax angles for the task, hand to mouth and down ...…….94
4.6B Upper limb and thorax angles for the task pronation / supination …………...95
4.6C Upper limb and thorax angles for the task, reach sideways to an elevated position …….………………………………….96
Chapter 5:
5.1 Lycra® arm splint ………………………………………………………………..102
5.2 Study design ……………………………………………………………………..108
5.3 Melbourne Assessment scores across all treatment conditions …...………116
5.4 Goal Attainment scores Group 1 and Group 2 ……………………………….117
5.5 Parent, teacher and child response to question, 1 on the
questionnaire “Do you think the splint makes a difference?”……..…………118
5.6 Benefits and disadvantages of the splint from the perspective of
the parent, teacher and child …………………………………………………..120
5.7 Parent, teacher and child response to question 3 on the questionnaire
“What do you think about wearing the splint?”………………...……...……..120
Chapter 6:
6.1 Study design ……………………………………………………………………..136
6.2 Static marker set, (yellow circles on the right section of the figure
represent markers and the red circle represents the wrist joint centre) …...138
6.3 Percentage of time in primary movement across all treatment
conditions………………………………………………………………………....144 6.4 Percentage of jerk in primary movement across all
treatment conditions ………………………………………………………….....144
6.5A 3D trajectory for a child with cerebral palsy at i. Baseline, ii.
Initial splint wear, iii. 3 months of splint wear,
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iv. Immediate splint removal ……………………………………………………145
6.5B Velocity, acceleration and jerk trace for child with
(baseline, initial, 3 months and initial off) and without cerebral
palsy (reach sideways) …………………………………………………………146
6.6 Percentage of jerk in primary movement across all treatment
conditions …..…………………………………………………………………….147
6.7 Normalised jerk and percentage of time in primary movement in subpopulations of children with cerebral palsy ……………………………..149
Chapter 7:
7.1 Upper limb posture of child with cerebral palsy - right hemiplegia ...……....157
7.2 Lycra® arm splint ………………………………………………………………..158
7.3 Study design ……………………………………………………………………..165
7.4 Camera configuration, for 3D motion analysis ……………………………….166
7.5 Static marker set, showing a re-creation of the markers
(pink) on the left and photographically on the right ……………………….....168
7.6 Static ‘pointer’ trial, identifying the left lateral epicondyle ….………………..169
7.7 Joint centres (red) and coordinate systems are displayed on
the left figure and markers (grey) on the right figure ………………………...172
7.8 The shoulder wing is highlighted in green, it is the plane
connecting the mid thorax, acromion and the shoulder joint centre ……….173
7.9 Reach forwards to an elevated position, (elbow flexion / extension)
for children without cerebral palsy and for children with cerebral palsy
at baseline, initial splint wear, 3 months after splint wear and
immediate splint removal………………………………………………………..176
7.10 Mean maximum elbow extension for the three reaching tasks …………….177
7.11 Supination / pronation task (elbow angle, supination / pronation),
for children without cerebral palsy and for children with cerebral palsy
at baseline, initial splint wear, 3 months after splint wear and immediate
splint removal ……………………………………………………………………180
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CHAPTER 1: INTRODUCTION
1.1 Introduction The International Classification of Functioning, Disability and Health (ICF) is part of the
World Health Organisation family of International Classifications. The overall aim of the
ICF is to provide an international standard to measure health and disability (World
Health Organisation, 2001a). It defines different domains for a person with a given
health condition from the perspective of the body, individual and society. These health
domains or health related domains are described as ‘body functions and structures’ and
‘activities and participation’ as seen in Figure 1.0.
Figure 1.0: Interaction of concepts (WHO, 2001a)
The ICF recognises the importance of contextual factors (environmental and personal) in
facilitating function or creating barriers for people with a disability (WHO, 2000).
Disability is an umbrella term for impairments, activity limitations or participation
restrictions (Boyd & Hays, 2001).
Cerebral palsy is the most common physical disability in childhood with the incidence in
Western countries at between 2 and 2.5 per 1000 live births (Hagberg, Hagberg,
Beckung & Uvebrant, 2001). It is a non-progressive permanent neurological disorder
caused by damage to the immature brain (Mayston, 2001; Stanley, Blair & Alberman,
2000). Impairments present in children with cerebral palsy occur as a direct result of the
brain injury or indirectly to compensate for underlying problems including; abnormal
muscle tone, limited variety of muscle synergies, contractures, altered biomechanics,
lack of fitness, loss of speed of movement, associated and mirror movements and
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hypertonicity, with the net result being limited functional ability (Brown & Walsh, 2000;
Mayston, 2001). Intervention to minimise impairments include therapy (splinting,
strengthening, positioning), selective surgery and pharmacology (O’Flaherty & Waugh,
2003). Splints are devices added to the body to support, position, or immobilise a part,
to prevent contractures and deformities, to assist weak muscles and restore function or
to reduce spasticity (Trombly, 1989). Lycra® arm splints are designed and fabricated in
Australia by Second Skin™. They comprise a series of lycra segments sewn together in
an orientation appropriate to produce a low force to resist the spastic muscle, while also
facilitating the antagonist muscles (Gracies, Marosszeky, Renton, Sandanam, Gandevia
& Burke, 2000; Wilton, 2003).
The goal of lycra® splinting is to facilitate functional movements during daily activities by
impacting on tone, posture and patterns of movement (Scope, 2001). As disability
affects the individual at several levels of the ICF this research aims to develop a
comprehensive and useful understanding of the intervention of lycra® arm splints in
children with cerebral palsy by employing measures at all levels of the ICF.
There is considerable variation in splinting practices and an ongoing debate on the value
of splinting for clients with neurological dysfunction. The reason for this is the paucity of
objective evidence regarding the therapeutic value of neurological splinting (Hill, 1988;
Mathiowetz, Bolding & Trombly, 1983; Reid, 1992a; Reid, & Sochaniwskj, 1992; Wallen
& O’Flaherty 1991; Wilton & Dival, 1997). The major flaw in the existing body of
literature on the effectiveness of splinting clients with upper limb hypertonicity is the lack
of reliable, valid and sensitive assessment tools.
Current best practice outcome measures for health related attributes include:
• Impairment: Melbourne Assessment of Unilateral Upper Limb Function (Randall,
Johnson & Reddihough, 1999); three dimensional (3D) motion analysis and range
of motion.
• Activity: Functional Independence Measure for Children (WeeFIM, Uniform Data
Set for Medical Rehabilitation, UDSMR, 1993).
• Participation: Goal Attainment Scale (Kiersuk, Smith & Cardillo, 1994).
• Environment: ICF Checklist (Version 21a Clinician Form, WHO, 2001b).
These various assessment tools demonstrate relevance to the population and
intervention being addressed; however, they have variable criteria of adequacy (validity,
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reliability, precision range, feasibility and practicality). Before these measures can be
used with confidence to determine the efficacy of lycra® arm splints further testing of the
adequacy of outcome measures is required.
The first part of this thesis addresses the criteria of adequacy of the Melbourne
Assessment and establishes a normative data base for 3D upper limb motion analysis.
These measures are then employed in the second half of the thesis to investigate the
efficacy of lycra® splints in children with cerebral palsy.
Three dimensional motion analyses is a powerful tool for a quantitative assessment of
movement in all degrees of freedom (Rau, Disselhorst & Schmidt, 2000). Vicon 370
(Oxford Metrics Ltd, Oxford, U.K.) is a 3D commercial motion analysis system that
employs a passive optical marker system to provide a visual record of body segment
positions (Anglin & Wyss, 2000). Testing has shown Vicon 370 (Oxford Metrics Ltd,
Oxford, U.K.) is a valid and reliable tool in the measurement of movement (Ehara,
Fujimoto, Miyazaki, Mochimaru, Tanaka & Yamamoto, 1997; Reid, Elliott, Alderson,
Hamer & Lloyd, 2004; Richards 1999). Three dimensional motion analysis is employed
as a standard measurement tool in the detailed diagnosis and treatment of gait in
children with cerebral palsy (Rau et al., 2000, Ỏunpuu, DeLuca & Davis, 2000).
Relatively few upper limb studies have been performed, particularly whole arm studies,
despite the importance of the upper limb in daily life (Anglin & Wyss, 2000).
To date there is minimal research investigating 3D angular kinematics (thorax, shoulder,
elbow and wrist) and 3D movement substructures in children with and without cerebral
palsy. Before 3D motion analysis can be used to measure the effectiveness of treatment
in a clinical population, normative data are required. Normative data assist in the
interpretation of clinical data, as it is through a comparative process with normative data
that the direction of change in a clinical population can be established. As development
is vertical, sequential and hierarchal, research in a paediatric population requires
comparison of individuals of the same age (Stein & Cutler, 2000). The first goal of the
thesis is to establish normative data for 3D angular kinematics (thorax, shoulder, elbow
and wrist) and 3D sub-structures for typically developing children aged between 5 to 15
years old. The second goal of the thesis is to compare the 3D angular kinematics and
sub-structures in children with and without cerebral palsy.
The Melbourne Assessment (Randall et al., 1999) is a relatively new assessment tool
designed to score quality of unilateral upper limb motor function in children with
neurological impairment. It’s responsiveness to detect change over time has not yet
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been established for children with cerebral palsy. For a test to be used to determine the
effectiveness of an intervention, the score must change in proportion to the patient’s
status change and remain stable when the patient’s status is unchanged (Portney &
Watkins, 2000). The third goal of this thesis is to further develop the sensitivity of the
Melbourne Assessment (Randall et al., 1999) so it can be used with confidence to detect
clinically significant change in clinical research in a population of children with cerebral
palsy.
The Melbourne Assessment (Randall et al., 1999) is a criterion based assessment
where performance of an individual is compared with a specified level of mastery or
achievement as outlined in the scoring criteria (Randall et al., 1999; Stein & Cutler,
2000). These operational performance standards are obtained by surveying a
representative sample of the general population (Stein & Cutler, 2000). No research has
been published on the representative sample employed to obtain the operational
performance standards for the Melbourne Assessment (Randall et al., 1999). The fourth
goal of this study is to review the operational performance standards outlined in the
Melbourne Assessment by comparing the scoring criteria with the performance of
typically developing children.
The major flaws with past research in the area of neurological upper limb splinting relate
closely to the lack of valid and reliable outcome measures for this population. This study
will provide further validity testing for the Melbourne Assessment (Randall et al., 1999)
and develop normative data for 3D upper limb motion analysis. This will enhance best
practice in the area of paediatric neurology in assessment, research and clinical care.
The second part of the thesis will employ previously mentioned measures to evaluate
the efficacy of lycra® arm splints in children with cerebral palsy. Lycra® arm splints are
prescribed by occupational therapists to optimise client’s function and independence.
No randomised controlled trial has documented their efficacy in children with cerebral
palsy, yet they are used clinically in this population based on anecdotal evidence. The
fifth goal of this research it to provide objective data on the efficacy of lycra® arm splints
at the level of impairment, activity and participation in children with cerebral palsy. The
measures of 3D motion analysis (angular kinematics and sub-structures), the Melbourne
Assessment (Randall et al., 1999) and range of movement will be used to investigate the
efficacy of lycra® arm splints at the ICF level of impairment. The WeeFIM will be
employed at the level of activity and the Goal Attainment Scale and Parental
Questionnaire at the level of participation. The ICF Checklist will be employed to provide
4
a functional profile of the children in the study, as well as to identify environmental and
contextual factors that impact on the outcome of the study.
This thesis presents an objective multifaceted approach to the measurements of
impairment, activity and participation, which might be impacted on through the wearing
of a lycra® arm splint. The research outcomes will therefore assist occupational
therapists in being able to provide optimal client management in the area of neurological
splinting based on objective evidence.
1.2 Aims This research comprises five separate but interrelated studies.
The aims of study one were to:
• Establish normative data for 3D movement sub-structures (absolute jerk,
normalised jerk, percentage of jerk in primary and secondary movement,
percentage of time in primary and secondary movement, peak velocity, peak
velocity as a percentage of distance in the primary movement, path directness,
movement time, task displacement and task distance) in children aged 5 to 15
years old, with no known neurological impairment.
• Compare 3D movement sub-structures in children with no known neurological
impairment and children with cerebral palsy (hemiplegia) aged 5 to 15 years old.
The aims of study two were to:
• Establish normative data for 3D angular kinematics (thorax and shoulder, elbow
and wrist joints) in children aged 5 to 15 years old, with no known neurological
impairment.
• Compare 3D angular kinematics in children with no known neurological
impairment and children with cerebral palsy (hemiplegia) aged 5 to 15 years old.
• Review the operational performance standards of the Melbourne Assessment
(Randall et al., 1999), by
a. comparing the scoring criteria for range of motion from the Melbourne
Assessment with 3D angular kinematic data of children with no known
neurological impairment.
b. comparing the total percentage score on the Melbourne Assessment
for children with no known neurological condition with the maximum
total percentage score of the Melbourne Assessment.
5
The aims of study three were to:
• Investigate the efficacy of lycra® arm splints at the impairment level using range
of motion and the Melbourne Assessment (Randall et al., 1999).
• Investigate the efficacy of lycra® arm splints at the activity level using the
Functional Independence Measure for Children (WeeFIM Guide from the UDSMR,
1993).
• Investigate the efficacy of lycra® arm splints at the participation level using Goal
Attainment Scaling (Kiersuk et al., 1994) and Parental Questionnaire (Knox,
2003).
• Investigate the impact of contextual factors (environmental and personal) on the
efficacy of lycra® arm splints using the ICF Checklist (Version 21a Clinician Form,
WHO 2001b).
The aims of study four were to:
• Measure change in movement sub-structures and quality of upper limb
movement in 16 children with cerebral palsy across all levels of the independent
variable measured at baseline, initial splint wear, after 3 months of splint wear,
immediate splint removal and 3 months after no splint wear.
• Investigate the sensitivity of the Melbourne Assessment to detect clinically
significant change in upper limb function.
The aim of study five was to:
• Measure change in angular kinematics in 16 children with cerebral palsy across
all levels of the independent variable measured at baseline, initial splint wear, after
3 months of splint wear, immediate splint removal and 3 months after no splint
wear.
1.3 Overview of thesis structure The introduction and related literature chapters set the scene for a series of papers that
comprised independent studies which address the central research aims. At times the
presentation of independent papers may seem repetitive; however it is felt that each
6
paper should stand alone for ease of reading. The final chapter succinctly integrates the
major findings from each study.
1.4 Definition of key terms
Activity limitation: Difficulties an individual may have in the performance of an activity
(WHO, 2000).
Cerebral palsy: A disorder of muscle control, which results from damage to a developing
brain (Reddihough & Ong, 2000).
Environmental factors: The physical, social and attitudinal environment in which people
live (WHO, 2001a, p.171).
Goal attainment: A movement or change towards the therapeutically determined goal
(Ottenbacher & Cusick, 1990).
Impairment: “Problems in body function or structures as a significant loss or deviation”
(WHO, 2001a, p.105).
Jerk index: The rate of change of acceleration or the third time derivative of position
(Feng & Mak, 1997). It is used to describe movement smoothness.
Lycra® arm splints: Semi-dynamic splints made of lycra that extend from the wrist to the
axilla (Second Skin, 2002).
Movement time: Time from the start of arm movement to the end of the movement
(Kluzik, Fetters & Coryell, 1990; Reid & Sochaniwskyj, 1992; & Reid, 1992b).
Normalised jerk: Jerk that has been normalised for different movement durations and
sizes (Teulings, Contreras-Vidal, Stelmach & Adler, 1997).
Participation restriction: Problems an individual may have in the manner or extent of
involvement in life situations (WHO, 2000).
Passive range of motion: The amount of movement possible at a joint when an external
force is used to move the limb (Trombly & Podolski, 2002).
7
Path directness of the hand: Path travelled in 3D space (based on accumulated vertical,
frontal and sagittal path lengths) between the starting point and end point (Feng & Mak
1997; Inzelberg, Flash, Schechtman & Korezyn, 1995; Reid & Sochaniwskyj, 1992; Reid,
1992b)
Unilateral upper limb function: The ability to reach, grasp, release and manipulation of
one upper extremity during tasks that are integral to performance of activities of daily
living are performed (Randall et al., 1999).
1.5 Delimitations and Limitations Delimitations
• The time frame of the study is limited to a 3 month intervention period when the
splint is worn.
• All assessments are conducted in a contrived context of a laboratory.
• The study is limited to children between the ages of 5 to 15 years.
Limitations
• The power of the study is determined by the accessible population.
• The sample may not be representative of all children with all forms of cerebral
palsy.
8
CHAPTER 2
Review of related literature 2.0 Introduction This review aims to present a synthesis of current literature on,
I. Upper limb splinting for children with cerebral palsy (hypertonicity)
II. The evidence for the effectiveness of upper limb lycra splinting in children with
cerebral palsy
III. Assessment methods available for children with cerebral palsy with particular focus
on all levels of the International Classification of Functioning Disability and Health
(ICF- WHO, 2001a)
IV. Variables of interest at the impairment level used in previous upper limb kinematic
studies
Parts one and two of the review entail a background summary of cerebral palsy and
splinting for hypertonicity and include an evidenced based practice review to provide
context for the study and highlight the need and direction for research. Part three
addresses assessments currently available to measure outcomes of upper limb splinting
in children with cerebral palsy at all levels of the ICF. Part four outlines the rationale of
chosen variables of interest at the ICF level of impairment supported by literature.
2.1 Upper limb splinting in cerebral palsy
2.1.1 Cerebral Palsy
Cerebral palsy is an ‘umbrella’ description covering a group of non-progressive, but often
changing, motor impairment syndromes secondary to abnormalities of the developing
brain (Mayston, 2001; Stanley, et al., 2000). The magnitude, nature of change, location
and timing of the damage to the brain will relate directly to the type and severity of the
impairments in body functions (Forssberg, Eliasson, Redon-Zouitenn, Mercuri &
Dubowitz, 1999). Common impairments of the upper limb in children with cerebral palsy
include weakness, associated and mirror movements, loss of speed of movement,
retention of the grasp reflex, dyspraxia, absent protective reflexes, trophic changes,
limited variety of muscle synergies, contractures, altered biomechanics, sensory
9
impairment, disuse and hypertonicity (Boyd et al., 2003; Brown & Walsh, 2000; Mayston,
2001). Hypertonicity has been defined clinically as an increased resistance to passive
movement, which becomes more marked as the speed and extent of the movement
increases. This increased resistance to movement is a result of both neural (spasticity)
and non-neural (physical properties of muscle and soft tissue) components (Copley &
Kuipers, 1999).
Additional impairments such as learning disability, epilepsy, visual impairment and
hydrocephalus frequently coexist in children with cerebral palsy (Beckung & Hagberg,
2002). Impairments in body functions may lead to activity limitations and participation
restrictions in people with cerebral palsy (WHO, 2001c). These impairments can impact
on educational outcomes, participation in activities of daily living and vocational options
for many children with cerebral palsy (Boyd et al., 2001).
Cerebral palsy is the most common physical disability in childhood (Reddihough &
Collins, 2003). Of every 1000 live births in Western Australia approximately 2.5 children
will be diagnosed as having cerebral palsy before the age of five years (Stanley &
Watson, 1992), a rate which is similar to that reported in other parts of the world
(Hagberg, Hagberg & Olow, 1993; MacGillivary & Campbell, 1995; Murphy, Yeargin-
Allsopp, Decoufle & Drews 1993).
There have been a number of attempts to classify cerebral palsy (Aicardi & Bax, 1998;
Palisano et al., 1997) but unfortunately, there is no one generally accepted classification.
The most common classification of cerebral palsy relates to the type of motor impairment
and distribution. There are two main types of motor impairment; spastic and dystonic.
Spastic cerebral palsy is the most common type occurring in about 80% of all cases
(Stanley et al., 2000). It is characterised by extreme stiffness or tightness in the muscles
that resist movement (hypertonicity), increased reflexes and static postures (Bax &
Brown, 2004). People with dystonic cerebral palsy have variable tone and unwanted
movements with dynamic posturing (Bax & Brown, 2004; Reddihough & Ong, 2000).
There are three commonly occurring distributions of spasticity; quadriplegia, diplegia and
hemiplegia. Quadriplegia is total body involvement with equal involvement of the upper
and lower limbs or mainly affecting the upper limbs (Mayston, 2001). If the lower limbs
are more affected than the upper limbs the term diplegia is used (Aicardi & Bax, 1998).
Hemiplegia is a unilateral motor disability (Aicardi & Bax, 1998; Hagberg & Hagberg,
2000). Hemiplegia is the most common cerebral palsy syndrome among children born
at term (Hagberg & Hagberg, 2000). Recently in the literature, the ICF classification of
10
cerebral palsy by the World Health Organization is being explored as it considers the
child, not only as an individual but within the context of their environment (Mayston,
2001).
2.1.2 Splinting for hypertonicity Intervention to manage upper limb hypertonicity includes pharmacological (Boyd et al.,
2004; Hurvuitz, Conti, Flansburg & Brown, 2000; Schneider & Gabler-Spira, 2002),
surgical (Stocker & Stuecker, 2002; Westwell-O’Connor, Deluca & Ounpuu, 2002) and
therapeutic techniques (Knox & Evans, 2002; Siebes, Wijnrocks & Vermeer, 2002).
Splinting is commonly used to complement these treatments (Duncan, 1989; Kent,
Gilberston & Geddes, 2002; Naganuma & Billingsley, 1990; Neuhaus et al., 1981). A
splint is an orthopaedic device for immobilisation, restraint or support of any part of the
body (Coppard & Lyn, 2001). Empirical evidence suggests hand splinting can produce
therapeutic outcomes for clients with upper limb hypertonicity (Foster & Ranka, 1997;
Kaine & Chapparo, 1997; McPherson, Becker & Franszczak, 1985; McPherson,
Kreimeyer, Aalderks & Gallagher, 1982; Mills, 1984; Rose & Shah, 1987; Wallen &
Mackay, 1995; Wilton & Dival, 1997).
The ultimate object of upper limb splinting is functional use of the hand (Wilton, 1984). A
review of the literature suggests preliminary objectives of splinting clients with
hypertonicity include:
• Prevention of deformity and contractures (Deshaies, 2002; Duncan, 1989;
Naganuma & Billingsley, 1990; Neuhaus et al., 1981; Wallen & O’Flaherty ,1991;
Wilton & Dival, 1997; Wilton, 1984)
• Maintenance of range of movement (Copley & Kuipers, 1999; Deshaies, 2002)
• Assistance in functional movement (Duncan, 1989; Kerem, Livanelioglu & Topcu,
2001; Naganuma & Billingsley, 1990; Wallen & O’Flaherty, 1991; Wilton & Dival,
1997; Wilton 1984)
• Reduction of hypertonicity (Deshaies, 2002; Kerem et al., 2001; Mackay &
Wallen, 1996; McPherson et al., 1985; McPherson, 1981; Rose & Shah, 1987;
Snook, 1979; Stern, 1980; Wallen & O’Flaherty, 1991; Wallen & Mackay, 1995;
Wilton & Dival, 1997)
• Maintenance of joint integrity (Deshaies, 2002; Duncan, 1989; Wallen &
O’Flaherty, 1991; Wilton, 1984)
• Aesthetics (Copley & Kuipers, 1999; Wilton & Dival, 1997)
• Oedema management (Copley & Kuipers, 1999)
11
• Pain management (Copley & Kuipers,1999; Kent et al., 2002; Deshaies, 2002)
• Maintenance of muscle balance (Deshaies, 2002; Duncan, 1989)
There are three main theoretical approaches to the management of hypertonicity in the
upper limb. These are biomechanical, neurophysiological and cognitive motor learning
approaches (Lohman, 2001). The first of these the biomechanical approach, adheres to
the principles of normal alignment, mobility and stability (Wilton & Dival, 1997).
Contractures and deformities are addressed by direct application of mechanical force
(Langlois, Mackinnon & Pederson 1989; Lohman, 2001). After the 1950s, greater
emphasis was given to the underlying causes of hypertonicity. The neurophysiological
approach was then developed, which aims to reduce hypertonicity through sensory
feedback, reflex inhibiting positions and sustained stretch (Lohman, 2001; Wilton &
Dival, 1997). The cognitive motor learning approach suggests that improvements in
positioning through the use of splints assists in the learning of more normal movement
patterns leading to improvements in function (Copley and Kuipers; 1999; Foster &
Ranka, 1997; Mills, 1984).
There is considerable variation in splinting practice. These variations include the design
of the splint, critical period for splinting, wearing schedule, duration of use and the
therapeutic rationale behind splinting (Copley & Kuipers, 1999; Langlois, Pederson &
Mackinnon, 1991). The above variations are largely due to the lack of consensus in the
literature regarding splinting practices. The existing body of literature on the
effectiveness of splinting clients with upper limb hypertonicity has eight primary flaws:
• Lack of valid and reliable measurement tools (Edmonson, Fisher & Hanson
1999)
• Lack of use of assessment tools that are sensitive to subtle changes in motor
function (Fetters & Kluzik, 1996; Siebes et al., 2002)
• Lack of assessment tools standardised for the population of school age children,
who have cerebral palsy (Naganuma & Billingsley, 1990).
• Inconsistency of research design and methodology, making a comparison
between studies difficult (Copley & Kuipers, 1999; Foster & Ranka, 1997;
Naganuma & Billingsley, 1990)
• Insufficient studies into the effects of splinting on function and occupational
performance. Measurements of impairments (i.e. muscle tone, range of
movement) are generally used as outcome measures (Foster & Rankin 1997;
Naganuma & Billingsley, 1990).
12
• Inconsistency in wearing schedules of splints in hours per day and over longer
periods of weeks or months (Langlois et al., 1989). Wearing times vary from 20
minutes (Kerem et al., 2001) through two hours (McPherson et al. 1982; Mills,
1984; Rose & Shah, 1987) to 42 hours (Wallen & Mackay, 1995; Wallen &
O’Flaherty, 1991).
• Inadequate sample size (McPherson, 1981; Mills, 1984)
• Lack of a control group in research designs (Mills, 1984).
The American Society of Hand Therapists (ASHT - 1992) classified splints as;
mobilisation, immobilisation and restrictive. This classification is based on the key
functions of the splint and the number of joints that are affected. Mobilisation splints are
designed to mobilise primary and secondary joints, while immobilisation splints aim to
immobilise the joints (Coppard & Lynn, 2001; Wilton & Dival, 1997). Restrictive splints
“limit a specific aspect of joint range of movement for the primary joints” (ASHT, 1992
p.9). The ASHT Splint Classification System has the potential to be a universal
language for communication and research.
In current literature, splints are classified according to the traditional system of static,
semi-dynamic and dynamic (Deshaies, 2002; Copley & Kuipers, 1999). Static
(immobilisation) splints have no moving parts and aim to immobilise to help prevent
further deformity, soft tissue contracture and to substitute for loss of motor function (Hill,
1988; Coppard & Lynn, 2001). Examples of static splints include the Johnstone
pressure splint (Kerem et al., 2001), dorsal wrist splint (Carmick, 1997), volar wrist splint
(McPherson et al., 1982) and the resting hand splint (Coppard & Lynn, 2001).
Dynamic (mobilisation) splints have moving parts to control or restore movement
(Deshaies, 2002; Wilton & Dival, 1997). They create an intermittent, gentle force on a
segment resulting in motion of a joint or successive joints (Wilton & Dival, 1997). The
force is created through elastic bands, springs or mechanical devices (Deshaies, 2002).
Semi-dynamic splints facilitate movement through the intrinsic elastic property of the
materials from which they are made. Materials such as lycra®, neoprene and rubber
foam are semi-dynamic (Copley & Kuipers, 1999; Stern, Callinan, Hank, Lewis,
Schousboe & Ytterberg, 1998). Examples of semi-dynamic splints include the neoprene
thumb abduction supinator splint (Casey & Kratz, 1988), lycra® Upsuits and lycra® arm
splints (Second Skin, 2002).
13
Second Skin™ lycra® splints are custom designed to suit the individual and consist of
sections of lycra stitched together under tension with a specific direction of pull (Corn &
Timewell 2003; Scope, 2003). The inherent properties of lycra create a low force to
resist the spastic muscle, while also facilitating the antagonist action (Wilton, 2003).
Extra support is given to the splint by including plastic boning (Scope, 2001). Second
Skin™ fabricate a large range of lycra® splints including the; Upsuit, Mobility Splint,
Working splint and dynamic lycra® arm splints (Second Skin, 2000).
The dynamic lycra® arm splint extends
from the wrist to the axilla with a zip for
easy application (see Figure 2.0). The
splint is designed to “promote better
hand and arm function by addressing
postural and tonal issues impacting on
the elbow” (Second Skin, 2002). The
splints are designed for clients with a
neurological condition including post-
traumatic head injury and cerebral
palsy. The arm splint is individually
prescribed based on two designs; the
pronation – flexion and supination –
extension splints. The pronation –
flexion arm splint is designed for clients
whose functional performance is limited
by strong elbow extension and
supination and the supination-extension
splint is used for clients whose
performance is limited by strong elbow
flexion and pronation (Second Skin,
2002). Second Skin lycra arm splints®
cost approximately $580.00 and last
children about six to twelve months due
to changes in upper limb morphology
and reduction in the elastic properties of
the lycra overtime.
Figure 2.0 Supination-extension
lycra® arm splint
14
Dynamic lycra® splints are believed to modify spasticity due to the effects of neutral
warmth, pressure and creation of a low intensity prolonged stretch on hypertonic
muscles (Copley & Kuipers, 1999). Neutral warmth and pressure reduce stimulation of
the thermal and tactile receptors, which then decreases the excitability of intermediate
neurons and motor neurons (Kerem et al., 2001). The mechanical properties of
prolonged stretch of lycra arm and hand splints have been established in adults with no
known neurological impairments (Gracies, Fitzpatrick, Wilson, Burke & Gandevia, 1997).
In adults with hemiplegia lycra arm and hand splints were shown to significantly improve
resting posture at the wrist, reduce wrist and finger flexion spasticity and reduce swelling
in patients with swollen limbs (Gracies et al., 2000).
2.2 Evidence based practice review – Upper limb splinting 2.2.1 What is the evidence for the effectiveness of lycra splinting in
children with cerebral palsy? Evidence-based research aims to provide the best possible guidance at the point of
clinical practice (Humphris, 2003). An evidence-based practice review was conducted to
investigate the evidence of the effectiveness of lycra splinting in children with cerebral
palsy at the level of impairment, activity and participation.
2.2.2 Methodology 2.2.2.1 Search Strategy
Using the levels of evidence defined by National Health and Medical Research Council
(NHMRC - 1999) the search strategy aimed to locate the following study designs:
Level I Systematic reviews and meta-analyses
Level II Randomised control trial
Level III Controlled trials, cohort or case-control analytic studies
Level IV Case series
Level V Expert opinion
2.2.2.2 Search Terms
Patient / Client: children or cerebral palsy
Intervention: splinting or semi-dynamic or lycra
Comparison: Nil
Outcomes: Any level of the ICF
15
Sites / Resources Searched
(see Appendix I)
2.2.2.3 Inclusion / Exclusion Criteria
Inclusion:
• Studies published in English
• Studies including children with cerebral palsy aged 0-18 years old
• Studies with the intervention of upper limb or full body lycra splinting
Exclusion:
• A second publication of the same study presenting the same results
• Studies which reported less than 50% or a non-defined proportion of the
participants were children with cerebral palsy
• Studies published before 1993
2.2.3 Results
Twenty-four relevant publications were located and categorized in table 2.0. The full
data synthesis table is available in appendix 2.2 for a more detailed synopsis of the
results.
16
Level of evidence
Number located
Authors
I 0
II 0
III 0
IV 7 • Blair, Ballantyne, Horsman & Chauvel, 1995
• Brownlee et al., 2000
• Corn and Timewell, 2003 & Corn et al., 2003
• Edmonson et al.,1999
• Knox, 2003
• Nicholson, Morton, Attfield & Rennie, 2001
• Scott-Tautum, 2003
V 16 • Capability Scotland, 2000
• Ballantyne & Colegate, 2003
• Blair, Ballantyne, Horsman & Chauvel, 1996
• Capability Scotland, 2004
• Chauvel, Horsman, Ballantyne & Blair, 1993
• Copley and Kuipers, 1999
• Harris, 1996
• Hylton & Allen, 1997
• Jone, 1995
• National Horizons Scanning Centre, 2002
• Paleg, Hubbard, Breit & O’Donnell, 1999
• Russell & Law, 1995
• Scope, 2001, 2003
• Scott-Tatum, 1999
• Shepherd, 1997
• Teplicky, 2002
Table 2.0: Study designs of relevant articles
The majority (16) of the studies reported in Table 2.0 were of the lowest form of
evidence according to the hierarchy of evidence used by the NHMRC (2000). Many of
these studies were opinions based on clinical experience and descriptive studies.
17
2.2.4 Discussion Seven studies were identified at level III on the hierarchy of evidence. From these
studies it can be concluded that there is inconclusive level 3b evidence to support the
prescription of lycra arm splints for children with cerebral palsy.
The effects of full body lycra garments on upper limb function in children with cerebral
palsy has been studied by Blair et al. (1995); Edmondson et al. (1999); Knox (2003); and
Nicholson et al. (2001).
Blair et al. (1995) obtained outcomes from three concurrent studies, a descriptive study,
a four-period crossover trial and a recipient-control study. They found immediate
improvements in postural stability and reduction in involuntary movement, increased
confidence to attempt motor tasks and improved dynamic function following wearing of
lycra® Upsuits. The results of these studies have been criticised by other researchers
and clinicians for failing to control a number of threats to internal validity (Nicholson et
al., 2001). Harris (1996) stated Blair et al. (1995) failed to employ a valid ABA design,
lacked examiner blinding and used subjective measures.
Knox (2003) aimed to evaluate the effects of wearing lycra garments in eight children
with cerebral palsy. A repeated measures design was used with participants tested
using the Gross Motor Function Measure (GMFM) and the Quality of Upper Extremity
Skills Test (QUEST). Power of this study was low as 50% of the participants (n = 8)
dropped out. Of the remaining four improvements in either the QUEST or GMFM were
reported.
Nicholson et al. (2001) evaluated upper limb function in 12 children (between the ages of
2 to 17 years) with cerebral palsy wearing lycra garments using 3D motion analysis
performing a reach and grasp task, the Paediatric Evaluation of Disability Index (PEDI)
and a parental / carer questionnaire. The authors found that all children made
improvements in at least one of the functional scales of the PEDI and scores for the
whole group showed significant gains. However the measures used need to be further
examined before confidence is given to the findings. The PEDI is a functional
assessment for the “evaluation of children aged 6 months to 7 years” (Feldman, Haley &
Coryell, 1990, p.602), yet the participants in this study were aged between 2 to 17 years.
18
The normative data used to validate movements of the upper limb during the reaching
task were based on one 31-year old male subject (Attfield, Pickering & Rennie, 1998).
Edmonson et al. (1999) used an unnamed assessment to examine gross motor skills,
balance and fine motor function in 15 children with cerebral palsy pre and post 12 month
lycra suit wear. Results were mixed; some children demonstrated little change on the
assessment, whilst others showed an improvement, especially those with athetosis,
ataxia and hypotonia.
Brownlee et al. (2000) evaluated hand and gauntlet splints for ten children with
hemiplegia and whole body suits for ten children with quadriplegia. A non-standardised
hand function assessment and GMFM were used to obtain a base line measure and
again after splinting. Six out of the ten children with hemiplegia showed functional
improvements with hand skill testing after eight weeks. No change was seen in children
with quadriplegia on the GMFM.
Blair et al. (1995) identified compliance as a major issue in lycra garment prescription.
Knox (2003), Rennie et al. (2000) and Nicholson et al. (2001) found that even though
children improved functionally, this improvement did not often outweigh the
disadvantages of wearing the suit. Disadvantages included constipation, urinary
incontinence, children required increased assistance with dressing and toileting,
restrictions when crawling and circulation difficulties. Blair et al. (1995) suggested that
lycra splinting applied only to the limbs may broaden the use of this intervention.
Corn et al. (2003) employed a single subject research design was employed to
investigate the effects of lycra® arm splints on four children with neurological deficits.
Using the Melbourne Assessment of Unilateral Limb Function as the measurement tool
(Melbourne Assessment – Randall et al., 1999) one child had a slight decline in upper
limb function, one had an improvement initially and two showed no significant change
between the baseline and intervention phase (Corn & Timewell, 2003; Corn et al., 2003).
It was suggested that as The Melbourne Assessment was a relatively new assessment
tool further investigation is required regarding its sensitivity to change (Corn & Timewell,
2003).
Scott-Tautum (2003) engaged a pre-test / post-test study design to evaluate the
functional gains of 40 participants (23 adults and 17 children with movement difficulties)
associated with dynamic lycra splinting. A variety of outcome measures were used
19
including the Canadian Occupational Performance Measure (COPM), Modified Ashworth
scale, Tardieu scale, OPCS disability scale, questionnaire, resting limb posture and
Chailey sitting ability scale. Significant differences were found related to the use of lycra
splints as measured by the COPM, Modified Ashworth scale, Tardieu scale (certain
muscle groups), OPCS disability scale and resting posture (Scott-Tatum, 2003)
These seven studies on their own do not provide sufficient evidence to justify the
expense and complexity associated with prescribing, fitting and training children with
Second Skin™ lycra® arm splints. No studies randomised participants or had a control
group. Randomised controlled trials are viewed as the best way of evaluating an
intervention as it attempts to decrease bias, manipulates a specific intervention and
requires study groups, which are sufficiently large to demonstrate a power effect of the
intervention (Humphris, 2003). There is a need for continued research to understand the
benefits and limitations of these splints and to build evidence to support splinting
practices in this area. The aim of this thesis was to use a randomised controlled trial
experimental design to investigate the effectiveness of Second Skin lycra® arm splints in
children with cerebral palsy at all levels of the ICF.
2.3 Measurement tools
A large number of assessments are available to measure health related attributes in
children with cerebral palsy (Ketelaar, Vermeer & Helders, 1998). In this study the ICF
is used as an organising framework to discuss assessments in all health related
domains for children with cerebral palsy. Assessments were reviewed in the literature
by means of four separate but related levels; impairment, activity limitation, participation
restriction and environment (WHO, 2001a).
The ICF defined impairment as “problems in body function or structure such as
significant deviation or loss” (WHO, 2001a p.10). A child with cerebral palsy may
experience impairments such as hypertonicity, muscle weakness, loss of selective
movement, musculoskeletal problems, and poor postural control (Mayston, 2001).
Activity limitations are difficulties an individual may have in executing activities (WHO,
2001a). The activity limitations for a child with cerebral palsy may include; limitations
walking or limitations with bimanual fine motor function (Beckung & Hagberg, 2002).
Participation restrictions refer to “problems an individual may experience in involvement
in life situations” (WHO, 2001a p.10). The participation restriction for a child with
20
cerebral palsy may involve difficulties in performing certain activities in mainstream
school or restrictions in specific play activities (Beckung & Hagberg, 2002).
Outcomes of lycra® arm splints are expected to be reported at the level of impairment,
activity and participation. This view was supported in an initial qualitative pilot study
which investigated goals, outcomes and influences of environmental factors from the
perspective of the family, child and occupational therapist during a lycra® arm splint
program (see Appendix J). The results of the pilot study demonstrated families and
occupational therapists described the short-term goals of the lycra® arm splint at the
level of impairment and activity and long-term goals at the level of activity and
participation. Outcomes were described at the level of impairment, activity and
participation. The influence of contextual factors especially attitudes of immediate family
members, friends, personal assistants, teachers and health professionals impacted on
the overall outcome of the success of the splinting intervention. These findings were
supported by a descriptive clinical trial of lycra garments in children with cerebral palsy
(Knox, 2003).
Assessments designed to measure changes in children with cerebral palsy at the level of
impairment, activity and participation were examined in this literature review and best
practice outcome measures identified. Change is not expected at the contextual level so
this domain is classified instead of assessed. This classification enables identification of
facilitators or barriers to the splinting intervention and highlights any extraneous
variables.
Measurement tools are discussed in this review that have been employed in past
research studies. Studies included in the review met the following criteria:
• Population - children with cerebral palsy (between 2-18 years old)
• Intervention – Upper limb splinting, casting or botulinum toxin A (botox)
• Outcome – Any level of the ICF
• Studies published after 1993
Additional assessments for this review not previously used in the above studies that met
set criteria will also be discussed. Three criteria were established in selecting additional
assessments for this review:
• Population – children with cerebral palsy (between 2-18 years old)
• Outcome – Any level of the ICF
21
• Assessments - published after 1993
All assessments were reviewed on the basis of:
• Health related attributes measured
• Target group
• Purpose (discriminative, predictive or evaluative)
• Nature (quantitative or qualitative)
• Type (test, checklist or observational method)
• Psychometric properties (reliability and validity)
• Evidence of responsiveness
2.3.1 Impairment
The impairment domain is the most prevalent outcome measure in the field of paediatric
disability (Foster & Ranka, 1997). Impairments of children with cerebral palsy may
include a combination of ‘fixed’ contractures due to muscle shortening and dynamic
contractures due to spasticity (Love et al., 2001).
Range of motion measures are used to document fixed contractures. The most common
outcome measure in the impairment domain of the studies reviewed was range of
motion (Autti-Rämö, Larsen, Tiamo & von Wendt, 2001; Carmick, 1997; Copley,
Watson-Will & Dent, 1996; Friedman, Diamond, Johnston & Daffner, 2000; Hurvitz et al.,
2000; Kaine & Chapparo, 1997; Mackay & Wallen, 1996; Scott-Tautum, 2003; Wallen &
Mackay, 1995).
Goniometers were used to measure range of motion in the above studies. Several
studies have examined inter-rater and intra-rater reliability of goniometric measurements
and problems have been identified (Rondelli, Murphy, Esler, Marciano & Cholmakjian,
1992). Extremity range of motion testing can be influenced by cooperation of the client,
identification of bony landmarks, different styles of goniometers, instructions of the
evaluator and position of the surrounding joints (Patel, Haig & Cook, 2000). These
conditions cause measurements to vary by 5 degrees or more (Patel et al., 2000).
Reports on the reliability of passive range of motion of the upper limb for children with
cerebral palsy are limited by small participation numbers (Harris, Smith & Krukowski,
1985) or by the use of questionable statistical methods (Sommerfeld, Fraser, Hensinger
22
& Beresford, 1981). More recently there have been reports on the test-retest reliability of
goniometric measurements in 19 children with cerebral palsy. Passive joint range at the
elbow (extension r = 0.92), forearm (supination r = 0.81) and wrist (extension r = 0.85)
were indicative of good test-retest reliability. Lower correlations were calculated for
shoulder abduction and flexion indicating poor test retest reliability (Glazier, Fehlings &
Steele, 1997). Rothstein, Miller and Roettger (1983) who investigated reliability of
goniometric measurements of passive elbow (flexion / extension) in a clinical population
showed, intra-tester and inter-tester reliability was high.
The Ashworth (Ashworth, 1964) combined with the Modified Ashworth Scale (MAS -
Bohannon & Smith, 1987) is the most widely cited measure of muscle tone in the
literature (Corry, Cosgrove, Walsh, McClean & Graham, 1997; Fehlings, Rang, Glazier &
Steele, 2000; Fehlings, Rang, Glazier & Steele, 2001; Scott-Tautum, 2003.; Wallen,
Waugh & O’Flaherty, 2004; Yang, Fu, Kao, Chan & Chen 2003). The Ashworth and
MAS are based on the amount of resistance assessed by the evaluator when moving the
joint through the available range of motion (Elovic, Simone & Zafonte, 2004). The MAS
differs from the Ashworth scale by the addition of grade “1+” and slight modifications to
the original definitions of Ashworth (1964), (Bohannon & Smith, 1987).
Adequate levels of reliability have been reported for the MAS in an adult population
(Allison, Abraham & Petersen, 1996; Bohannon & Smith, 1987; Gregson et al., 1999;
Katz, Rovai, Brait & Rymer, 1992; Sloan et al., 1992; Smith, Jamshidi & Lo, 2002). The
authors of the MAS reported that there was good inter-rater reliability in its use as an
assessment tool for elbow flexor spasticity secondary to intercranial pathology
(Bohannon & Smith, 1987). The literature further supports the reliability of the MAS in
assessing upper limb spasticity of stroke patients (Brashear et al., 2002). Questionable
reliability has been found when this tool was used with the lower limb (Allison et al.,
1996; Blackburn, van Villet & Mockett, 2002). Reliability of the MAS has not been
reported for the upper limb of children with cerebral palsy. However Ashworth scores
have been shown to consistently reduce in children with cerebral palsy after surgical
intervention designed specifically to reduce spasticity (Butler & Campbell, 2000;
McLaughlin et al., 1998; Scott-Tautum, 2003).
The Tardieu scale was used as a measure of spasticity in a study of the effectiveness of
upper limb botox (Wallen et al., 2004). Wallen et al. (2004) used this scale to establish a
significant increase in the angle of first catch in at 2 weeks (reduction in spasticity), but
only the elbow maintained a significant difference at 3 and 6 months. The modified
23
Tardieu scale is another measure of spasticity used to quantify the difference between
dynamic contractures due to increased muscle tone and fixed contractures in children
with cerebral palsy (Boyd & Graham, 1999). The modified Tardieu scale more formally
addresses the issue of velocity of movement compared with the MAS (Elovic et al.,
2004).
The modified Tardieu scale has been used in clinical studies to assess the suitability of
intervention in both the upper (Gracies et al., 2000) and lower limbs (Boyd, Barwood,
Ballieu & Graham, 1998 & Love et al., 2001). In a validity study of clinical measures, the
modified Tardieu scale was demonstrated to be able to measure changes following
spasticity management (Boyd et al., 1998). Gracies et al. (2000) used the Tardieu scale
as a measure of spasticity and found in their study of lycra splints in adults with
hemiplegia that prolonged stretch provided by the lycra garments, increased the angle
where spasticity was first observed. In a study of 17 children and 23 adults with
movement disorders lycra splints were found to have a positive effect, by reducing the
level of spasticity present in certain muscles as measured by the Tardieu scale (Scott-
Tautum, 2003.).
Although the modified Tardieu scale has been used to assess outcomes of intervention
its reliability and validity has not been well documented. In a population of children with
cerebral palsy (hemiplegia) it was found that the modified Tardieu scale may be of
limited value in assessing biceps spasticity in the upper extremities (Mackey, Walt, Lobb
& Stott, 2004).
Resonant frequency was employed as a measure of spasticity in two upper limb botox
studies (Boyd et al., 2003; Corry et al., 1997). In these studies, a torque generator
motor attached to a low-friction conduction potentiometer was used to record
displacement (Brown & Walsh 2000; Walsh, 1992). The resonant frequency varies with
the state of the muscle, being higher when there is voluntary stiffening. Brown, van
Rensburg, Walsh, Lakie & Wright (1987) reported in a study of 13 children with
hemiplegia that the resonant frequencies of the spastic upper limb were significantly
elevated compared with their non-affected upper limb. With spasticity both stiffness and
dampening are causes of resistance to motion. Dampening was investigated by
“dividing the velocity at resonance on the normal side with that of the hemiplegic side at
the same torque level” (Brown & Walsh, 2000 p.134). Stiffness and dampening were
also used to measure muscle tone by Corry et al. (1997).
24
Grip strength has been employed as an outcome measure in paediatric studies of upper
limb botox using a dynamometer (Wong, Ng & Sit, 2002); vigrometer (Autti-Rämö et al.,
2001) and sphygmomanometer (Fehlings et al., 2000 & 2001). No statistically significant
increase in muscle power was found by Wong, Ng & Sit (2002) possibly because the
case numbers were small (n=5). Thumb grip was observed to diminish if doses of botox
were too high (Autti-Rämö et al., 2001). Grip strength was also used to measure the
effectiveness of Upsuits® in children with cerebral palsy. Results found no relationship
between grip strength and Upsuit® wear for children with cerebral palsy (Blair et al.,
1995).
Handgrip dynamometers are the most frequently used isometric dynamometer for
assessment of upper extremity strength (Patel et al., 2000). The handgrip dynamometer
has substantial normative data based on age and gender (Kellor, Frost, Silberberg,
Iversen & Cummings, 1971; Stephens, Pratt & Parks, 1996; Stephens, Pratt &
Michlovitz, 1996;). However no normative data is currently available for children with
cerebral palsy. In a study of grip strength in children with cerebral palsy it was found,
that an oil filled bulb measured grip strength reliably and objectively (Hallam &
Weindling, 1998). Good test re-test reliability was reported in sphygmomanometic
measurement of grip strength in children with cerebral palsy, however only half of the
participants were able to perform the grip strength test (Glazier et al., 1997).
Upper limb motion analysis is the quantified measurement of upper limb movement
patterns and forces during activity. In the past motion analysis has primarily focused on
gait analysis. Gait analysis has been used for pre-surgical planning and post-surgical
follow up in children with cerebral palsy (Aminian, Vankoski, Dias & Novak, 2003;
Gough, Eve, Robinson & Shortland 2004; Kay, Rethlefsen, Ryan & Wren, 2004;
Metaziotis, Wolf & Doederlein, 2004; Van der Linden, Aitchison, Hazelwood, Hillman &
Robb, 2003) and as an outcome measure for the use of botox in the lower limb
(Papadoniklakis et al., 2003; Sarioglu, Serdaroglu, Tutuncuoglu & Ozer, 2004; Wong et
al., 2004).
Normal gait is a symmetrical cyclic sequence of movements (Rab, Petuskey & Bagley,
2000). For each person over four years of age the timing of gait and characteristics of
gait parameters are highly repeatable (Rau et al., 2000). Three dimensional gait
analyses is an objective and repeatable outcome measure for children with cerebral
palsy (Steinwender, et al., 2000).
25
The use of the upper limb in daily life is extremely diverse as it can be used to reach,
grasp, manipulate and point (Rau et al., 2000). Shoulder mobility for everyday tasks is
large, multi-planar and exhibits significant inter-subject variability (Rab et al., 2000). Due
to these complexities, there is currently no standardisation for upper limb motion
analysis. The methods, biomechanical models, marker position, tasks, coordinate axis
definitions and 3D motion sequences vary between studies. Standardisation proposals
for the hand, wrist, elbow and shoulder have been submitted by several research groups
to the International Society of Biomechanics (Wu & Cavanagh, 1995).
A variety of 3D motion analysis methods have been employed in research studies
including the non-optical measure of magnetic tracking (An, Browne, Korinek, Tanaka &
Morrey, 1991). Optical measures include the use of markers that are primary and active
such as light emitting diodes or secondary and passive. Passive surface markers are
retroflective and illuminated by a primary light source close to each camera. This
method of 3D upper limb motion analysis has been employed by a number of
researchers to assess various movements (De Groot, 1997; Elliott, Wallis, Sakurai,
Lloyd & Besier, 2002; Mackey, Walt, Lobb, Reynolds & Stott, 2002; Rab, Petuskey &
Bagley, 2002; Rymer & Beer, 2000; Schmidt, Disselhorst-Klug, Silny & Rau, 1999;
Simoneau, Hambrook, Bachschmidt & Harris, 2000; Van der Helm & Pronk, 1995)
Vicon 370 (Oxford Metrics Ltd, Oxford, U.K.) is a 3D commercial motion analysis system
that employs a passive optical marker system to provide a visual record of marker
positions (Anglin & Wyss, 2000). Testing has shown that the Vicon 370 (Oxford Metrics
Ltd, Oxford, U.K.) system can measure the average distance between two markers
within 1 mm of the actual value (RMS error = 0.062 cm, Richards, 1999). Vicon 370
(Oxford Metrics Ltd, Oxford, U.K.) has also been demonstrated capable of measuring
the absolute angle within 1.5° of the actual value (RMS error = 1.421, Richards, 1999).
Reid et al. (2004) determined the repeatability of elbow motion using the measure of the
average coefficient of multiple correlations (CMCs) in typically developing children in all
planes of movement using the above system (see Appendix K). The repeatability was
found to be good to excellent (flexion / extension CMC = 0.92, abduction / adduction
CMC = 0.77, supination / pronation CMC = 0.82). In a intra-subject repeatability of
elbow motion in children with cerebral palsy, within a test day the CMCs for flexion /
extension (0.78), abduction / adduction (0.69) and supination / pronation (0.62) were
lower than for those without cerebral palsy. Results indicated the upper limb kinematics
of children with cerebral palsy is quite repeatable in all planes of motion for five
functional tasks (see Appendix L).
26
The results from the clinical studies by Feng and Mak (1997); Kluzik et al. (1990);
Schellekens, Scholten & Kalverboer, (1983) and Trombly (1992) also showed that
motion analysis can be used to systematically and quantitative evaluate upper extremity
movement and be used for repeated review of disordered movement.
Upper limb 3D models reconstruct marker positions from multi-camera observations.
The model is used to calculate the kinetic and kinematic properties of the upper limb.
Four upper limb 3D kinematic models, each with different marker positioning, have been
reported that have the potential to be used in a clinical setting (Kadaba et al., 1989; Rab
et al., 2002; Rau et al., 2000; Schmidt et al., 1999). A nine marker kinematic model was
used by Schmidt et al. (1999) and 21 markers were employed in an upper limb analysis
of cerebral palsy by Mackey et al. (2002). A marker set comprising 15 markers with a
helmet containing three additional markers was used in a study of upper extremity
kinematics in participants with a brachial plexus lesion (Rab et al., 2000). In a study of
cricket bowling two marker sets were used, one based only on the anatomical landmarks
(13 markers, Elliott et al., 2002) and one utilising technical positions that are not reliant
on anatomical markers during dynamic motion (7 markers) (Lloyd, Alderson & Elliott,
2000).
Tasks used in upper limb motion analysis have included: abduction and adduction of the
shoulder (Rau et al., 2000); hand to mouth movement (Mackey, Walt & Stott, 2003; Rau
et al., 2000); Melbourne Assessment tasks (Reid et al., 2004); tracking task – 8 shaped
curve (Schmidt et al., 1999); cricket bowling (Lloyd et al., 2000; Elliott et al., 2002);
reaching (Gronley et al., 2000; Kluzik et al., 1990; Fetters & Todd, 1987; Mackey et al.,
2003; McPherson et al., 1991; Nakano et al., 1999; Trombly, 1992); hand to nose
(Mackey et al., 2003); hand to head movements (Rab et al., 2000); a wave (Rab et al.,
2000); touch hand to back pocket (Rab et al., 2000); receive change (Rab et al.,2000); a
tapping task (Schellekens et al.,1983); arm movement on a digitising tablet (Flash,
Inzelberg, Schechtman & Korczyn, 1992; Teulings et al., 1997; Thomas, Yan &
Stelmach, 2000); throwing a ball (Yan, Hinrichs, Payne & Thomas, 2000); reach and
grasp a cone (Michaelsen, Luta, Roby-Brami & Levin, 2001); food chopping task (Wu,
Trombly, Lin & Tickle-Degnen, 1998); hair combing and drinking (Gronley et al., 2000).
The tasks chosen relate largely to the reason why the study was conducted. Activities of
daily living for example are often studied in order to establish requirements for orthoses
or prostheses (Anglin & Wyss, 1999).
27
The Quality of Upper Extremity Test (QUEST) (DeMatteo et al., 1992) is a criterion
referenced measure which assesses upper limb movement on the basis of 34 items
divided into four domains (Sakzewski, Ziviani & Van Eldik, 2001). It was developed for
use with children aged 18 months to 8 years, who have cerebral palsy (Hickey & Zivaini,
1998). Reliability testing of the QUEST was conducted by the authors of the
assessment. Initial inter-rater reliability for the total score of the QUEST was 0.95 and
test-retest reliability ranged from 0.75-0.95 (DeMatteo et al., 1992). High inter-rater
reliability of the QUEST was supported by Law et al. (2000) with an interclass correlation
of 0.93, using a sample of 40 children with cerebral palsy. Correlation between the
QUEST and the Peabody Developmental Motor Scale was high (0.84) (DeMatteo et al.,
1992). A study by Law et al. (1997) found the correlation of the QUEST with the
Peabody Motor Scale (Folio & Fewell 1983).
Responsiveness of the QUEST was examined in a clinical trial of neurodevelopmental
therapy and casting. The trial the group, who received upper extremity casting,
demonstrated statistically significant improvements in quality of movement as measured
by the QUEST compared with the group who received no casting (Law et al., 1991).
The QUEST has also been used to determine the efficacy of upper limb botulinum toxin
in children with cerebral palsy (Fehlings et al., 2000 & 2001 & Lowe, Novak, Cusick &
McIntosh, 2002). The total score for the involved side on the QUEST demonstrated a
statistically significant improvement favouring the botulinum toxin treatment group
(Fehlings et al., 2000).
The Melbourne Assessment of Unilateral Upper Limb Function (Randall et al., 1999)
abbreviated to the Melbourne Assessment is a criterion-referenced test for children
between the ages of 5 and 15 years with neurological impairment. The assessment is
designed to measure a child’s unilateral upper limb motor function based on 16 items
involving reach, grasp, release and manipulation (Johnson et al., 1994).
The investigation into an assessment’s validity requires other tests, which are
psychometrically adequate. During the development phase of the Melbourne
Assessment there were no known reliable assessments that specifically quantified upper
limb movements in children with cerebral palsy. The Melbourne Assessment was
instead compared with the expert clinical judgment of four clinicians and a 0.87
agreement was reported (Johnson et al., 1994). The authors of the study concluded that
if the clinician’s assessment was accepted the Melbourne Assessment must be a valid
28
test (Randall et al., 1999). In a more recent study of construct validity of the Melbourne
Assessment very high correlation coefficients were calculated between the Melbourne
Assessment and self care (0.939) and mobility (0.783) domains of the Paediatric
Evaluation and Disability Inventory (PEDI- Feldman et al., 1990) (Bourke-Taylor, 2003).
The authors of the Melbourne Assessment examined reliability of the assessment during
its development. In a population of 20 children with cerebral palsy high inter-rater
reliability (0.95) and intra-rater reliability (0.97) were established for total score (Randall,
Carlin, Chondros & Reddihough, 2001). Results also revealed high internal consistency
of test items (α = 0.96) (Randall et al., 2001). The findings supported the reliability of the
Melbourne Assessment as a tool of measuring quality of unilateral upper limb movement
in children with cerebral palsy.
The authors of the Melbourne Assessment investigated its sensitivity in a population of
11 children at the early stages of cerebral insult. This clinical population was chosen as
the children were likely to improve rapidly over a short period of time. A paired t-test
was used to compare the mean of the score of assessments one and two and of
assessments two and three. The timing of the assessments were individualised as
assessments coincided with the occurrence of small but clinically significant change as
determined by clinical judgement. Results indicated a significant improvement in the
mean score from assessment one to two (p =.01) however, improvement from the
second to the third assessment was not significant (p = .83). The authors identified one
subject with a considerable reduction in score from assessment two to three. When this
subject’s score was removed from the analysis the mean score for the remaining
subjects showed considerable improvement from assessment two to three (Randall et
al., 1999). The Melbourne Assessment has been used to investigate the outcomes of
botulinum toxin (botox) and lycra® splints in children with cerebral palsy (Corn et al.,
2003; Wallen et al., 2004). Wallen et al. (2004) found no significant improvement on the
Melbourne Assessment following injection of botox in the upper limb. Of the four
children in the study investigating outcomes of lycra® splint wear, one child had a
significant decline, one had an initial improvement and the remaining children showed no
change. Both studies suggested that the Melbourne Assessment was not sensitive
enough to detect change in the sample of children with cerebral palsy (Corn et al., 2003;
Wallen et al., 2004).
Other assessments used in previous research studies at the impairment level include:
web space measurement (Wong et al., 2002) and Erdhardt’s functional analysis
29
(Brownlee et al., 2000). These assessments are either not standardised for the
population of children with cerebral palsy or have no established reliability or validity
measures.
Past research has revealed that a combination of outcome measures from within the
dimensions of interest may be the most useful approach to determining intervention
efficacy (Knox, 2003). Three outcome measures were chosen at the impairment level
for this thesis. Best practice supports the use of the following measures for children
aged 5 to 15 years with cerebral palsy at the impairment level; The Melbourne
Assessment (Randall et al. 1999), 3D motion analysis and range of motion using a
goniometer.
The Melbourne Assessment (Randall et al., 1999) was chosen as the clinical
assessment tool rather than the QUEST due to the age range of participants in the
study. The QUEST was standardised on children aged 18 months to 8 years, whereas
the Melbourne Assessment was standardised on a population of children with
neurological disorders aged 5 to 15 years, which is the age range of participants in this
study. Three dimensional motion analyses was also chosen as a measure due to its
ability to detect small but clinically important changes in movement. Although the
Melbourne Assessment has been shown to be a valid and reliable measure of quality of
upper limb function, further studies are required on its sensitivity. Past research
demonstrates that 3D motion analysis can be used to systematically evaluate upper
extremity movement and be used for repeated reviews of disordered movement (Feng &
Mak, 1997; Kluzik et al., 1990; Schellekens et al., 1983; Trombly, 1992). Range of
motion (measured with a goniometer) was also chosen to monitor fixed contractures due
to muscle shortening to ensure range of motion of the participants is maintained through
out the study.
2.3.2 Activity
Activity is the performance of a task or action by an individual (WHO, 2000). For
children with cerebral palsy examples of every day activities include dressing, eating,
writing, washing, socialising and shopping (Law & Baum, 2001). Most studies that look
at the efficacy of hand splints, casting or botox injections in children with cerebral palsy
do not measure change in the ICF domain of activity. A review of outcome measures at
the activity level, designed for children with cerebral palsy, showed there are a limited
30
number of reliable, valid clinical assessment tools for this clinical population (Ketelaar et
al., 1998).
In past research in the areas of upper limb splinting, casting and following botulinum
toxin injections, measures used at the ICF level of activity include the Functional
Independence Measure for Children (WeeFIM - USMDR, 1993), the Paediatric
Evaluation of Disability Inventory (PEDI - Hayley, Coster, Ludlow, Haltiwanger &
Andrellos, 1992), the Gross Motor Function Measure (GMFM - Russell Rosenbaum,
Avery & Lane, 2002) and the Jebsen Hand Function Test (Taylor, Sand & Jebsen,
1973).
The WeeFIM is a discriminative and evaluative measure of disability that builds on the
organisational format of the Functional Independence Measure for adults (Granger,
Hamilton, Keith, Zielenzy & Sherwin, 1986). A minimal data set is used to track
outcomes over a number of settings (Msall, DiGaudio, Rogers et al., 1994). The
WeeFIM aims to measure changes in function over time to assess the burden of care
(type and amount of assistance) in terms of physical, technological and financial
resources (Braun, 1991). The WeeFIM consists of six domains: self-care, sphincter
control, transfers, locomotion, communication and social cognition (Ketelaar et al.,
1998). It employs a seven level ordinal scale to measure a range of functional abilities
from complete dependence to independence (Ottenbacher et al., 1996). The WeeFIM
can be used with non-disabled children from 6 months to 7 years and children who
possess a functional or developmental delay from 6 months to 21 years (USMDR, 1998).
Test-retest, equivalence, intra-rater and inter-rater reliability have been established for
the WeeFIM. Internal consistency was not reported in the studies reviewed. Test-retest
reliability for children with neurodevelopmental disability (number – n = 100) exceeded
0.90 (Msall et al., 1996), for school aged children with motor impairments (n = 28)
Pearson r values ranged from 0.83-0.99 (Msall, DiGaudio & Duffy et al., 1993). Test-
retest was established for children without disabilities (n = 37) with an intraclass
correlation coefficient (ICC) score of 0.98 (Ottenbacher et al., 1996). Inter-rater reliability
of the WeeFIM has been reported for 28 school-children with motor impairments
(Pearson r 0.74-0.76) (Msall, DiGaudio & Duffy et al., 1993). Inter-rater reliability for
children with disabilities (n = 205) was established with a short delay (ICC = 0.97) and
for a long delay (ICC = 0.90) (Ottenbacher et al., 2000). In the same study, intra-rater
reliability with a short delay ranged from 0.96 to 0.99 with an ICC for the total score 0.98.
31
The WeeFIM can be administered through direct observation, interview or a combination
of these approaches (Sperle, Ottenbacher, Braun, Lane & Nochajski, 1997). A study
investigating the equivalence reliability of direct observation and interview with parents
found agreement between the two methods of administration (ICC = 0.93) (Sperle et al.,
1997). These findings were supported by Ottenbacher et al. (1996), who found no
statistically significant differences in the comparison of retest interviews conducted
personally and those obtained over the telephone.
The WeeFIM has good content validity. Its development was based on judgmental and
statistical methods (Letts & Bosch, 2001). Construct validity has been developed in five
separate studies. Strong correlations were found between item scores and age in a
population of 111 healthy children (Braun 1991). Scores, were able to distinguish
children (n = 66) with major and no impairments and were related to parent’s perceptions
of the child’s health status (Msall et al., 1993). In a comparison of 30 disabled and 37
non-disabled children significant differences were found on most subscales between the
two groups (Ottenbacher et al., 1996).
Concurrent validity of the WeeFIM was assessed in a population of 100 children with
neurodevelopmental disability using the Vineland Adaptive Behaviour Scale (VABS) and
the Batelle Developmental Screening Inventory (BDSIT). Correlation between the total
WeeFIM and VABS and WeeFIM and BDSIT exceeded 0.85 (Msall et al., 1996). A
similar study in a population of 205 children with developmental disabilities found the
correlation for total scores from the VABS, BDSIT and WeeFIM ranged from 0.72 to 0.94
(Ottenbacher et al., 1999). Concurrent validity of the WeeFIM and PEDI in a population
of 41 children with acquired brain injury or developmental disability was reported to be
greater than 0.88 for self-care, transportation / locomotion and communication / social
function (Ziviani et al., 2001).
Sensitivity to change has been reported in a descriptive study of 20 children with
cerebral palsy, who underwent orthopaedic surgery and physiotherapy. WeeFIM
mobility scores were greater for children with diplegia than quadriplegia or hemiplegia
(McAuliffe, Wenger, Schneider & Gaebler-Spira, 1998). However the WeeFIM and PEDI
(self-care and caregiver activities of daily living - ADL) were used as clinical measures of
activity in research evaluating botulinum toxin in the upper limb of children with
hemiplegia (Hurvitz et al., 2000). Change was observed at the impairment level (range
of motion and Ashworth Scale) but no change was noted in the functional measures
(WeeFIM and PEDI). The authors attributed the limitations in documentation of
32
functional improvement to the lack of sensitivity in current functional assessment tools
(Hurvitz et al., 2000).
The PEDI (Hayley et al., 1992) is a standardised assessment tool designed to describe a
child’s functional status, evaluate programs and monitor changes in individuals or groups
(Letts & Bosch, 2001). It is designed to be used with children who are chronically ill or
disabled and aged between 6 months to 7.5 years (Ketelaar et al., 1998). The
assessment is organised into three measurement dimensions: functional skills, caregiver
assistance and modifications or adaptive equipment used (i.e. splints, wheelchair)
(Hayley et al., 1992; Ketelaar et al., 1998).
Overall the reliability and validity of the PEDI is excellent (Letts & Bosch, 2001).
Concurrent validity is supported by moderately high Pearson’s product moment
correlations between the BDIST and the PEDI summary scores (r=0.70-0.80) (Feldman
et al., 1990). Construct validity for the PEDI scores established a significant difference
between disabled and non-disabled groups (Feldman et al., 1990).
The PEDI has been used to evaluate the effectiveness of upper limb botulinum toxin-A in
children with cerebral palsy (Fehlings et al., 2000 & 2001; Lowe et al., 2002; Yang et al.,
2003). Fehlings et al. (2000) found a statistical difference in the raw scores of the
parent-completed self-care domain of the PEDI. In this single-blind design study
children and parents knew whether they were in the treatment or control group. This
may have impacted on the parental completed PEDI (Fehlings et al., 2000).
Improvements were also seen in self-care capabilities in terms of caregiver assistance in
the study by Yang et al. (2003). The PEDI, has also been used to evaluate lycra
garments in children with cerebral palsy (Nicholson et al., 2000). Research findings
indicate that the PEDI, although a well-validated form of assessments may not have
been sensitive enough to detect functional change over a short period of time (Rennie,
Attfield, Morton, Polak & Nicholson, 1999).
The Gross Motor Function Measure (GMFM- Russell et al., 2002) is a standardised
observational instrument designed and validated to measure change in gross motor
function over time in children with cerebral palsy (Bower, Mitchell, Burnett, Campbell &
McLellan, 2001). Dimensions include sitting, crawling and kneeling, standing and
walking / running / jumping (Msall, Rogers, Ripstein, Lyon & Wilczenski, 1997). There
are two versions of the GMFM, the original 88 item measure (GMFM-88) and the more
recent 66 item measure (GMFM-66). Both versions have been shown to be reliable,
33
valid tools that are sensitive to clinically important change in motor function (Russell et
al., 1989; Bower, McLellan, Arney & Campbell, 1996).
Test-retest reliability of the GMFM-66 has been established to be high (ICC = 0.99)
(Russell, Avery, Rosenbaum, Raina, Walter & Palisano, 2000). A study of 15
physiotherapists, who had received no training or experience in using the GMFM
revealed good inter-rater (0.77) and intra-rater reliability (0.88) when scoring videos of
three children with cerebral palsy performing the test tasks (Nordmark, Hagglund &
Jarnlo, 1997).
In a comparison study of the GMFM, PEDI, the Child Health Questionnaire (Landgraf,
Abetz & Ware, 1996) and the Paediatric Outcome Data Collection (Daltroy, Liang,
Fossel & Goldberg, 1998) the GMFM was found the most valid scale in detecting
differences in children’s health among motor groups. In the same study internal
consistency of the GMFM was found to be high and the test scores strongly correlated
with the PEDI (McCarthy, Silberstein, Atkins, Harryman, Sponseller & Hadley-Miller,
2002). The GMFM has been validated by demonstrating its capacity to detect change
in gross motor function in children with cerebral palsy (Kolobe, Palisano & Stratford,
1998). A responsiveness analysis by the assessment’s authors of the GMFM-66
showed a significant time x age x severity interaction with children under five years of
age (Russell et al., 2002).
The GMFM was used to evaluate the effectiveness of lycra Upsuits in children with
quadriplegia. This study found that video evidence demonstrated better truncal balance
and control in four of the children, however, the GMFM did not measure this change in
motor function (Brownlee et al., 2000). In a case study to evaluate a dynamic trunk
splint the subject’s GMFM score remained unchanged, but the therapist and parent
reported new functional skills of rolling and prop- to- sit consistently with the vest on
(Paleg et al.,1999).
The Jebsen-Taylor Test of Hand Function (Taylor et al., 1973) was used as one
measure in an open-labelled study of botulinum toxin in 11 children with cerebral palsy
(Wong et al., 2002). This test involves seven timed manual activities. Normal values for
dominant and non-dominant hands in males and females between the ages of 6-19
years have been established (Taylor et al., 1973). Sand, Taylor & Sakuma, (1973) and
Sand, Taylor, Hill, Kosky and Rawlings (1974) have applied this test to a population of
children with myelomeningocele and mental handicap. The assessment is not
34
standardised for the cerebral palsy population. Test-retest reliability is deemed excellent
for the Jebsen-Taylor Test of Hand Function. Content, criterion and responsiveness
validity have not yet been determined (DeMatteo, Law, Russell, Pollock, Rosenbaum &
Walter, 1993).
To meet the need to measure outcomes in the activity domain researchers investigating
outcomes of upper limb splinting, basting and botox have formulated new tests
(Brownlee et al., 2000; Exner & Bonder, 1983) with limited information given on the
method of validation of the test. Other standardised measures for children with cerebral
palsy at the ICF level of activity include the Activities Scale for Kids, Vinelands Adaptive
Behaviour Scale, Functional Motor Assessment Scale and the Battelle Developmental
Inventory Screening Test.
The measure chosen to be employed in this study at the activity level is the WeeFIM. As
outlined above the WeeFIM and PEDI both have excellent reliability and validity and
questionable sensitivity. The WeeFIM was chosen over the PEDI as the PEDI is
designed to be used with children aged between 6 months to 7.5 years, whereas the
population of this thesis is children aged 5 to 15 with cerebral palsy. The WeeFIM was
designed to meet the needs of this population.
The GMFM is designed to measure various motor skills i.e. walking, running, jumping,
standing and sitting (Russell et al., 2002). The WeeFIM’s domains measure functional
skills including; eating, dressing, toileting, transfers, dressing, communication
(Ottenbacher et al., 1999). Improvement in participant’s performance, when wearing the
lycra® arm splint, is usually observed in finger feeding, cutlery use, dressing, using toilet
paper, transfers, dressing, and communication access (Second Skin, 2002). The
constructs are measured by the WeeFIM are more closely related to the expected
outcomes of the lycra® arm splint than those measured by the GMFM and are therefore
chosen over the GMFM to measure outcomes in the study at the level of activity.
2.3.3 Participation Participation refers to the area of life in which individuals are involved, have access to
and have societal opportunities or barriers (Australian Institute of Health and Welfare,
AIHW, 2000). Areas of participation for a child with cerebral palsy may include personal
care, education, play, recreation and societal relationships (Law & Baum, 2001).
35
On review of past research in the area of upper limb splinting, casting and botulinum
toxin, the most frequently used measures at the ICF level of participation are the Goal
Attainment Scale (GAS – Kiersuk et al., 1994) and the Canadian Occupational
Performance Model (COPM - Law et al., 1998).
The COPM and GAS can be used at any level of the ICF (Unsworth, 2000). The health
related attributes measured by the GAS relate directly to the goals of the client, their
current level of functioning and the nature of the intervention. If the goal of the client
was to improve joint range of motion then the GAS is being utilised at the impairment
level. If the client’s goal was to be able to catch a ball the activity level is being
measured. A goal at the participation level may include the client being an active
member of their local netball team. The COPM also works at multiple levels of the ICF.
However some authors just include the GAS at the contextual / environmental level of
the ICF and the COPM at the level of participation (Boyd & Hays, 2001).
The GAS is an individualised criterion referenced measure that can be used to assess
qualitative changes and small but clinically important improvements in motor
development and function (Palisano, 1993). The primary strength of the GAS is its
ability to evaluate individualised change over time (Ottenbacher & Cusick, 1990). The
GAS provides a framework for the development of goals that are “measurable,
attainable, desired by all and socially functionally and contextually relevant”
(Ottenbacher & Cusick, 1993 p.520). It can be used to compare the performance across
clients in the same program or one client over time.
Three studies investigating the outcome of botulinum toxin in children with cerebral palsy
have employed the GAS as an outcome measure (Boyd et al., 2003; Lowe et al., 2002;
Wallen et al., 2004). Average achievement score of 50 were not reached on the GAS
(42 and 47 at 3 and 6 months respectively), however, all children made some progress
on some of the outcome goals (Wallen et al., 2004). Boyd et al. (2003) established a
significant difference between baseline and intervention measures using the GAS. The
results of Lowe et al. (2002) are yet to be published. The GAS has also been previously
used in research with children with physical and or communication needs (Brown, Effgen
& Palisano, 1998; Clark & Caudrey, 1983; King et al., 1998; King, McDougall, Tucker et
al., 1999; King, McDougall, Palisano, Gritzan & Tucker, 1999; Maloney, Mirrett, Brooks &
Johannes, 1978; McLaren & Rogers, 2003; Mitchell & Cusick, 1998; Palisano, Haley &
Brown, 1992; Palisano, 1993; Stephens & Haley, 1991).
36
Research into the content validity of the GAS in infants with motor delays found that
between 77% and 88% of the therapists’ ratings for each dimension met the criteria for
content validity (Palisano, 1993). Ways to improve content validity of the GAS have
been outlined in the literature and include supplementing the GAS with other
standardised assessments (Kiresuk et al., 1994) and employing randomly selected goals
(Brown et al., 1998). Low to moderate concurrent validity of the GAS with norm-
referenced scales has been reported (Cytrynbaum, Ginath, Birdwell & Brandt, 1979;
Kiresuk & Lund, 1978; Palisano et al., 1992). Palisano et al. (1992) considered their
results provided evidence that the GAS and the Peabody Developmental Motor Scale
measured different aspects of motor development. Other authors believed that the GAS
would only moderately correlate with norm-referenced measures due to the idiosyncratic
nature of the GAS (Cytrynbaum et al., 1979).
Only one study has reported on the responsiveness of the GAS. In a study of infants
with motor delays the GAS was found to be a more responsive measure to change in
motor goals than behavioural objectives (Palisano, 1993). The sustained use of the
GAS in research, clinical settings and program evaluation is testimony to its clinical utility
(Donnelly & Carswell, 2002).
In a review of five individualised outcome measures (GAS, COPM, Assessment of Motor
and Process Skills, Target Complaints and the Patient Specific Functional Scale) the
GAS demonstrated the strongest evidence of reliability (Donnelly & Carswell, 2002).
Moderate ICC (0.59 - 0.65) and inter-rater reliability rates (between r = 0.51 and r = 0.91)
have been reported for the GAS (Cytrynbaum et al., 1979; Kiresuk & Sherman, 1968).
Cytrynbaum et al., (1979) suggested that reliability studies of the GAS are problematic
as it is not possible to determine the degree to which the client, interviewer, or
methodology is represented in the scores used. Cardillo & Smith (1994) suggest
improvement to the reliability of the GAS may include involving experienced therapists,
providing comprehensive training in the GAS to therapists, ensuring goals are well
written and the use of independent raters.
The Canadian Occupational Performance Measure (Law et al., 1998) is a semi-
structured interview aimed to capture the client’s self perception of functioning in terms
of occupational performance (McColl & Pollack, 2001). The COPM focuses on the core
areas of occupational performance; self -care, productivity and leisure. Clients are
asked to identify activities they perform throughout a normal day and then asked what
37
activities they find difficult. The importance of each activity is then scored using a 1-10
scale. The same scoring procedure is repeated for the five most important items to
determine the client’s self perception of performance and satisfaction with their
performance (Bosch, 1995; Law et al., 1998). The COPM has been used to evaluate
lycra splints in both adults and children with movement disorders. Significant difference
relating to the use of lycra splints for both performance and satisfaction scores for
everyday activities were reported (Scott-Tautum, 2003).
The COPM has recently been supported in terms of several types of validity and client
utility and reliability. In a sample of 61 disabled individuals, community utility was
evaluated highly by participants. All individuals reported no problems in understanding
the COPM; 75% of the same population also found the COPM useful in identifying and
rating problems. In the same study construct and criterion validity was supported
(McColl, Paterson, Davies, Doubt & Law, 2000). Construct validity of the COPM were
also demonstrated in a study comparing therapeutic interventions for children with
cerebral palsy (Law et al., 1997).
No reliability studies have been published in peer review studies for the COPM. In an
unpublished study of older clients the COPM has shown very good test-retest reliability
(correlation coefficient of r = 0.80 for performance and r = 0.89 for satisfaction) and low
internal consistency. The low internal consistency may partially be explained by the
unique client centred focus of the COPM (Bosch, 1995). In a second study that
examined test-retest reliability of the COPM, ICC’s of 0.63 for performance and 0.84 for
satisfaction were reported (Sanford, Law, Swanson & Guyatt, 1994 cited in Donnelly &
Carswell, 2002).
The School Functional Assessment (SFA - Coster, Deeney, Haltiwanger & Haley, 1998)
is used to measure a student’s performance in functional tasks that support the student’s
participation in the academic and social aspects of the school program (Edwards &
Baum, 2001). Four constructs are measured; social participation, activity setting, activity
performance and component processes (Coster, 1998). The results of two test-retest
reliability studies demonstrated a range of interclass coefficients from 0.80 to 0.99.
Internal consistency was calculated by coefficient alphas and ranging between 0.92 -
0.98 (Edwards & Baum, 2001). To date no published intervention studies of upper limb
botox, splinting or casting have employed the SFA as an outcome measure.
38
The GAS was chosen as the measure of participation in this thesis of the efficacy of
lycra® garments as it is an individualised client centred outcome measure. This ensures
the problems measured are specific to the child and the child and family are involved in
the identification of problem areas (Donnelly & Carswell, 2002). The COPM is also an
individualised client centred outcome measure. Both the COPM and the GAS have
demonstrated good responsiveness, low validity and adequate reliability. The benefits of
the GAS over the COPM are that the clinical utility of the GAS and its past use in the
area of physical rehabilitation.
2.3.4 Contextual Factors
Contextual factors include environmental factors extrinsic to the individual (e.g. attitudes,
social norms, culture) as well as personal factors. Environmental factors “make up the
physical, social and attitudinal environment in which people conduct their lives” (AIHW,
2003 p.6). Personal factors such as age, gender and fitness have an impact on how the
disablement is experienced. Contextual factors interact with the person to determine the
level and extent of their participation (Rondinelli & Duncan, 2000). It is not anticipated
that outcomes of lycra® arm splinting will be observed at the level of contextual factors.
However the importance of the role of contextual factors facilitating function or creating
barriers for the participants in the study is recognised. These factors may be extraneous
variables in the study and need to be classified to identify change (WHO, 2000).
The ICF Checklist (Version 21a Clinician Form, WHO, 2001b) is a tool which may be
used to describe human functioning and health for individuals of all ages (Appendix R).
Functioning is described as the interaction between body functions / structures, activities
and participation and environmental factors (WHO, 2001a). Alphanumeric codes
describe in detail aspects of human functioning. Every code is then followed by a
qualifier (Battaglia et al., 2004). The ICF Checklist (Version 21a Clinician Form, WHO,
2001b) is a shortened version of the classification and only uses three digits.
The applicability and reliability of the ICF Checklist were determined by correlating it with
well established measures of function, including the Wechsler Intelligence Scale for
Children – Revised (WISCR- Wechsler 1991), the Gross Motor Function Measure
(GMFM-88 – Russell et al., 2002) and Functional Independence Measure (Keith et al.,
1987). The ICF Checklist proved to be applicable, reliable and strongly correlated with
established scales (USMDR, cited in Letts & Bosch, 2001). In a study of 176 children
with cerebral palsy aged 5-8 years old the ICF was found to provide a good framework
39
to help plan intervention for specific functional goals and to ascertain the child’s
participation in society (Beckung & Hagberg, 2002).
Part three of the ICF Checklist (WHO, 2001b) investigates environmental factors.
Environments include products and technology, natural environment and human
changes to the environment, support and relationships, attitudes, services and systems
and policies (WHO, 2001c).
Environmental factors are coded from the perspective of the individual whose situation is
described. They are also coded according to the first qualifier, which indicates the
extent to which a factor is a facilitator or a barrier. A five point scale is employed to
indicate the degree to which a particular environmental factor is a barrier or facilitator to
a person’s function (WHO, 2001a). An environment with facilitators can improve the
experience of a child with cerebral palsy, while one with barriers or without facilitators
will restrict their participation (AIHA, 2003). Part four of the ICF Checklist looks at other
contextual factors including personal factors.
Instruments for measuring the physical environment have primarily been developed for
specific age groups focusing mainly on seniors (Canadian Mortgage & Housing
Corporation, 1989; Clemson, 1997; Letts, Scott, Burtney, Marshall & McKean, 1998;
Moos, 1986; Lawton, Moss, Fulcomer & Kleban, 1982).
The only published assessments of the physical environment that met this thesis’s
criterion for assessment were The Home Environment: Home observation for
measurement of the environment (revised edition, Caldwell & Bradley, 1984) and the
Infant / Toddler Environment Rating (Harms, Cryer & Clifford, 1990). The Home
Environment: Home observation for measurement of the environment assessment was
designed for children aged from birth to 13 with any diagnosis. It aims to describe and
discriminate “the quality and quantity of stimulation and support for cognitive, social and
emotional development available to the child in the home environment” (Bradley, Rock,
Caldwell & Brisby, 1989 p. 314). Excellent reliability (rigor, internal consistency and
inter-rater) and validity (rigor and content) has been reported, as well as adequate
construct and criterion validity (Bradley & Caldwell, 1988; Coopers, Letts, Rigby, Stewart
& Strong, 2001).
The Infant Toddler Environment Rating Scale is designed for clients from birth to 21
months and aims to measure child care settings. It assesses both the physical (safety,
40
architecture, accessibility, design) and institutional factors (program structure / policy). It
has excellent inter-rater and internal consistency and adequate test re-test reliability
(Coopers et al., 2001).
Instruments for measuring the social and attitudinal environment are also primarily
designed for the adult population. Measures of social support for adults include the
Interpersonal Support Evaluation List (Cohen, Mermelstein, Kamarck & Hoberman,
1985); Social Support Inventory for people with disabilities (McColl & Friedland, 1989)
and Interview Schedule for Social Interaction (Henderson, Duncan-Jones, Byrne & Scott,
1980).
The Child Health Questionnaire (CHQ – Landgraf et al., 1996) is designed to measure
the physical and psychological well-being of children five years and older regardless of
diagnosis (Letts & Bosch, 2001). The CHQ focuses on the personal domain of
contextual factors as well as some areas of participation. The CHQ-PF-28 is a 28-item
parent report paediatric outcome measure. The CHQ is also available in extended
parent report formats (PF-50 & PF-98) and a child report (CF-87) (Pencharz, Young,
Owen & Wright, 2001).
Internal consistency of the CHQ has been established for the general population as well
as some clinical groups (Landgraf et al., 1996). Observer and test-retest reliability have
not currently been reported in research studies or the test manual (Letts & Bosch, 2001).
Content validity was established through the development of the CHQ (Landgraf et al.,
1996). The CHQ has been used as a measurement tool in an outcome study of botox in
the upper limb of children with cerebral palsy (Boyd et al., 2003). Results of the study
found that both groups (training with and without botox) improved significantly over time
in participation and societal changes as measured by the CHQ.
In a previous multiple case study investigating the effectiveness of lycra garments a
parental questionnaire was employed to collect information about contextual factors and
parents views on the benefits of the splints. There has been no reliability or validity
testing for the questionnaire. The results from the questionnaire were presented as a
descriptive component of the study. However this parental questionnaire provided
essential qualitative information about the splinting intervention (Knox, 2003).
Part three and four of the ICF Checklist (Version 21a Clinician Form, WHO, 2001b) are
the chosen classification of contextual factors to be used as part of this thesis as they
41
address all physical environments i.e. school, home and the community. The Home
Environment; Home observation for measurement of the environment assessment only
measures the home environment. Whereas children in this study will predominately wear
the splint at school. This required an assessment that could classify the school
environment, as well as other environments. The Infant Toddler Environment Rating
Scale is designed for young children (0-21 months). It is therefore not applicable to this
thesis as the population is children aged 5 to 15 years.
The CHQ is standardised for the population, however it addresses only a small number
of contextual factors as it does not address the physical environment. While lycra®
splinting does not aim to impact on the contextual factors of the wearer, it is still
considered essential to consider these factors to determine any variables the contextual
environment may influence during the course of this study. The ICF Checklist is not
employed as an assessment but rather as a descriptive component of the thesis to
classify contextual factors at all levels of the dependant variable. The parental
questionnaire (Knox, 2003) will also be employed in this study to identify contextual
factors. A preliminary study will be conducted to investigate the validity and reliability of
the parental questionnaire before it is employed as a measure in this study.
2.4 Variables of interest at the impairment level Factors were identified as the primary variables of interest for the study at the level of
impairment based on:
• Past research looking at the difference between upper limb movements in
subjects with and without hypertonicity
• Past research investigating the outcome of upper limb splinting, casting and
botox in children with cerebral palsy using motion analysis as a measurement
tool
• Objectives of lycra® arm splints
There is no consensus in the literature about the selection of kinematic variables used in
upper limb motion analysis. Motion analysis literature was reviewed for studies that
clearly discriminated the performance of people with and without neurological
impairment and reflected change in performance. The kinematic variables that emerged
as potential variables for the study of the efficacy of lycra® arm splints include,
42
movement time, target accuracy, velocity, path directness, smoothness, hand path
trajectory and angular displacement of involved segments and joints.
Variables of interest at the impairment level derived from previous studies to quantify
upper limb movements include temporal, linear and angular kinematics. The most
commonly employed temporal properties are movement time (Bernhardt, Bates &
Matyas, 1998; Gréa, Desmurget & Prablanc, 1999; Kluzik et al., 1990; Michaelsen et al.,
2001; Thomas et al., 2000; Yan, Thomas, Stelmach & Thomas 2000; Wu et al., 1998)
and initiation or reaction time (Bennett, Marchetti, Iovine & Castiello, 1995; Flash et al.,
1992). Movement time is the time from the onset of the arm movement to the target
(Yan & Thomas et al., 2000). A working definition of movement time determines the
difference between movement onset and completion, as the times the tangential velocity
of the path to the target rose above or fell and remained below 10% of the peak
tangential velocity (Michaelsen et al., 2001; Novak, Miller & Houk, 2000). A second
definition of movement completion was the “time when velocity crossed below a
threshold of ∀10°/s and stayed there for at least 30 ms” (Novak et al., 2000, p.421).
This later definition was been employed to ensure the movement really stopped after it
slowed down.
Movement time has been shown to discriminate between performances of adults with
and without neurological impairment (Bernhardt et al., 1998; Feng & Mak, 1997;
Trombly, 1992; Wu et al., 1998). Subjects with spasticity have a longer movement time
than subjects with normal muscle tone. However, McPherson and colleagues (1990)
found no significant difference in the time it took people with and without cerebral palsy
to do a required movement using electromyographic analysis. Movement time is also
referred to in the literature as movement duration (Bennett et al., 1995; Gréa et al., 2000;
Jeannerod, 1984; Teng & Kamm, 2002). Movement time has been found to be a
sensitive measure of recovery of motor performance following a cerebral vascular
accident (Trombly, 1992). In a study of the effects of neurodevelopment treatment on
reaching, in children with cerebral palsy it was found that children’s reach was
significantly faster following treatment (Kluzik et al., 1990).
Movement initiation time, reaction time or response time is the time taken from the start
signal until movement onset (Bennett et al., 1995; Flash et al., 1992; Yan & Thomas et
al., 2000; Yan & Hinrichs et al., 2000). The term movement initiation not reaction time
was used in an analysis of the drinking action of patients with Parkinson’s disease
(Bennett et al., 1995). Movement response time was shown to be considerably slower in
43
children with non-optimal neurological status than in control subjects (Schellekens et al.,
1983).
A movement path is viewed in the literature as the geometric curve a hand follows in
space (Flash et al., 1992). This is considered linear distance and measured along the
path of motion (LeVeau, 1992). In neurologically healthy subjects, the movement path of
the hand in a planar horizontal reaching movement is roughly straight (Inzelberg, Flash,
Korczyn,1990), whereas the hand path of individuals with neurological impairment are
less direct (Charlton, 1992; Chieffiet, Gentilucci, Allport, Sasso, Rizzolatti, 1993; Flash et
al., 1992; Inzelberg et al., 1995; Wu et al., 1998). The length of the path the hand
travelled did not differ significantly after neurodevelopmental therapy in children with
cerebral palsy (Kluzik et al., 1990).
Linear displacement is the change in location of the hand and is measured in a straight
line from the initial position to the final position (Hamill & Knutzen, 1995). Path
indirectness (directness index) is defined in the literature as the difference between the
actual path of the hand (linear distance) and the shortest path of the hand (linear
displacement) (Bernhardt et al., 1998). The more direct a subject’s movement is the
closer the directness index is to unity (Teng & Kamm, 2002). Path directness has also
been discussed in terms of movement linearity (Yan & Thomas et al., 2000), and the
straightness index (Thelen, Corbetta & Spence, 1996).
Target accuracy is employed as a variable of interest in eight of the 16 Melbourne
Assessment tasks (Randall et al., 1999). Endpoint error (target accuracy) was also used
to measure kinematic performance in a rapid knob-turning task. Endpoint error was
calculated by computing the distance of the pointer from the centre of the target at the
end of the movement (Novak et al., 2000).
The movement path is differentiated from the trajectory as the trajectory refers to both
the path and to the time history position along the path (Flash et al., 1992). A trajectory
is the 3D movement of the hand in space from the initial to the final position (Flash &
Hogan, 1985). Studies on the timing of upper limb movements in adults identify that the
general path is a U-shaped trajectory (Jeannerod, 1984). Patients with Parkinson’s
disease differentiated from controls by generating trajectories with asymmetrical velocity
profiles and lacking smoothness (Flash et al., 1992).
44
Speed is a sub skill of the scoring criteria for one task (hand to mouth and down) of the
Melbourne Assessment (Randall, et al., 1999). Speed is defined as the time rate of
change over distance moved (Hall, 1999). In kinematic studies of the upper limb,
velocity was used to describe upper limb movement more than speed. Velocity is the
change in position (displacement) that occurs during a given period of time (Hamill &
Knutzen, 1995).
Analysis of velocity has been used to understand upper limb movements in people with
Parkinson’s disease (Bennett et. al., 1995), adults and children performing rapid arm
movements (Yan & Thomas et al., 2000) and adults (Jeannerod, 1984). Movement by
adults of the hand to an object identify a fast-velocity initial phase and a slow-velocity
final phase resulting in a unimodal bell-shaped profile (Flash et al., 1992). The major
trajectory abnormality for patients with idiopathic torsion dystonia was that they were
less symmetric and had a longer deceleration component than adults with no known
neurological condition (Inzelberg et al., 1990). Velocity profiles have been found to differ
between children and adults (Stelmach & Thomas, 1997).
It is assumed that one of the major goals of motor coordination is the production of the
smoothest possible movement of the hand (Flash & Hogan, 1985; Hogan & Flash,
1987). Trajectories of individuals without neurological impairment generally contain a
smooth bell shaped tangential velocity profile (Flash & Hogan, 1985; Inzelberg et al.,
1990; Nakano et al., 1999) and a smooth acceleration profile. In contrast, people with
cerebral palsy (Kluzik et al., 1990) or impairments after cerebral vascular accident
(Trombly, 1992) have been shown to exhibit multiple peaks during the performance of
upper limb tasks. Studies of reaching in adults with and without spasticity have shown
subjects without spasticity have smoother movements (Bernhardt et al., 1998; Feng &
Mak, 1997; McPherson et al., 1991; Michaelsen et al., 2001; Trombly, 1992). In a study
of lycra garments in children with cerebral palsy, one of the variables of interest of
motion analysis was smoothness of movement. In individual children, smoothness of
movement compared with the normative band was observed when wearing the splints
(Nicholson et al., 2001).
Fluency is a sub-skill in the scoring criteria in eight of the tasks of the Melbourne
Assessment (Randall, et al., 1999). Fluency refers to “the ability of the movement to
flow smoothly and freely without jerkiness or tremor” (Randall, et al., 1999 p.45).
Quantitative measures of smoothness in the literature include movement units
(Bernhardt et al., 1998; Fetters & Todd, 1987; Kluizk et al.,1990; Michaelsen et al., 2001;
45
Thelen et al., 1996; Trombly, 1992; Wu et al., 1998, Teng & Kamm, 2002), movement
elements (McPherson et al., 1991), jerk (Flash & Hogan, 1985; Feng & Mak, 1997;
Krylow & Rymer, 1997) and normalised jerk (Teulings et al., 1997; Thomas et al., 2000;
Yan & Hinrichs et al., 2000; Yan & Thomas et al., 2000).
A movement unit is defined as one wave of acceleration or deceleration (Fetter & Todd,
1987; Wu et al., 1998). The working definition of the movement unit includes a preset
threshold, which unfortunately is not consistently employed in studies. The threshold
has been given as increasing values for at least 20 ms and followed by decreasing
values for at least 20 ms (Michaelsen et al., 2001), as well as a speed maximum
between two minima where the difference between the maximum speed and both
minima exceed 1 cm/s (Thelen et al., 1996). A movement unit has also been termed a
movement element in the literature (McPherson et al., 1991; Schellekens et al., 1983;
von Hofsten & Ronnqvist, 1988).
Movement unit as a measure of smoothness was employed by Bernhardt et al. (1988) in
their study investigating the accuracy of therapists’ visual judgment about kinematic
features of upper limb movements. It was also used to investigate the curvature-speed
relationship of reaching movements in five to nine month old infants (Fetters & Todd,
1987). This study found a tight coupling of the curvature speed relationship (movement
unit) regardless of distance or duration of reach. McPherson et al. (1991) used the
number of movement elements as a measure of the quality of movement and found
significant differences in the number of movement elements in people with and without
cerebral palsy. The number of movement units per reach was shown to decrease
significantly in children following neurodevelopmental therapy (Kluzik et al., 1990).
Children with an optimal neurological status were found to have less movement
elements than children with minor neurological dysfunction (Schellekens et al., 1983).
The number of movement units defined depends on a certain pre-set threshold
amplitude of acceleration and deceleration (Feng & Mak, 1997). There currently is no
objective pre-set threshold for children.
Jerk is the rate of change of acceleration or the third time derivative of position and has
been used to describe upper limb movement smoothness by Feng & Mak (1997), Flash
& Hogan (1985), Hogan & Flash (1987) and Thomas et al. (2000). In comparison to
subjects without spasticity, subjects with spasticity exhibit higher average jerk (Feng &
Mak, 1997). Yan, Hinrichs and colleagues (2000) found children have less smooth
movements than adults using jerk as the measure of smoothness. Thomas et al. (2000)
46
expanded this research and identified that jerk decreased as a function of practice and
the decreases were greater in children than in adults.
Jerk depends on the size and duration of the movement therefore it needs to be
normalised to enable a comparison of coordination difficulties in patterns of different
shapes, sizes and durations (Teulings et al., 1997). Absolute jerk may not be suitable
for children’s movements that are considerably different in terms of length and duration
(Yan & Thomas et al., 2000). Kitazawa, Goto & Urushihara (1993) normalised the
integrated jerk by distance and duration and applied it to the reaching movements before
and after lesioning of the cerebella nuclei in cats. The influence of movement length or
duration was removed from the jerk measure by dividing the time integral of square jerk
(length² / duration5) by the length² / duration5 of the movement (Kitazawa et al., 1993).
This study showed that normalised jerk is effective in quantifying and discriminating
reaching movements before and after lesioning of the cerebella nuclei in cats.
Normalised jerk has since been used to reflect the fine motor coordination deficits in
patients with Parkinson’s disease (Stelmach Thomas, 1997; Teulings et al., 1997); to
identify developmental characteristics of young girls over arm throwing (Yan & Thomas
et al., 2000), to identify developmental features of rapid aiming arm movements across
the lifespan (Yan & Hinrichs et al., 2000) and to investigate changes in movement
substructures as a function of practice (Thomas et al., 2000).
Angular displacement is the angular change related to a body segment or joint (Hill,
1999). Both relative and absolute angles are used as variables of interest in angular
kinematic studies. The relative angle is measured between adjacent body segments as
apposed to the absolute angle, which is measured in respect to an absolute reference
line (Hill, 1999). The relative angle is used in the scoring criteria in the Melbourne
Assessment (Randall et al., 1999). Angular kinematics including; range of motion
(shoulder flexion, adduction and rotation and elbow flexion and supination); proximal and
distal stability for a segment endpoint and compensatory movements (sagittal, coronal
and transverse plane movement of the trunk) were the primary variables of interest in a
study testing the efficacy of lycra garments on movement (Nicholson et al., 2001).
Changes in joint range (Feng & Mak, 1997; Gronley et al., 2000; Michaelsen et al., 2001)
and spatial and temporal inter-joint coordination patterns (Michaelsen et al., 2001) have
been analysed in previous research to describe reaching movements. The absolute
angle of the elbow has been measured with respect to the horizontal plane (Feng & Mak,
47
1997) and motion at the shoulder has been measured as relative to the thorax, as
defined by a 3D global coordinate system (Gronley et al., 2000).
Trunk flexion has been measured in millimetres from the sagittal displacement of the
sternal marker (Michaelsen et al., 2001). Using these angular kinematics, limitations in
elbow and shoulder movement have been correlated (r = -0.91 to r = -0.96) to clinical
stroke severity. These results highlight the importance of assessing both the active joint
movement, as well as the amount of compensatory trunk and shoulder girdle motion
(Michaelsen et al., 2001).
Three-dimensional motion analysis will be used in this study as one of many measures
to investigate the efficacy of lycra® arm splints at the impairment level. Variables need
to be able to detect subtle changes in upper limb motor function in children with cerebral
palsy. After review of past literature these variables include movement time, target
accuracy, path directness, velocity, normalised jerk, hand path trajectory and angular
displacement.
2.5 Conclusion The evidence based practice review of upper limb splinting in children with cerebral
palsy demonstrates the low level of available evidence to support clinical practice.
Further randomised controlled trials are necessary to provide evidence of the
effectiveness of lycra® arm splints in children with cerebral palsy, before they can be
used with confidence in clinical practice.
The review of current assessments suggests the most reliable, valid and sensitive
instruments for testing children with cerebral palsy aged between 5 to 15 years are
range of motion, 3D motion analysis, the Melbourne Assessment, WeeFIM and GAS. In
this thesis the measures of range of motion, 3D motion analysis and the Melbourne
Assessment will be employed at the impairment level to measure change in motor
function of children with cerebral palsy at all stages of the independent variable
(baseline, initial splint wear, after 3 months of splint wear, immediate splint removal and
3 months post splint wear). To assess change in activity limitations The WeeFIM will be
employed and the Goal Attainment Scale will be used to measure participation
restrictions. Preliminary studies will aim to develop further evidence for the
psychometric properties of the Melbourne Assessment, parental questionnaire (Knox,
48
2003). A normative data base will also be established for 3D motion analysis (angular
kinematics and movement sub-structures) to enable interpretation of the data from the
population of children with cerebral palsy
49
CHAPTER 3 Three Dimensional Quantification of Movement
Variables during Function in Children with and without Cerebral Palsy
Abstract Three-dimensional kinematic data from the trunk and upper extremity were collected
with a seven-camera Vicon (Oxford, U.K.) motion analysis system. The affected limb of
10 participants had cerebral palsy (hemiplegia), (four female and six male), with a mean
age of 10.0 years (SD 2.5) were tested. The left and right upper limbs of three
participants, who had no known neurological condition (one female and two male with a
mean age of 11.7 years, SD 1.3) were similarly analysed. All participants completed
four functional upper limb movement tasks taken from the Melbourne Assessment of
Unilateral Upper Limb Function (Randall et al., 1999).
The objective of this research was to provide a quantitative comparison of movement
substructures between children with and without cerebral palsy. Absolute jerk,
normalised jerk, percentage of jerk in primary and secondary movement, percentage of
time in the primary and secondary movement, percentage of distance moved in the
primary and secondary movement, peak velocity, peak velocity as percentage of
distance in primary movement, path directness, movement time, task displacement and
task distance were calculated for the wrist joint centre. This location was considered
representative of the final common pathway for the whole movement.
The variables representative of the movement substructures showed a significant
difference in movement variables in children with and without cerebral palsy and
demonstrated that motion analysis and particularly jerk, precisely quantify movement
deficits. Results of the study have important implications to therapeutic intervention for
children with cerebral palsy, highlighting the importance of multisensory feedback and
the benefits of practice.
50
Introduction
Cerebral palsy is an ‘umbrella’ description covering a group of non-progressive, but often
changing, motor impairment syndromes secondary to abnormalities of the developing
brain (Mayston, 2001; Stanley et al., 2000). Within the wide range of presentations of
cerebral palsy, hemiplegia is a unilateral motor disability (Aicardi & Bax, 1998; Hagberg
& Hagberg, 2000) and is the most common cerebral palsy syndrome among children
born at term (Hagberg & Hagberg, 2000). Common impairments of the upper limb in
children with hemiplegia include unilateral weakness, limited variety of muscle synergies,
contractures, altered biomechanics, sensory impairment, disuse and hypertonicity (Boyd,
Morris & Graham, 2001; Mayston, 2001). These impairments can impact on educational
outcomes, participation in activities of daily living and vocational options for many
children with cerebral palsy (Boyd et al., 2001).
The Melbourne Assessment of Unilateral Upper Limb Function (Randall, et al., 1999),
abbreviated to the Melbourne Assessment, is a criterion-referenced test for children
between the ages of 5 and 15 years with neurological impairment. The assessment is
designed to measure a child’s unilateral upper limb motor function based on 16 items
involving; reach, grasp, release and manipulation (Bourke-Taylor, 2003; Johnson et al.,
1994).
The Melbourne Assessment was chosen as the overarching measurement tool for the
study, as items selected for inclusion in this assessment focus on the performance
component of motor abilities that are representative of the most important components
of upper limb function. Items from the Melbourne Assessment were also selected on the
basis that they relate to functional tasks and are of particular difficulty for children with
cerebral palsy (Randall et al., 1999). The Melbourne Assessment has also been shown
to be a reliable and valid tool for measuring upper limb function in children with cerebral
palsy (Bourke-Taylor, 2003; Johnson et al., 1994; Randall et al., 1999).
Movement substructures were identified as variables of interest for this study based on
research looking at the difference between upper limb movements of participants with
and without neurological impairment. The most commonly employed temporal variable
in previous studies is movement time (Bernhardt et al., 1998; Gréa et al., 2000; Kluzik et
al., 1990; Michaelsen et al., 2001; Thomas et al., 2000; Yan & Thomas et al., 2000; Wu
et al., 1998). Movement time has been shown to discriminate between performances of
51
adults with and without neurological impairment (Bernhard, et al., 1998; Feng & Mak,
1997; Inzelberg et al., 1995; Trombly, 1992; Wu et al., 1998). Subjects with
hypertonicity have a longer movement time than subjects with normalised muscle tone
(Bernhardt et al., 1998; Gréa et al., 1999; Kluzik et al., 1990; Michaelsen et al., 2001;
Thomas et al., 2000; Yan & Thomas et al., 2000; Wu et al., 1998). Movement time has
also been found to be a sensitive measure of recovery of motor performance following a
cerebral vascular accident (Trombly, 1992).
Analysis of velocity profiles have been used to understand upper limb movements in
people with Parkinson’s disease (Bennett et. al., 1995), adults and children performing
rapid arm movements (Yan & Thomas et al., 2000) and adults prehension movements
(Jeannerod, 1984). In adults without cerebral palsy, movement of the hand to an object
comprises a fast velocity initial phase and a slower velocity final phase resulting in a
unimodal bell-shaped profile (Flash et al., 1992, Yang, Zhang, Huang & Jin 2002a &
2002b). This velocity profile alters in people with neuromuscular disorders. The major
abnormality in hand path trajectories of patients with idiopathic torsion dystonia was that
they were less symmetric and had a longer decelerative component compared with
normative data (Inzelberg et al., 1995). Velocity profiles have also been found to differ
between children and adults. Profiles of children were less smooth, less linear and had
more variation than profiles of adults (Stelmach & Thomas, 1997).
Simple upper limb movements in subjects with no known neurological condition can be
considered to have two parts – the primary (reflecting the ballistic controlled phase) and
secondary movement (reflecting the final corrective phase) (Thomas et al., 2000). The
end of the ballistic phase has been classified as the point when the acceleration curve
crosses the zero line a second time (Meyer, Abrams, Kornblum, Wright & Smith, 1988).
There is currently no research available on the identification of primary and secondary
components of movements in subjects with neurological impairment.
Non-pathological movements are qualitatively smooth and graceful (Hogan & Flash,
1987). This smoothness can be quantitatively assessed by analysis of the rate of
change of acceleration or the third time derivative of displacement defined as jerk (Feng
& Mak, 1997; Flash & Hogan, 1985; Hogan & Flash, 1987; Thomas et al., 2000). Adults
with spasticity exhibit higher average jerk when compared with adults without spasticity
(Feng & Mak, 1997). Using jerk as a measure of smoothness, Yan and Thomas et al.
(2000) found children with no known neurological impairment have less smooth
movements than adults. Thomas et al. (2000) expanded this research and identified that
52
jerk decreased as a function of practice and the changes were greater in children than in
adults. Absolute jerk may not be a suitable measure for children’s movements that are
considerably different in terms of length and duration (Yan & Thomas et al., 2000).
When analysing jerk within measured movement profiles it is important that jerk is
normalised with respect to length and duration of the movement. Normalisation enables
a comparison of patterns of different shapes, sizes and durations (Teulings et al., 1997).
Kitazawa et al., (1993) normalised the integrated jerk by distance and duration and
applied it to reaching movements before and after lesioning of the cerebella nuclei in
cats. The influence of movement length and duration was removed from the jerk
measure by dividing the time integral of squared jerk (length² / duration5) by the length² /
duration5 of the movement (Kitazawa et al., 1993). Kitazawa et al., (1993) showed that
normalised jerk is effective in quantifying and discriminating reaching movements before
and after lesioning of the cerebella nuclei in cats.
Normalised jerk has also been used to reflect the fine motor coordination deficits in
patients with Parkinson’s disease (Stelmach & Thomas 1997; Teulings et al., 1997); to
identify developmental characteristics of young girl’s overarm throwing (Yan & Thomas
et al., 2000); to analyse developmental features of rapid aiming arm movements across
the lifespan (Yan & Hinrichs et al., 2000) and to investigate changes in movement
substructures as a function of practice (Thomas et al., 2000).
Therapeutic strategies are often formed on the principal that restoring movement
substructures will reduce activity limitations in children with cerebral palsy. However
detailed and systematic research to support these principals is limited with respect to
movement substructures in children with and without cerebral palsy. This has resulted in
the application of therapies based on poorly validated assumptions of movement
(Trombly, 1992).
The aims of this study were to;
• establish normative data for movement sub-structures in typically developing
children
• investigate the difference in movement sub-structures in typically developing
children and children with cerebral palsy
53
Method This study was a descriptive research design with the objective to analyse the difference
between selected movement variables in children with and without cerebral palsy. Ten
children with cerebral palsy were recruited from the population of a larger study
investigating the efficacy of lycra® arm splints (see Table 3.1 for descriptive data of
participants). Three children without cerebral palsy were recruited through internal
advertisement at The University of Western Australia. Participants, who could not follow
one step instructions or who had significant sensory disturbances, were excluded.
Signed consent was received from parents or guardians of children in both groups (see
Appendix A and B). Ethical permission was obtained from The University of Western
Australia Human Ethics Committee.
Age Arm Assessed
Sex % score of Melbourne Assessment
Height (cm) Arm Length (cm)
1 9 L F 65.57 134.2 40.5
2 9 L F 67.21 140.0 42.1
3 12 R M 85.25 161.8 51.9
4 8 R M 40.98 134.5 42.2
5 8 L M 56.56 133.1 43.1
6 13 R M 54.92 171.4 56.1
7 9 R F 78.69 146.2 43.5
8 8 L F 68.03 135.5 42.9
9 11 L M 55.74 154.5 50.3
10 13 L M 51.64 167.2 54.5
Table 3.1: Descriptive data of participants who have cerebral palsy
Twenty-one 10 mm retro-reflective markers were placed at selected anatomical
landmarks on the upper limb and trunk (Figure 3.1). Two markers defined the hand, on
the first and fifth metacarpal heads and two markers were used in defining the wrist joint,
at the ulna and radius styloid processes. A three marker triad was placed on the
forearm and another triad on the upper arm to identify these segments. The shoulder
was marked at the acromion and at anterior and posterior sites. The trunk was defined
by markers at C7, clavicle and sternum, with markers placed at these sites. The
opposite shoulder was also marked at the acromion, and finally the head was identified
with four markers (left and right front of head and left and right back of head).
54
Participants were seated on a stool at a table and performed four tasks taken from the
Melbourne Assessment (reach forwards, reach forwards to an elevated position, reach
sideways to an elevated position and hand to mouth and down). Participants then
completed a full Melbourne Assessment. The Melbourne Assessment was administered
by a qualified occupational therapist according to the directions in the manual and
videotaped for scoring. Participants’ percentage scores for the Melbourne Assessment
are also included in Table 3.1.
A seven-camera Vicon 370 (Oxford Metrics, Oxford U.K.) motion analysis system
operating at 50 Hz was used to record the three-dimensional (3D) marker positions and
movements during i) a static subject calibration trial; and ii) dynamic trials comprising
four tasks taken from the Melbourne Assessment. The marker sets used were the i)
static subject calibration marker set (see Figure 3.1) and the ii) functional movement
marker set - a subset of the static set. The 3D position of the markers were
reconstructed using a customised model in Vicon Workstation Software (Oxford Metrics
Ltd, Oxford UK) in the static and functional movement trials. A kinematic model of the
head, trunk, upper arm, forearm and hand was created utilising Vicon BodyBuilder ®
(Oxford Metrics Ltd, Oxford UK) software and used to analyse the 3D movement of the
wrist joint centre throughout the functional tasks. The outward movement for each trial
was used for jerk analysis as consistent with the Melbourne Assessment. Three trials
for each dynamic task were selected for analysis.
55
Figure 3.1: Static calibration marker set, represented photographically and by the
reconstructed marker and joint centre positions in Vicon Workstation (the wrist joint
centre is represented in red)
The wrist joint centre was defined as the mid-point between the ulna and radial styloid
processes as identified by anatomical markers in the static trial and reconstructed
relative to the position of the forearm marker cluster during dynamic trials (the wrist joint
centre is highlighted in Figure 3.1). Once the position of the wrist joint centre was
determined, the data were filtered using a Woltering spline procedure in the Vicon
Workstation® software. A mean squared error (MSE) of 20 was determined by residual
analysis based on the sample of children without a neurological condition to enable
between group comparison of children with and without cerebral palsy (Appendix H).
Movement substructures were analysed for the 3D wrist joint centre using custom written
‘Jerk Analysis’ computer software (Labview, National Instruments Inc, Texas, U.S.A.).
This ‘Jerk Analysis’ software was modified from a 2D program developed by Thomas et
al. (2000).
To date no research has investigated movement substructures using 3D movement.
However a 3D analysis is necessary for children with cerebral palsy, as movement
difficulties are not limited to the sagittal plane. Gait analysis has shown that using a 2D
system may result in significant errors when measuring movement in children with
cerebral palsy (Ounpuu et al., 2000). To get a full understanding of the complexities of
56
motion (in three planes) and the multiple levels of involvement (abnormalities at the
trunk, shoulder, elbow and wrist) 3D motion analysis is required to accurately analyse
upper limb movement in children with cerebral palsy.
Intra-rater reliability of the ‘Jerk Analysis’ software was performed to determine the
stability of identification of primary and secondary movements by the one examiner
across time. One hundred and forty four trials were included in the analysis for the
population of children with and without cerebral palsy. Cronbach’s coefficient alpha was
employed to determine internal consistency of the percentage of distance in the primary
movement over repeated trials. Good reliability (alpha = .9985) was established for one
raters ability to identify primary and secondary movements using the ‘Jerk Analysis’
computer software (Portney & Watkins, 2000).
Movement start and finish points were identified from the 3D kinematic as well as 2D
video footage. Movement start was defined as movement of the wrist joint away from
the marked position and movement end was defined as the initial point of sustained
contact with the target or initial point when the child sustained contact between the
mouth and the biscuit and the mouth / face. These definitions are consistent with the
guidelines for the Melbourne Assessment (Randall et al., 1999).
Dependant variables were defined as;
• Movement time - time from the start of the arm movement to the target (Yan &
Thomas et al., 2000). The lower the score of movement time the faster the
movement speed (Thomas et al., 2000).
• Task displacement - change in location of the hand, measured in a straight line
from the initial to the final position (Hamill & Knutzen, 1995).
• Directness index - ratio between the actual path of the hand (linear distance) and
the theoretical shortest path of the hand (linear displacement) (Bernhardt et al.,
1998). The more direct a subject’s movement, the closer the directness index is
to unity (1) (Teng & Kamm, 2002.).
• Velocity - change in position (displacement) that occurs during a given period of
time (Hamill & Knutzen, 1995).
• Peak velocity – time at which the tangential acceleration became zero (Inzelberg
et al., 1995).
57
• Jerk index - rate of change of acceleration or the third time derivative of position
(Feng & Mak, 1997; Flash & Hogan 1985; Hogan & Flash 1987; Thomas et al.,
2000).
• Normalised jerk – jerk that has been normalised for different movement durations
and sizes by dividing integrated squared jerk by length2/ duration5 per movement
(Teulings et al., 1997).
• Primary movement – the initial ballistic movement determined by calculating the
maximum slope on the acceleration curve and adjusting it to the minimum slope
on the velocity chart. The identification of the primary movement was then
confirmed by visual inspection of the acceleration, velocity, jerk and SD graph of
the movement (see Figure 3.2).
• Percentage of jerk in primary movement – jerk in the primary sub-movement
divided by overall movement jerk (Thomas et al., 2000).
Velocity
0100200300400500600700800
Velocity
Primary movement
Acceleration
-3000
-2000
-1000
0
1000
2000
3000
Acceleration
Primary movement
Jerk
0
20000000
40000000
60000000
80000000
100000000
120000000
Jerk
Primary movement
mm.s-1 mm.s-2
3D Trajectory
Z
Y
X
Figure 3.2: Figure includes wrist joint centre velocity, acceleration, jerk and 3D trajectory
used to identify the primary movement
58
Data Analysis Non-parametric tests were employed for comparison between the group of children with
and without cerebral palsy as the assumptions of population normality and homogeneity
of variance could not be satisfied. A two-tailed Mann-Whitney with a significance level of
.05 was used to test if the two samples (children with and without cerebral palsy) came
from the same population. A Bonferroni correction was applied to protect against the
likelihood of making a type 1 error. The Bonferroni correction was made to individual
variables enabling the overall level of significance to remain at .05 (Portney & Watkins,
2000). The number of trials analysed for the group of children with CP was 120 and 72
trials were analysed for children without cerebral palsy.
Results Table 3.2 presents a summary of the mean descriptive data and Mann-Whitney
(Bonferroni corrected) p values for children with and without cerebral palsy for three
trials across four tasks. Table 3.3(A-D) outlines a summary of the mean descriptive data
for the individual tasks for children with and without cerebral palsy.
59
Variable Group Median Range Mann-Whitney p-
value Movement time CP
Non CP 1.62 1.26
3.40 2.36
.0001
Total distance CP Non CP
413.06 412.39
902.81 649.30
1.0000
Task displacement
CP Non CP
325.89 392.42
525.98 563.13
1.0000
Directness index CP Non CP
1.21 1.06
0.98 .23
<.0001
% distance primary movement
CP Non CP
79.14 94.21
87.92 74.91
<.0001
% time primary movement
CP Non CP
53.15 73.11
75.98 73.37
<.0001
Jerk index CP Non CP
6565.40 1968.51
4065144.56 36873.03
<.0001
Normalised jerk CP Non CP
81.03 44.37
2000.88 178.05
<.0001
Normalised jerk in primary movement
CP Non CP
45.98 39.40
1333.47 116.53
1.0000
Normalised jerk in secondary movement
CP Non CP
26.95 1.35
1193.01 99.16
<.0001
% jerk in primary movement
CP Non CP
65.98 97.97
96.74 72.11
<.0001
% jerk in secondary movement
CP Non CP
34.02 2.03
96.74 72.11
<.0001
Peak velocity CP Non CP
609.42 700.52
1462.29 1276.34
0.3065
Peak velocity % distance primary movement
CP Non CP
54.16 44.93
183.31 133.93
0.0156
Table 3.2: Mean data for all movement tasks for children with and without cerebral palsy
60
Movement Time (s)
Directness Index
Normalised jerk % of time in primary
movement
Non CP
Mdn
Range
1.16
1.46
1.07
0.13
47.73
115.84
67.82
45.96
CP
Mdn
Range
1.46
1.86
1.22
0.64
79.48
223.48
45.82
73.86
Table 3.3A: Mean descriptive data, for the task reach forwards for children with and
without cerebral palsy
Movement Time (s)
Directness Index
Normalised jerk % of time in primary
movement
Non CP
Mdn
Range
1.26
2.22
1.05
0.10
54.78
176.97
69.22
51.53
CP
Mdn
Range
1.88
2.90
1.25
0.91
92.05
482.87
47.60
67.47
Table 3.3B Mean descriptive data, for the task reach forwards to an elevated position
for children with and without cerebral palsy
Movement Time (s)
Directness Index
Normalised jerk % of time in primary
movement
Non CP
Mdn
Range
1.52
1.66
1.12
0.23
49.45
174.44
72.07
72.87
CP
Mdn
Range
1.67
2.12
1.22
0.73
92.39
347.24
56.81
57.97
Table 3.3C Mean descriptive data, for the task reach sideways to an elevated position
for children with and without cerebral palsy
61
Movement Time (s)
Directness Index
Normalised jerk % of time in primary movement
Non CP
Mdn
Range
1.26
0.82
1.05
0.13
31.19
59.02
83.14
42.47
CP
Mdn
Range
1.52
3.18
1.14
0.72
45.70
1994.03
59.81
71.34
Table 3.3D Mean descriptive data, for the task hand to mouth and down, for children
with and without cerebral palsy
Movement time
Movement time in the population of children with and without cerebral palsy differed
significantly for a two-tailed test at .05 (p = 0.0001). The median movement time of all
movement tasks for children with cerebral palsy (Mdn = 1.62 s, Range = 3.40 s) was
greater than for children without cerebral palsy (Mdn = 1.26 s, Range = 2.36 s). For
children with (Mdn = 1.46s, Range = 1.86s) and without cerebral palsy (Mdn = 1.16s,
Range = 1.46s) the lowest median movement time was for the reach forward task. For
both groups the highest median movement time was for the reach sideways to an
elevated position task.
Total Distance and Task Displacement
No significant difference was found for a two-tailed Mann-Whitney test at .05, in the
scores for children with and without cerebral palsy in the movement variables of total
distance (p = 1.00) and task displacement (p = 1.00). This indicates that the task
requirements were essentially the same for both children with and without cerebral
palsy.
Directness Index
A significant difference was found when comparing the means for directness index in
children with and without cerebral palsy (p = < 0.0001). The more direct a subject’s path
is to the end point the closer the directness index is to unity. Children with cerebral
palsy were shown to have a less direct path to the end point with a median directness
index of 1.21 (Range = 0.98). The median directness index of children without cerebral
palsy was 1.06 (Range = 0.23). Three dimensional trajectories of the wrist joint centre
62
for the Melbourne task, reach sideways to an elevated position, are illustrated in Figure
3.3 The task that required the subjects to reach sideways to an elevated position had a
directness index furthest away from unity for both children with (Mdn = 1.22, Range =
0.73) and without (Mdn =1.12, Range = 0.23) cerebral palsy.
Y X Z
Y
X Z
Y
Figure A Child with cerebral palsy, Directness index = 1.77
Figure B Child without cerebral palsy, Directness Index = 1.01
Figure 3.3: Three-dimensional trajectories of the wrist joint centre for children with
cerebral palsy (A) and for children without cerebral palsy (B)
Percentage of time and distance in primary movement
A significant difference was found in the percentage of time (p = <0.0001) and
percentage of distance (p = <0.0001) in the primary movement when comparing the
means of children with and without cerebral palsy. A trend was evident for children with
cerebral palsy spending a shorter percentage of time (Mdn = 53.15%, Range = 75.98 %)
and distance (Mdn = 79.14%, Range = 87.92%) in the primary movement compared with
children without cerebral palsy (time Mdn = 73.11%, Range = 73.37%; distance Mdn =
94.21%, Range = 74.91%).
Jerk index and normalised jerk
Using a two-tailed Mann-Whitney test at .05 with a Bonferroni correction a significant
difference was identified in the jerk index (p = <0.0001) and normalised jerk (p =
<0.0001) in children with and without cerebral palsy. The median jerk index for children
with cerebral palsy (Mdn= 6565.40, Range = 4065144.56) was higher than the jerk index
for children without cerebral palsy (Mdn = 1968.51, Range = 36873.03). Normalised jerk
followed the same pattern for children with cerebral palsy recording a median of 81.03
63
(Range = 2000.88) and children without cerebral palsy had a median of 44.37 (Range =
178.05). The hand to mouth and down task had the greatest normalised jerk (Mdn=
1994.03, Range = 45.70) and reach forwards the lowest normalised jerk (Mdn = 79.48,
Range = 223.48) for children with cerebral palsy.
Normalised jerk in primary and secondary movements
A significant difference was found in normalised jerk in the secondary (p = <0.0001) but
not the primary (p = 1.000) movements, in children with and without cerebral palsy. A
trend was evident for children with cerebral palsy having a greater normalised jerk in the
primary (Mdn = 45.98, Range = 1333.47) and secondary (Mdn = 26.95, Range =
1193.01) movements compared with children without cerebral palsy.
Percentage of jerk in primary and secondary movements
The percentage of jerk in the primary movement (p = < 0.0001) and secondary (p =
<0.0001) movements was significantly different for children with or without cerebral
palsy. The percentage of jerk in the secondary movement was greater for children with
cerebral palsy (Mdn = 34.02, Range = 96.74) compared with children without cerebral
palsy (Mdn = 2.03, Range = 72.11). The percentage of jerk in the primary movement
was greater for children without cerebral palsy (Mdn = 97.97, Range = 72.11) compared
with children with cerebral palsy (Mdn = 65.98, Range = 96.72). Figure 3.4 illustrates
acceleration and jerk traces for a child without cerebral palsy (3.4A) and with cerebral
palsy (3.4B) during the task, reach sideways to an elevated target.
Acceleration
-5000-4000-3000-2000-1000
010002000300040005000
Acceleration
Jerk
0
1000000000
2000000000
3000000000
4000000000
Jerk
mm.s-2
Figure 3.4A: Acceleration and jerk trace for a child without cerebral palsy, during the
task reach sideways to an elevated target
64
Acceleration
-3000
-2000
-1000
0
1000
2000
3000
4000
Acceleration
Jerk
0
1000000000
2000000000
3000000000
4000000000
Jerk
mm.s-2
Figure 3.4B: Acceleration and jerk trace for a child with cerebral palsy, during the task
reach sideways to an elevated target
Peak velocity and peak velocity as a percentage of the distance of the primary
movement
Peak velocity as a percentage of distance of the primary movement was significantly
higher for children with cerebral palsy (p = 0.0156) when compared with children without
cerebral palsy. Peak velocity as a percentage of distance in the primary movement in
children with cerebral palsy (Mdn = 54.16, Range = 183.31) was higher than in children
without cerebral palsy (Mdn = 44.93, Range = 133.93). No significant between group
differences were found for peak velocity ( p =0.3065). There was a trend for children
with cerebral palsy to have a smaller peak velocity (Mdn = 609.42, Range = 1462.29)
compared with children without cerebral palsy (Mdn = 700.52, Range = 1276.34). In
children with cerebral palsy peak velocity and peak velocity as a percentage of distance
of the primary movement were, highest for the task reach sideways to an elevated
position.
Discussion
Fitts (1992) law proposed a relatively linear relationship between speed of movement
and the level of task difficulty with movement time increasing for task complexity. This
has been supported in recent research by Yang et al. (2002a), who found that as tasks
become easier the index of difficulty decreased while the index of performance
increased. Tasks taken from the Melbourne Assessment performed by children with
cerebral palsy can then be ranked in complexity (from the easiest to most difficult); reach
forwards, hand to mouth, reach forwards to an elevated position and reach sideways to
an elevated position A similar pattern was found for children without cerebral palsy,
65
supporting the time relationship between task complexity and movement variables. This
was evidenced by tasks with a higher level of complexity having a directness index
further away from unity and a higher normalised jerk than tasks that were easier.
Movement time was greater for tasks that involved movement away from the midline and
the coordination of shoulder and elbow motion, for example reaching to an elevated side
target. Trajectory errors were also most evident in these tasks. This is consistent with
the findings of Rymer and Beer (2000) in a population of adults, who had hemiplegia.
Simple goal directed movements are considered to have two parts; the initial ballistic
phase (primary movement), and then the final corrective phase (secondary movement).
The end of the ballistic phase has been defined as when the acceleration trace crosses
the zero line for a second time (Thomas et al., 2000). The initial programmed ballistic
phase is suggested to be under central neural command, whereas the secondary
corrective phase relies on sensory feedback (Meyer et al., 1988). In this study children
with cerebral palsy spent a reduced percentage of time and distance in the ballistic
movement compared with children without cerebral palsy. This suggests that
performance of children with cerebral palsy is poorer, as less of their movement is under
central control. Young children and older adults also spent a reduced percentage of
time and distance in the primary movement compared with adults (Stelmach & Thomas,
1997). In a task that required rapid hitting of a target, 15 % to 30 % of the total
movement distance occurred in the primary phase for young and elderly subjects
whereas 80% of the movement distance occurred in the primary phase for a 24 year old
subject (Stelmach & Thomas, 1997).
The knowledge that children with cerebral palsy have a longer secondary movement has
implications for therapeutic intervention. Children with cerebral palsy make multiple
adjustments in their trajectories to enable them to successfully achieve their goal. These
adjustments rely on visual, auditory and / or somatosensation feedback. In past
research visual cues, have been reported to dominate over auditory and somatosensory
cues (Spence, Nicholls & Driver, 2001; Wallace & Newell, 1983). However audition and
somatosensation can provide important cues particularly when stimuli are occluded or
outside the current field of view (Soto-Faraco, Kingstone & Spence, 2003). This
research highlights the importance of multisensory feedback to optimise children’s
success with performance of purposeful movements of the upper limb.
Children with cerebral palsy have a smaller length of their primary movement and
increased jerk compared with children without cerebral palsy. Previous research has
66
demonstrated that with practice the primary sub-movement is lengthened and jerk
decreases. These changes were substantially larger in children than adults (Thomas et
al., 2000). This highlights the importance of practice for children with cerebral palsy.
The Deterministic Interactive-corrections model (Crossman & Goodeve, 1983) assumes
that a movement includes a series of discrete sub-movements. These sub-movements
take constant time increments to complete and travel at a constant proportion of the
remaining distance. This model does not appear to accommodate for movement of
children with cerebral palsy. The Optimised Sub-movement Model (Meyer et al., 1988)
allows for online adjustments after the initial phase. This model has been used to
explain lifespan data (Stelmach & Thomas, 1997) and may allow a better understanding
of the movement of children with cerebral palsy.
In adults and children without any known neurological impairment it has been assumed
that movement towards a target includes either one or two sub movements regardless of
target distance and width (Meyer et al., 1988). The initial sub movement is assumed to
be programmed to end at the target. If the primary sub movement ends at the target,
then no secondary movement is needed. If the primary sub movement misses the target
a secondary movement is assumed to correct the error.
In the acceleration traces for all tasks for children without cerebral palsy one or two sub-
movements were observed and the velocity curve had less than three peaks (Figure
3.5). In the population of children with cerebral palsy, two or more sub-movements were
observed and the velocity curve often had multiple peaks. Children with cerebral palsy
had a shorter ballistic movement often followed by multiple corrective movements. On
visual inspection of the 3D graphs it was evident that children with cerebral palsy often
over or under correct during the secondary movement and then require a third or fourth
sub-movement to reach the target. Greater than two sub-movements have also been
observed in previous research in adults and children without neurological impairment
(Crossman & Goodeve, 1983; Jagacinski, Repperger, Moran, Ward & Glass, 1980;
Stelmach & Thomas, 1997). In a study investigating speed / accuracy trade-offs in
young and elderly subjects a similar pattern of multiple peaks on the velocity curve and
multiple crossings on the zero acceleration line were observed in young (six year) and
elderly (74 year) participants (Stelmach & Thomas, 1997).
67
Velocity
0
200
400
600
800
1000
1200
Velocity
Acceleration
-4000-3000-2000-1000
010002000300040005000
Acceleration
Figure 3.5: Typical velocity and acceleration curve for a child without cerebral palsy
Velocity
0
100
200
300
400
500
600
700
Velocity
Acceleration
-4000-3000-2000-1000
01000200030004000
Acceleration
Figure 3.6: Typical velocity and acceleration curve for a child with cerebral palsy
Children without cerebral palsy demonstrated smoother arm movements than children
with cerebral palsy. As a higher order derivative of displacement, jerk has a relatively
greater sensitivity to movement change than the first two derivatives (velocity and
acceleration). Jerk offers unique information about the process or characteristics of
upper limb movements in children with cerebral palsy and may be better at
discriminating arm movement performance than other forms of instrumentation (Thomas
et al., 2000). A greater appreciation of movement disorders may promote the
development of more effective therapy for children with cerebral palsy.
This research corroborates findings of past research and adds to the knowledge base of
motor deficits in children with cerebral palsy. It also supports the use of the ‘jerk
analyses as an important tool in the analysis of movement in children with and without
cerebral palsy.
68
CHAPTER 4 Application of the Melbourne Assessment and 3D Upper
Limb Motion Analysis in children with and without cerebral palsy
Abstract The Melbourne Assessment of unilateral upper limb function (Melbourne Assessment) is
a criterion-referenced test developed for use with children aged 5 to 15 years with
neurological impairment. The scoring criteria is based on typically developing children
however, there is currently no published research on how these children perform on the
Melbourne Assessment. This study aims to investigate the difference between typically
developing children and the expected mean score of 100% on the Melbourne
Assessment. The study also investigates the relationship of the performance of these
children in the sub-skill range of movement for five tasks from the Melbourne
Assessment with three dimensional (3D) motion analysis of the same tasks. Therapy
and surgery rely on an understanding of the biomechanics of the upper limb and trunk,
however, there is limited research to support these assumptions in children both with
and without cerebral palsy. The third aim of this study is to investigate the differences in
maximum angle and total range of movement at the trunk, shoulder, elbow and wrist in
children with and without cerebral palsy during five tasks taken from the Melbourne
Assessment.
In this study children with and without cerebral palsy were assessed using the complete
Melbourne Assessment and 3D motion analysis during five functional tasks. Ten
participants with a mean age of 10.0 years (SD 2.5), diagnosed with cerebral palsy
(hemiplegia) were assessed. A further 10 children without cerebral palsy were age and
sex matched to the sample of children with cerebral palsy. All the children without
cerebral palsy were assessed using the complete Melbourne Assessment and three
children were assessed using 3D motion analysis. Both the left and right limbs of the
children without cerebral palsy were measured and the collective data were taken to
represent a ‘typical’ control participant. Three dimensional joint kinematic data of the
trunk and upper limb were acquired using a seven-camera Vicon motion analysis
system.
69
Results of the study demonstrated significant differences in the mean scores of typically
developing children and the expected mean of 100% on the Melbourne Assessment.
Differences were evident between the Melbourne Assessment’s sub-skill range of
motion (as determined my maximum attained value) and the maximum angle recorded
using 3D motion analysis in typically developing children. Results of the study
demonstrate significant differences in angular kinematics (maximum angle and total
range of movement) for children with and without cerebral palsy. The methodology
developed in this study provides improved insight into biomechanics of the upper limb
and trunk during functional tasks in children both with and without cerebral palsy.
Introduction The Melbourne Assessment (Melbourne Assessment – Randall et al., 1999) is an
evaluative tool that measures unilateral upper-extremity quality of movement in children
with neurological impairment aged 5 to 15 years (Bourke-Taylor, 2003). Construct and
content validity of the Melbourne Assessment are established (Bourke-Taylor, 2003;
Johnson et al., 1994) and support for concurrent-criterion validity exists (Randall et al.,
1999, Johnson et al., 1994). Test-retest reliability is high (Randall et al., 2001) and
internal consistency and inter-rater and intra-rater reliabilities for the total scores are
moderate to high (Randall et al., 1999; Randall et al., 2001).
The 16 test items on the Melbourne Assessment examine unilateral reach, grasp,
release and manipulation (Wallen et al., 2004). The Melbourne Assessment is scored
from a videotape of the child’s performance as the task is attempted. Results are
recorded on a score sheet (refer to Appendix E) comprising 16 items and 37 scores,
consisting of three, four and five point scales. The scoring criteria is individually defined
for each test item and the manual for the Melbourne Assessment lists the specific criteria
to be used to determine the level at which to score the child’s performance for each test
item (Randall et al., 1999). The scoring criteria are based on the performance of
typically developing children. Appendix F demonstrates a sample of the scoring criteria.
To date no studies have investigated whether a sample of typical children aged between
5 and 15 achieve maximum scores on the Melbourne Assessment. One unpublished
study investigated if a sample of 30 typical children aged 2 to 4 achieved maximum
scores on an adapted version of the Melbourne Assessment. In this study Randall,
Imms & Carey, (2004) found that the mean percentage scores for the whole group were
98.68%, which was statistically different to the expected mean of 100%.
70
Cerebral palsy is the most common physical disability in childhood with the incidence in
Western countries at between 2 and 2.5 per 1000 (Hagberg et al., 2001). Cerebral palsy
is an umbrella term covering a group of non-progressive but often changing motor
impairments secondary to damage to the immature brain (Mutch, Alderman, Hagberg,
Kodama & Perat 1992, Becher, 2002). Hemiplegia is a unilateral motor disability mostly
spastic in type. The characteristic clinical features of hemiplegia are unilateral paresis
and spasticity (Aicardi & Bax, 1992). Other components of upper limb dysfunction may
also include; weak grasp, loss of speed of movement, retention of grasp reflex, absence
of protective reflexes, associated and mirror movements, loss of fine motor skill, loss of
sensation, and a small thin upper limb (Brown & Walsh, 2000).
Three dimensional motion analyses provides valuable information about compensatory
and actual movements used by children with cerebral palsy to achieve their functional
goals. Children with cerebral palsy have poor selective movement and use
compensatory movements to achieve independence during functional tasks. These
movements, combined with spasticity, predispose these children to contractures and
deformity. Physical deformities can impair self esteem, function and quality of life
(Graham, 2004). Therapy and surgery aim to promote function and prevent and
ameliorate contractures and deformities based on assumptions about movement of
children with cerebral palsy. There is a lack of clear knowledge about upper limb
movement deficits (actual and compensatory) in children with cerebral palsy. This
research aims to add to the knowledge base of movement in children with cerebral palsy
by quantitatively analysing upper limb movements in children with hemiplegia using 3D
motion analyses.
Vicon 370 (Oxford Metrics Ltd, Oxford, U.K.) is a 3D commercial motion analysis system
that employs a passive optical marker system to provide a visual record of body
segment positions (Anglin & Wyss, 2000). Three dimensional motion analysis is a
powerful assessment of movement in all degrees of freedom (Rau et al., 2000). Testing
has shown that the Vicon 370 (Oxford Metrics Ltd, Oxford, U.K.) system is a valid
(Richards, 1999) and reliable measurement tool (Reid et al., 2004). Reid et al. (2004)
reported good to excellent repeatability values for, flexion / extension (coefficient of
multiple correlations - CMC = 0.92), abduction / adduction (CMC = 0.77), supination /
pronation (CMC = 0.82) (see Appendix K). In an intra-subject within day repeatability of
elbow motion in children with cerebral palsy CMCs for flexion / extension (0.78),
abduction / adduction (0.69) and supination / pronation (0.62) were lower than for those
without cerebral palsy. Results indicated the upper limb kinematics of children with
71
cerebral palsy is quite repeatable in all planes of motion for the five functional tasks
selected from the Melbourne Assessment (see Appendix L).
To date the only published upper limb 3D kinematic data on children with cerebral palsy
is limited to one study of three children with hemiplegia. Angles at the wrist, elbow and
shoulder (flexion and extension) were obtained at the moment of grasping. In this study
children grasped a cube at different positions within reaching distance. The study aimed
to investigate the extent to which participants with hemiplegia took their movement
limitations into account when planning and performing sequences. For two participants
the wrist joint contributed the largest range in hand orientation, followed by the shoulder
angle. The third participant did not change her grasp pattern throughout the experiment
(Mutsaarts, Steenbergen & Meulenbroek, 2004).
Kinematic angular data were used as one variable of interest to investigate the effect of
trunk restraints on reaching movements in a population of adults with hemiplegia.
Change in joint range at the shoulder (flexion / extension, abduction / adduction) and
elbow (flexion / extension) were calculated through computing vectors joining the
appropriate infrared light emitting diodes. Trunk flexion was measured in millimetres
from the sagittal displacement of the sternal marker and sagittal displacement was
calculated as a percentage of end point path length. A negative correlation (r -.91 to -
.96) was found between unrestrained reaching and abnormal trunk recruitment and
limitations in elbow and shoulder movements (Michaelsen et al., 2001).
A 3D analysis of elbow movement in adult subjects with and without spasticity found that
subjects with spasticity exhibited larger variations in the angle defined by the transverse
plane by the elbow joint (Feng & Mak, 1997).
Three dimensional kinematic analysis of the shoulder during functional tasks have been
reported in other clinical areas. In a study of one child with a brachial plexus lesion,
improvements in shoulder external rotation and abduction were observed by comparing
post operative shoulder movement with shoulder movement of the non affected limb
(Rab et al., 2000). In an adult population of men with C6 tetraplegia both active and
passive ranges of shoulder elevation in subjects were limited during activities of daily
living (Gronley et al., 2000). To date no study has been published that investigates 3D
movements about the shoulder, elbow, wrist and trunk during functional tasks for a
clinical population.
72
The aims of the study were therefore to:
1. Determine whether typically developing children achieve maximum total
percentage scores on the Melbourne Assessment.
2. Determine whether typically developing children achieve the required maximum
range of motion (as measured by 3D motion analysis) to score optimally in the
sub-skill range of motion for the tasks; reach forwards, reach forwards to an
elevated position, reach sideways to an elevated position, pronation / supination
and hand to mouth and down.
3. Determine if there is a significant difference in the maximum range of motion in
children with and without cerebral palsy for the Melbourne Assessment tasks;
reach forwards, reach forwards to an elevated position, reach sideways to an
elevated position, pronation / supination and hand to mouth and down.
4. Determine if there is a significant difference in the total range of movement of the
thorax, shoulder, elbow and wrist in children with and without cerebral palsy for
the Melbourne Assessment tasks; reach forwards, reach forwards to an elevated
position, reach sideways to an elevated position, pronation / supination and hand
to mouth and down.
Methods Ten children with hemiplegia (six male, four female) aged between 8 and 13 years (M =
10, SD = 2.5) participated in the study. The left side was more affected in six children
the right side was more affected in the other four children.
In past studies of people with hemiplegia, participants have acted as their own controls
by performing the experimental task with the affected and non-affected limbs
(Steenbergen & van der Kamp, 2004; Trombly, 1992; Van Thiel, Meulenbroek, Smeets &
Hulstijn, 2002). Research has shown that the non-affected limb of participants with
hemiplegia shows signs of movement disorders (Hermsdörfer, Laimgruber, Kerkhoff, Mai
& Goldenberg, 1999). This makes comparison with the non-affected limb a suboptimal
comparison for research. In this study, 10 children with no known neurological condition
were matched for age and sex with the children in the study who have cerebral palsy.
These children were recruited through internal advertising at the University of Western
Australia. Data were collected on all 10 children without cerebral palsy for the
Melbourne Assessment and on three of these ten children for 3D motion analysis. Of
the three children whose data were collected using 3D motion analysis, one was female
and two were male (mean age = 11.6, SD = 1.16 years). Collective data of the six upper
73
limbs from these participants were used as representative data of a typical control
patient. A consent form was signed by a parent or guardian in both groups and approval
was granted from the ethics committee of Western Australia (see Appendix A and B).
Research was performed in accordance with the ethical standards laid down in the 1964
Declaration of Helsinki.
All assessments took place in the movement analysis laboratory at the University of
Western Australia, in a quiet, well-lit room with minimal distractions. For both the
Melbourne Assessment and 3D motion analysis children sat on a stool at a table. The
stool and table were adjusted so children were sitting with their feet touching the floor
and hips and elbows at approximately 90 degrees of flexion. For both the Melbourne
Assessment and 3D motion analysis each task began with the child’s hand on a marked
position in the child’s midline at a forearm’s distance from the child’s chest. The
Melbourne Assessment was videotaped according to the guidelines from the Melbourne
Assessment manual (Randall et al., 1999). The 3D motion analysis tasks were also
videotaped following these guidelines as well as by three digital video cameras in the
sagittal and frontal (anterior and posterior) view. The Melbourne Assessment and the
tasks for 3D motion analysis were administered by a qualified occupational therapist
familiar with the requirements for each test item and components of the movements
scored on the Melbourne Assessment. The order of administration of the Melbourne
Assessment and 3D motion analysis was randomised for each child to help control for
the effects of fatigue and learning. The testing protocol was repeated for children
without cerebral palsy as their dominant and non-dominate upper limbs were assessed.
Children with cerebral palsy repeated the testing protocol twice with their non-dominant
upper limb. The order of testing dominant and non-dominant limbs was also
randomised,
Thorax, shoulder, elbow and wrist motion was recorded using a Vicon 370 (Oxford
Metrics Ltd, Oxford, U.K.) motion analysis system. This system utilises seven infrared
cameras operating at 50 Hz positioned around the testing table such that all of the
markers could be seen by at least two of the cameras throughout the upper limb tasks
(see Figure 4.1).
74
Figure 4.1: Room set up
Twenty-one, light weight, spherical, retroflective markers with a diameter of 10 mm were
placed at anatomical landmarks on the subject’s trunk and upper limb in a similar
configuration to the procedures of Schmidt et al. (1999) and Lloyd et al. (2000). Two
markers were used to define the hand (first and fifth metacarpal heads) and two markers
were used in the calculation of the wrist joint centre (ulna and radius styloid processes).
A three marker triad was placed on the forearm and another triad on the upper arm to
identify 3D movements for these segments. Markers used to define the shoulder joint
centre included the acromion and anterior and posterior sites (Figure 4.2). The trunk
was defined using C7, clavicle and sternum, with markers placed at these three sites.
The opposite shoulder was also marked at the acromion to provide an indication of
shoulder alignment and finally the head was identified with four markers, (left and right
front of head and left and right back of head).
75
Figure 4.2: The figure on the left is a participant with the static marker set, the figure
on the right is a polygon animation of the participant with the markers represented by
white circles
Before commencement of the Melbourne Assessment tasks, static trials were recorded
to establish joint centres and anatomical frames of reference. These static trials
included two ‘pointer’ trials, whereby a standardised pointer rod was used to ‘point’ at the
medial and lateral epicondyle landmarks (see Figure 4.3). This alternative method of
calculating the epicondyle sites and elbow axis was used in an effort to reduce errors
associated with excessive skin movement over bony landmarks (epicondyles).
Figure 4.3: A static ‘pointer’ trial using the standardised rod to point at the medial and
lateral epicondyle landmarks
76
The dynamic marker set is a sub-set of the original static marker set. The markers that
defined the wrist joint and shoulder joint centre were removed, as they were only
required in the initial joint definition static trials.
The five movements that were tested were taken from the Melbourne Assessment. The
test items were chosen that scored motor function of the wrist, elbow and shoulder and
were representative of important components of every day upper limb activities. The
items chosen were; reach forwards, reach forwards to an elevated position, reach
sideways to an elevated position, hand to mouth and down, and supination. Subjects
were instructed to perform each task a minimum of three consecutive times at their self
selected speed.
Data Analysis For each task motion data was divided into a lift and return or supination and pronation
phase based on motion data. Videotape recordings were viewed to confirm the position
of the event marker. Only the lift or supination phase was used in the analysis as
consistent with the scoring of the Melbourne Assessment. Three trials for each dynamic
task were selected for analysis. When there were more than three available trials
selecting the trial were done by eliminating the trial furthest away from the average. The
tasks reach forward, reach forward to an elevated position and reach sideways to an
elevated position were calculated from the average maximum elbow extension. The
task pronation / supination was calculated from the average maximum elbow supination
and the task hand to mouth and down was calculated from the average maximum elbow
flexion. This was the chosen method of selecting trials as if the best trial was selected
the assumption of uncorrelated error variance would be violated (Mullineaux, Bartlett &
Bennett, 2001).
A kinematic model of the upper limb and trunk created in Vicon BodyBuilder® Software
(Oxford Metrics Ltd, Oxford, U.K.) produced the 3D joint angles of the thorax, shoulder,
elbow and wrist during functional tasks. Analysis of the kinematics included; thorax (3 df
= flexion / extension, lateral flexion / extension and rotation), shoulder (3 df = abduction /
adduction, internal / external rotation and flexion / extension) elbow (3 df = flexion /
extension, abduction/ adduction and supination / pronation) and wrist (2 df = flexion /
extension and radial / ulna deviation).
77
The shoulder joint centre was identified as the centre of the three shoulder markers
placed at the acromion and at posterior and anterior sites. The shoulder joint centre was
defined in relation to the triad of markers placed on the upper arm and is reconstructed
relative to the position of the triad in dynamic trials. The elbow axis was defined as the
axis connecting the medial and lateral epicondyles as identified in the pointer trials, the
mid-point of which was defined as the elbow joint centre. The medial and lateral
epicondylar sites are reconstructed relative to the upper arm triad during dynamic trials.
The wrist joint was defined in a similar manner to the elbow joint centre. The ulna and
radial styloid process’ markers act to define the joint axis, the mid-point of which was the
wrist joint centre. These markers were reconstructed relative to the forearm triad
markers, in the dynamic trials.
The upper arm segment is defined by the upper arm triad with the origin at the elbow
joint centre while the forearm segment is defined by the forearm triad with the origin at
the wrist joint centre. The hand segment is defined by the hand markers and the wrist
joint centre with the origin lying between the two hand markers (see Figure 4.4).
Shoulder Wing
Head
y
x z
y
x z
y
x z
y
x z
Upper Arm
Forearm
Hand
Thorax
Torso
y
x z
y
x z
y
x z
Figure 4.4: Upper arm model, left figure representing markers, right figure
representing joint centres and coordinate system
78
The shoulder angles were defined as the relative movement of the upper arm segment
about the shoulder wing segment acting through the shoulder joint centre. The shoulder
wing was defined as the plane connecting the mid thorax (between C7 and clavicle
markers); acromion and the shoulder joint centre (Figure 4.5). This definition of the
shoulder joint was a more accurate representation of shoulder movement compared with
the relative movement of the upper arm segment to the thorax. The method of defining
shoulder angles in relation to the shoulder wing is of particular importance in the
population of children with cerebral palsy as their trunk position during functional tasks
(often flexed, laterally flexed to the unaffected side and rotated to the affected side)
impacts on the accurate calculations of the shoulder joint angle if calculated from the
thorax.
Figure 4.5: Shoulder wing segment
Elbow angles were identified as the relative movement of the forearm segment with
reference to the upper arm segment acting about the elbow joint centre. The wrist
angles were described as the movement of the hand segment about the forearm
segment acting through the wrist joint centre. Torso rotation and lateral flexion,
extension data are adjusted for left and right differences to enable comparison of the
total sample of children with and without cerebral palsy.
To enable a comparison with results from the range of movement sub-scale on the
Melbourne Assessment angular conversions to the data from Vicon BodyBuilder® were
79
made to assist with clinical interpretation. Consequently values for shoulder abduction,
elbow extension, wrist extension; elbow pronation and elbow supination were converted
to the Melbourne Assessment angular conventions (Table 4.1).
Melbourne Assessment Vicon Body Builder Conversion of Vicon Body Builder
Shoulder Abduction (calculated in relation to the
thorax)
Shoulder abduction (calculated in relation to the
shoulder wing)
Shoulder Abduction +
shoulder wing elevation and
depression
Elbow extension Minimum elbow flexion 180° - minimum elbow
flexion
Wrist extension Minimum wrist extension Change negative to positive
Forearm pronation (start
position of forearm mid-position ) Maximum pronation (start
position at an assumed
anatomical position, axes aligned)
Maximum pronation - 90°
Forearm supination (start
position of forearm mid-
position )
Minimum supination (start
position at an assumed
anatomical position, axes aligned)
90° - minimum elbow
supination
Table 4.1: Conversions of Vicon Body Builder Data
The nonparametric Mann-Whitney U test (one-tailed, α .01) was employed to test if there
was a significant difference between the group of children with and without cerebral
palsy. There were 10 children with cerebral palsy in Group 1 (nA = 10) and 3 children
without cerebral palsy in Group 2 (nB = 3). The median was employed as the measure of
central tendency and the range the measure of variability, when comparing children with
and without cerebral palsy, as the distribution was skewed (Stein & Cutler, 2000). As
several analyses are being run on the same sample there is a risk of inflating the value
of α if each test is performed at the same 0.05 criterion. A Bonferroni correction was
applied with the overall value of α (.05) being divided by the number of comparisons (8:
thorax – total range and maximum; shoulder – total range and maximum; elbow – total
range and maximum and wrist – total range and maximum). However to protect against
making a type II error the overall value was divided by 4 (number of comparisons divided
by 2). Therefore the p value for each individual comparison must be 0.0125 or less to be
considered significant (Portney & Watkins, 2000).
80
Percentage scores used for analysis for the Melbourne Assessment were calculated by
dividing the total raw score by the total possible score. Percentage scores have been
used in past research when analysing Melbourne Assessment data by, Randall et al.
(2004) and Wallen et al. (2004). Both research teams employed parametric tests when
analysing the differences between groups. A one-tailed single sample t-test (α = .05)
was calculated to compare the mean scores on the Melbourne Assessment between
children without cerebral palsy and the expected mean of 100%. This method of
analysis was chosen as it enables a direct comparison with the with the work of Randall
et al. (2004) who investigated if typical children aged 2 to 4 years achieved maximum
scores on the Melbourne Assessment.
Results The percentage scores for the Melbourne Assessment for children with (dominant and
non-dominant upper limb) and without cerebral palsy is listed in Table 4.2. For the non-
dominant upper limb, only three out of the 10 children without cerebral palsy scored
100% on the assessment and for the dominant upper limb four out of the 10 children
scored 100% on the assessment. The mean percentage scores for the dominant and
non-dominant limbs of children without cerebral palsy were 98.85 (SD = 1.94) and 98.77
(SD = 1.98) respectively. A one-tailed single sample t-test demonstrated a statistically
significant difference between the non-dominant upper limb of children without cerebral
palsy and the expected mean of 100% t (18) = 1.871, p < .05, and between the dominant
upper limb of children without cerebral palsy and the expected mean of 100%, t (18) =
1.96, p < .05. A 95% confidence range, that the difference between the mean scores of
the study group and the expected mean of 100% is a true difference was calculated as -
2.44 to 0.14 for the non-dominant upper limb and as -2.55 to 0.19 for the dominant upper
limb.
81
Child’s age Children without cerebral palsy (non-dominant) %
Children without cerebral palsy (dominant) %
Children with cerebral palsy (affected limb) %
9
99.18 98.36 65.57
9
99.18 99.18 67.21
12
100.00 100.00 85.25
8
99.18 99.18 40.98
8
99.18 100.00 56.56
13
99.18 98.36 54.92
9
100.00 100.00 78.69
8
93.44 93.44 68.03
11
99.18 100.00 55.74
13
100.00 99.18 51.64
M = 10
SD = 2.5
M = 98.77
SD = 1.98
M = 98.85
SD = 1.94
M = 62.46
SD = 13.17
Table 4.2: Percentage scores on the Melbourne Assessment for each sub-population
Children without cerebral palsy performed least optimally on the Melbourne Assessment,
range of motion sub-skill. For the task reach forwards, one child (non-dominant upper
limb) did not achieve the optimal score for range of motion as their wrist was flexed on
the initial point of contact with the target. For this same task, one child used greater than
30° of trunk flexion (non-dominant and dominant upper limb) and consequently did not
achieve the optimal score for range of motion. For the task hand to mouth and down,
two out of the 10 children were at greater than 15° of trunk flexion when the biscuit
contacted their mouth and subsequently did not achieve the optimal score for this sub-
skill. One child (non-dominant) worked in a range of less than the expected 80° - 100° of
shoulder abduction for the task reach sideways to an elevated position.
82
For the task reach forwards, the median scores for 3D motion analysis for the group of
children without cerebral palsy fell within the range required to score optimally for the
sub-skill range of motion (Table 4.3A). The median of 28.7° and range of 23.5° for trunk
flexion (minimum = 22.2°, maximum = 45.7°) indicated that some of the children without
cerebral palsy were working in a range of greater than 30° of trunk flexion during the
task reach forwards. For the task reach forwards to an elevated position children without
cerebral palsy had a median of 53.9° of forearm pronation (range = 27.6°), which is less
than the 60° - 90° of forearm pronation required to achieve optimally in the sub-skill
range of motion for this task. For all other variables of the task, reach forwards to an
elevated position, children without cerebral palsy had a median score that would achieve
optimal points for range of motion on the Melbourne Assessment (see Table 4.3B).
For the task reach sideways to an elevated position children without cerebral palsy had
less shoulder abduction (median = 72.5°, range = 12.5°) than the required 80° to 100° to
achieve optimally for this sub-skill and had a median of 35.7° of internal rotation at the
shoulder (range = 48.6, minimum = 11.76, maximum = 60.39). This indicates that all
children performed the task with some internal rotation, not the neutral shoulder rotation
specified in the Melbourne Assessment, to achieve optimally for this sub-skill. In the
task reach sideways to an elevated position children without cerebral palsy achieved a
median forearm pronation (median = 56.7, range = 35.58) less than the desired 60° - 90°
required to achieve an optimal score for range of motion (Table 4.3C).
For the task pronation / supination children without cerebral palsy achieved a median of
75.2° of supination (range = 41.5°). This is within the range of 45° - 90° of supination
required to achieve the maximum score for this task (see Table 4.3D).
For the task hand to mouth and down children without cerebral palsy had a median of
28.7° of trunk flexion (range = 19.0°), which is greater than the desired 0° - 15° of trunk
flexion as stated in the Melbourne Assessment. For this task children without cerebral
palsy also used more shoulder flexion (median = 52.0, range = 31.38) compared with the
0° - 45° of shoulder flexion required to score optimally on the range of motion sub-skill.
For the remaining variables the median range of motion for children without cerebral
palsy was within the recommended range to achieve the optimal score on the Melbourne
Assessment (see Table 4.3E).
83
Sub-skill range of motion
Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value
Some trunk flexion (<
30°)
Mdn = 28.7,
Range = 23.5
Mdn = 46.7,
Range = 30.2
50.0
p < .001
Shoulder flexion within
30° - 80° range
Mdn = 60.2,
Range = 39.8
Mdn = 48.0,
Range = 106.3
141.0
p = .006
Internal rotation of
shoulder
Mdn = 28.9,
Range = 38.3
Mdn = 27.6,
Range = 60.5
253.0
p = .717
Elbow extension within
135° - 180° range
Mdn = 161.1,
Range = 40.3
Mdn = 129.0,
Range = 41.7
62.0
p <.001
Wrist in neutral or
extension
Mdn = 18.4 (extension),
Range = 28.5
Mdn = 12.9
(extension)
Range = 77.7
232.0
p = .418
Table 4.3A: Melbourne Assessment Task: Reach forwards, maximum angle
Sub-skill range of motion
Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value
Some trunk flexion (<
30°)
Mdn = 26.0,
Range = 12.1
Mdn = 39.4,
Range = 31.9
38.0
p = <.001
Shoulder flexion within
80° - 145° range
Mdn = 68.1,
Range = 44.9
Mdn = 46.5,
Range = 94.3
58.0
p = <.001
Internal rotation of
shoulder
Mdn = 19.0,
Range = 39.7
Mdn = 29.7,
Range = 38.5
171.0
p = .035
Elbow extension within
135° - 180° range
Mdn = 141.0,
Range = 52.8
Mdn = 123.7,
Range = 63.8
81.0
p = <.001
Forearm pronated 60° -
90°
Mdn = 53.9 (pronation),
Range = 27.6
Mdn = 5.5 (pronation),
Range = 3.4
59.0
p = <.001
Wrist in neutral or
extension
Mdn = 16.6 (extension),
Range = 32.37
M = 22.9 (extension),
Range = 83.2
213.0
p = .225
Table 4.3B: Melbourne Assessment Task: Reach forwards to an elevated position,
maximum angle
84
Sub-skill range of motion
Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value
Some trunk displacement
and head righting
Mdn = 32.6,
Range = 19.9
Mdn = 38.7,
Range = 30.4
172.0
p = .037
Shoulder abduction
within 80° - 100° range
Mdn = 72.5,
Range = 12.5
Mdn = 40.8,
Range = 18.2
0.0
p = <.001
Neutral shoulder rotation Mdn = 35.7 (internal),
Range = 48.6
Mdn = 33.5 (internal),
Range = 45.1
242.0
p = .551
Elbow extension within
135° - 180° range
Mdn = 161.2,
Range = 40.3
Mdn = 127.3,
Range = 50.6
35.0
p = <.001
Forearm pronated 60° -
90°
Mdn = 56.7 (pronation),
Range = 35.58
Mdn = 37.7 (pronation)
Range = 65.9
119.0
p = .001
Wrist in neutral or
extension
Mdn = 18.4 (extension),
Range = 28.5
Mdn = 21.1 (extension),
Range = 84.5
209.0
p = .194
Table 4.3C: Melbourne Assessment Task: Reach sideways to elevated position,
maximum angle
Sub-skill range of motion
Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value
Forearm supinated 45° -
90°
Mdn = 75.2 (supination),
Range = 41.5
Mdn = -5.8 (supination),
Range = 89.22
4.0
p = <.001
Table 4.3D: Melbourne Assessment Task: Pronation / supination, maximum angle
85
Sub-skill range of motion
Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value
Trunk flexion within 0° -
15° range
Mdn = 28.7,
Range = 19.0
Mdn = 43.4,
Range = 32.8
89.0
p = <.001
Shoulder flexion within 0°
- 45° range
Mdn = 52.0,
Range = 31.38
Mdn = 34.6,
Range = 125.9
145.0
p = .008
Shoulder abduction
within 0° - 75° range
Mdn = 39.6,
Range = 14.8
Mdn = 35.7,
Range = 36.3
37.0
p = <.001
Internal rotation of
shoulder
Mdn = 24.8 (internal),
Range = 60.9
Mdn = 23.9, (internal)
Range = 50.4
258.0
p = .798
Elbow flexion within 110°
- 150° range
Mdn = 133.6,
Range = 21.46
Mdn = 136.3,
Range = 56.1
207.0
p = .180
Wrist in neutral or
extension
Mdn = 47.0 (extension),
Range = 23.7
M = 35.4 (extension),
Range = 61.3
139.0
p = .005
Table 4.3E: Melbourne Assessment Task: Hand to mouth and down, maximum angle
A one-tailed (α = .01) Mann-Whitney U test established a significant difference between
children with and without cerebral palsy for the variables trunk flexion, shoulder flexion
and elbow extension within the task reach forwards (Table 4.3A). Children with cerebral
palsy had greater trunk flexion (median = 46.7°, range = 30.2) than children without
cerebral palsy (median = 28.7°, range = 23.5), U = 50.0, p < .001. Children with cerebral
palsy had a significantly smaller maximum shoulder flexion (median = 48.0°, range =
106.3) than children without cerebral palsy (median = 60.2°, range = 39.8), U = 141.0, p
=.006. Children with cerebral palsy had less elbow extension (median = 129.0°, range =
41.7) than children without cerebral palsy (median = 161.1°, range = 40.3), U = 62.0, p <
.001.
A similar pattern with statistically significant differences at the trunk (flexion, U = 38, p <
.001), shoulder (flexion, U = 58, p < .001) and elbow (extension, U = 58, p < .001) was
established for the task reach forwards to an elevated position (Table 4.3.B). For this
task forearm pronation was also measured and a significant difference was recognised
between the two groups of children with and without cerebral palsy, (U = 59.0, p < .01).
Children without cerebral palsy had greater maximum pronation (median = 53.9°, range
= 27.6) than children with cerebral palsy (median = 35.5°, range = 83.4).
86
For the task reach sideways to an elevated position, children without cerebral palsy had
a greater shoulder abduction angle (median = 72.5°, range = 12.5) than children without
cerebral palsy (median = 40.8°, range = 18.2), U = 0.0, p <.001. Children both with
(median = 35.7°, range = 48.6) and without cerebral palsy (median = 33.5°, range =
45.1), were in internal rotation on initial point of sustained contact with the target.
Children without cerebral palsy had a greater maximum pronation (median = 56.7°,
range = 35.6) than children with cerebral palsy (median = 37.7°, range = 65.9), U =
119.0 p =.001. Consistent with the tasks reach forwards and reach forwards to an
elevated position children with cerebral palsy had less elbow extension (median =
127.3°, range = 50.6) than children without cerebral palsy (median = 35.7°, range =
48.6), U = 35.0, p < .001 (Table 4.3C).
For the task pronation / supination children without cerebral palsy had a greater
maximum supination value (median = 75.2° supination, range = 41.5) compared with
children with cerebral palsy (median = -5.8° supination, range = 89.22), U = 4.0, p < .001
(Table 4.3D).
For the task hand to mouth and down children with cerebral palsy had greater trunk
flexion (median = 43.4°, range = 32.8), than children without cerebral palsy (median =
28.7°, range = 19.0) U = 89.0, p < .001. Children without cerebral palsy had greater
shoulder abduction, U = 37.0, p < .001, shoulder flexion, U = 145.0, p =.008, and wrist
extension U = 139.0, p < .005 than children with cerebral palsy (Table 4.3E).
Children with cerebral palsy employed greater compensatory movements of the trunk in
all degrees of movement to achieve functional tasks. A statistically significant (one –
tailed test, α .01) change in the total range of thorax flexion / extension was found
between children with and without cerebral palsy for the tasks; reach forwards (U = 83.0,
p <.001), reach forwards to an elevated position (U = 144.0, p = .007), reach sideways to
an elevated position (U = 63.0, p < .001), pronation / supination (U = 14, p < .001) and
hand to mouth and down (U = 98.0, p < .001). For all tasks, children with cerebral palsy
had a greater total range of movement in thorax flexion and extension than children
without cerebral palsy (Tables 4.4A to E).
A statistically significant (one –tailed test α .01) difference in the total range of thorax
lateral flexion / extension was found between children with and without cerebral palsy for
the tasks; reach sideways to an elevated position (U = 43.0, p < .001), pronation /
87
supination (U = 96.0, p < .001) and hand to mouth and down (U = 96.0). Children with
cerebral palsy have increased lateral flexion of the contralateral side (the side opposite
to their affected side) than children without cerebral palsy (Figure 4.6A to C).
A statistically significant (one –tailed test α .01) change in the range of torso rotation was
found between children with and without cerebral palsy for the tasks, reach sideways to
an elevated position (U = 78.0, p <.001), pronation / supination (U = 18.0, p <.001) and
hand to mouth and down (U = 128.0, p < .001). Children with cerebral palsy rotated
forwards in the direction of their affected limb (Figure 4.6A to C).
No significant difference (one –tailed test α .01) was established for the total range of
shoulder movement (flexion / extension) for the tasks reach forwards to an elevated
position (U = 204.0, p = .160) and hand to mouth and down (U = 232.0, p = .418). For
shoulder abduction a significant difference was established in the total range of
movement between children with cerebral palsy (median = 24.4°, range = 55.7) and
without cerebral palsy (median = 45.2°, range = 45.6) for the task, reach sideways to an
elevated position, U = 75.0, p < .001. No significant difference was established between
the two groups for total range of shoulder abduction for the task hand to mouth and
down, U = 251.0, p = .694. No significant difference was established for the total range
of shoulder flexion extension for the tasks reach forwards to an elevated position (U =
204.0, p = .160) and hand to mouth and down (U = 232.0, p = .418).
A significant difference (one –tailed test α .01) was established for the total range of
elbow flexion / extension in children with and without cerebral palsy for the tasks reach
forwards to an elevated position (U = 134.0, p = .004) and reach sideways to an
elevated position (U = 64.0, p < .001). For both of these tasks children with cerebral
palsy worked in a range of movement significantly smaller than children without cerebral
palsy (see Table 4.2 and 4.3). For the task reach forwards no significant difference was
established in range of elbow flexion / extension for children with and without cerebral
palsy, U = 191.0, p = .092. No significant difference was established between children
with and without cerebral palsy for the tasks; reach forwards to an elevated position (U =
182.0, p = .061) reach sideways to an elevated position (U = 218.0, p = .268) and hand
to mouth and down (U = 206.0, p = .173) for the range of forearm rotation.
For all reaching tasks, a significant difference was established between children with and
without cerebral palsy in the range of wrist flexion / extension. The range of movement
88
employed by children with cerebral palsy was greater for all reaching tasks than the
range of movement used by children without cerebral palsy (Tables 4.4A to C). A
significant difference (one –tailed test α .01) was established for the range of wrist radial
/ ulna deviation in children with and without cerebral palsy for the tasks reach forwards
(U =46.0, p <.001), reach forwards to an elevated position (U = 56.0, p <.001), reach
sideways to an elevated position (U = 39.0, p < .001) and supination / pronation (U =
51.0, p < .001). For these tasks, children with cerebral palsy used a significantly greater
range of radial / ulna deviation compared to children without cerebral palsy (Table 4.4A
to C). Figure 6A to C shows that children with cerebral palsy have a greater maximum
ulna deviation.
Range of movement Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value
Thorax flexion /
extension
Mdn = 2.6,
Range = 7.1
Mdn = 8.3,
Range = 25.93
U = 83.0,
p <.001
Elbow flexion /
extension
Mdn = 49.9 , Range =
57.4
Mdn = 41.0,
Range = 74.8
U = 191.0,
p = .092
Elbow rotation Mdn =16.1 ,
Range = 17.2
Mdn = 24.9,
Range = 83.1
U = 191.0,
p = .092
Wrist flexion / extension Mdn = 10.9 , Range =
20.0
Mdn = 29.7 , Range =
62.7
U = 74.0,
p <.001
Wrist ulna / radial
deviation
Mdn = 7.8,
Range = 12.7
Mdn = 19.44, Range =
41.29
U = 46.0,
p <.001
Table 4.4A: Total range of movement, for the task reach forwards
89
Range of movement Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value U
Thorax flexion /
extension
Mdn = 5.0,
Range = 6.0
Mdn = 7.9,
Range =21.4
U = 144.0,
p = .007
Thorax lateral flexion /
extension
Mdn = 10.6,
Range = 15.7
Mdn = 12.4,
Range = 22.0
U = 214.0,
p = .233
Thorax rotation Mdn =9.6,
Range =14.9
Mdn =9.6,
Range = 27.0
U = 261.0,
p = .848
Shoulder rotation Mdn = 31.2,
Range = 41.5
Mdn = 20.8,
Range = 51.2
U = 211.0,
p = .209
Shoulder flexion /
extension
Mdn = 52.3,
Range = 47.5
Mdn = 36.7,
Range = 138.2
U = 204.0,
p = .160
Elbow flexion /
extension
Mdn = 51.3,
Range = 51.7
Mdn = 28.1,
Range = 100.8
U = 134.0,
p = .004
Elbow rotation Mdn = 16.2,
Range = 19.5
Mdn = 21.4,
Range = 106.5
U = 182.0,
p = .061
Wrist flexion / extension Mdn = 14.6,
Range = 24.8
Mdn = 37.9,
Range = 83.2
U = 86.0,
p <.001
Wrist ulna / radial
deviation
Mdn = 9.0,
Range = 13.9
Mdn = 23.6,
Range = 87.0
U = 56.0,
p <.001
Table 4.4B: Total range of movement for the task, reach forwards to an elevated
position
90
Range of movement Children without
cerebral palsy Children with cerebral palsy
Mann-Whitney U and p value U
Thorax flexion /
extension
Mdn = 4,3,
Range = 10.6
Mdn = 10.6,
Range = 32.3
U = 63.0,
p <.001
Thorax lateral flexion /
extension
Mdn = 4.8,
Range = 10.6
Mdn = 17.6,
Range = 71.1
U = 43.0,
p <.001
Thorax rotation Mdn = 10.3,
Range = 14.7
Mdn = 19.1,
Range = 44.6
U = 78.0,
p <.001
Shoulder rotation Mdn = 48.4,
Range = 59.9
Mdn = 43.1,
Range = 47.6
U = 167.0,
p = 0.28
Shoulder abduction /
adduction
Mdn = 45.2,
Range = 45.6
Mdn = 24.4,
Range = 55.7
U = 116.0,
p = .001
Elbow flexion /
extension
Mdn = 86.4,
Range = 61.8
Mdn = 36.0,
Range = 100.5
U = 64.0,
p <.001
Elbow rotation Mdn = 25.9,
Range = 25.2
Mdn = 27.0,
Range = 70.4
U = 218.0,
p = .268
Wrist flexion / extension Mdn = 17.01, Range =
34.0
Mdn = 41.2,
Range = 102.1
U = 52.0,
p <.001
Wrist ulna / radial
deviation
Mdn = 12.9,
Range = 29.6
Mdn = 33.3,
Range = 117.7
U = 39.0,
p <.001,
Table 4.4C: Total range of movement for the task, reach sideways to an elevated
position
91
Range of movement Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value
Thorax flexion /
extension
Mdn = 4.3,
Range = 10.6
Mdn = 10.6,
Range = 32.3
U = 14.0,
p <.001
Thorax lateral flexion /
extension
Mdn = 4.8,
Range = 10.6
Mdn = 17.3,
Range = 71.1
U = 24.0,
p <.0010
Thorax rotation Mdn = 10.3,
Range = 14.7
Mdn = 19.1,
Range = 44.6
U = 18.0,
p <.001
Elbow rotation Mdn = 25.9,
Range = 25.2
Mdn = 27.0,
Range = 70.4
U = 18.0,
p <.001
Wrist flexion / extension Mdn = 17.0,
Range = 34.0
Mdn = 41.4,
Range = 102.1
U = 207.0,
p = .180
Wrist ulna / radial
deviation
Mdn = 12.9,
Range = 29.6
Mdn = 33.3,
Range = 117.7
U = 51.0,
p <.001
Table 4.4D: Total range of movement for the task, pronation / supination
92
Range of movement Children without cerebral palsy
Children with cerebral palsy
Mann-Whitney U and p value
Thorax flexion /
extension
Mdn = 0.9,
Range = 5.8
Mdn = 5.5,
Range = 24.1
U = 98.0,
p <.001
Thorax lateral flexion /
extension
Mdn = 1.2,
Range = 4.6
Mdn = 4.3,
Range = 13.1
U = 96.0,
p <.001
Thorax rotation Mdn = 0.7,
Range = 1.6
Mdn = 3.4,
Range = 19.8
U = 128.0,
p = .002
Shoulder rotation Mdn = 8.0,
Range = 29.32
Mdn = 9.3,
Range = 22.8
U = 253.5,
p = .717
Shoulder flexion /
extension
Mdn = 14.6,
Range = 21.1
Mdn = 15.2,
Range = 37.6
U = 232.0,
p = .418
Shoulder abduction /
adduction
Mdn = 9.0 ,
Range = 16.0
Mdn = 7.6,
Range = 29.7
U = 251.0,
p = .694
Elbow flexion /
extension
Mdn = 59.1,
Range = 35.5
Mdn = 47.7,
Range = 55.9
U = 125.0,
p = .002
Elbow rotation Mdn = 17.6,
Range = 25.8
Mdn = 19.7,
Range = 69.0
U = 206.0,
p = .173
Wrist flexion / extension Mdn = 12.3 , Range =
45.0
Mdn = 16.3,
Range = 62.8
U = 240.0,
p = .523
Wrist ulna / radial
deviation
Mdn = 13.5,
Range = 31.0
Mdn = 14.7,
Range = 76.1
U = 233.0,
p = .431
Table 4.4E: Total range of movement for the task hand to mouth and down
93
TransverseSagittal Frontal Flexion Flexion Thorax Flexion / Extension
5
15
25
35
45
55
Angl
e
Thorax Lateral Flexion / Extension
-15
5
25
Angl
e
Thorax Rotation
-25-15-55
1525
Angl
e
Forwards Flexion Contralateral
Extension Ipsilateral Backwards
Shoulder Flexion / Extension
-200
20406080
Angl
e
Shoulder Adduction / Abduction Shoulder Internal / External Rotation
-30
20
70
Angl
e
Flexion
-80-60-40-20
020
Angl
es
Adduction Internal
Abduction Extension
External Legend
Children with cerebral palsy
Elbow Flexion / Extension
507090
110130150
Angl
e
Elbow Pronation / Supination
80
100
120
140
160
180
100% Cycle
Angl
eFlexion
Pronation
Children without cerebral palsy
Extension Supination
Wrist Flexion / Extension
-60-40-20
020
100% Cycle
Angl
e
Wrist Ulna / Radial Deviation
-40
-20
0
20
40
100% Cycle
Angl
e
Flexion Ulna
Extension Radial
Figure 4.6A: Upper limb and thorax angles for the task, hand to mouth and down
94
Sagittal Frontal Transverse
Thorax Flexion / Extension
5
15
25
35
45
55
Angl
e
Thorax Lateral Flexion / Extension
-25
-5
Thorax Rotation
-30
-10
10
30
Angl
e
Flexion Forwards
15
35Contralateral
Angl
e
Backwards Ipsilateral
Extension
95
Wrist Ulna / Radial Deviation
0
-20
0
20
40
100% Cycle
Angl
e
Elbow Pronation / Supination
0
50
100
150
100% Cycle
Angl
e
200
Wrist Flexion / Extension
-30-10
10
100% Cycle
Angl
e
Pronation
-50
30Flexion Ulna
Extension -4Radial Supination
Legend
Children with cerebral palsy
Children without cerebral palsy
Figure 4.6B: Upper limb and thorax angles for the task pronation / supination
Sagittal Frontal Transverse
Thorax Flexion / Extension
5
15
25
35
45
55
Angl
e
Thorax Lateral Flexion / Extension
-25
-5
15
35
Angl
e
Thorax Rotation
-45
-25
-5
Flexion Contralateral
15
Angl
e
Forwards
Ipsilateral Backwards Extension
96
Shoulder Flexion / Extension
-30-1010305070
Angl
e
Shoulder Adduction / Abduction
-100-80-60-40-20
Angl
es
Shoulder Internal / External Rotation
-35
15
Angl
e
Flexion Adduction Internal
Extension External Abduction
Elbow Pronation / Supination
-10
40
90
140
190
100% Cycle
Angl
e
Legend Elbow Flexion / Extension
-50
0
50
100
150
Angl
e
Pronation Flexion Children with cerebral
palsy
Children without cerebral palsy
Supination
Extension
Wrist Ulna / Radial Deviation
-40
10
100% Cycle
Angl
e
Wrist Flexion / Extension
-40
10
100% Cycle
Angl
e
Ulna Flexion
Extension Radial
Figure 4.6C: Upper limb and thorax angles for the task, reach sideways to an elevated position task
Discussion For the Melbourne Assessment a statistically significant difference between the mean
scores for typically developing children (dominant, t (18) = 1.96, p < .05 and non-
dominant t (18) = 1.87, p < .05 upper limb) and the expected mean of 100% was
established. This was consistent with the findings of Randall et al. (2004), which
examined if typically developing children aged 2 to 4 years achieved maximum
scores on the Melbourne Assessment – version 2. A mean of 98.68% was
established for children aged 2 to 4 years, which is less than the mean of 98.85%
(dominant) and 98.77% (non-dominant), established in this study in children aged 8
to 13 years old.
Although a statistically significant difference in mean scores on the Melbourne
Assessment was established in this study, the 95% confidence interval suggested
that a ‘true’ difference in mean scores was most likely to occur between 0.1% and
2.4% (non-dominant) and 0.2% and 2.6% (dominant), thus, a difference would not be
considered clinically significant. This is also similar with the findings of Randall et al.
(2004) in the sample of children aged 2 to 4 years.
Differences in the individual scoring criteria for the Melbourne Assessment and 3D
motion analysis data were established for the tasks reach forwards to an elevated
position, reach sideways to an elevated position, hand to mouth and down and
supination / pronation. The discrepancies between the individual scoring criteria for
the Melbourne Assessment and the data for 3D motion analysis, in the sample of
typically developing children, indicates that for some of the tasks on the Melbourne
Assessment the range of motion sub-skill may not reflect typically developing
children. These inconsistencies were constant in the data from the complete
Melbourne Assessments for typically developing children in the range of movement
sub-skill. Data from the Melbourne Assessment and 3D motion analysis highlight
that typically developing children have increased trunk flexion (reach forwards, hand
to mouth and down), wrist flexion (reach forwards) and reduced shoulder abduction
(reach sideways to an elevated position) than that required to score optimally in the
sub-skill range of motion. A difference was also established in maximum range of
motion measured by 3D motion analysis and the sub-skill range of motion for forearm
pronation (reach forwards to an elevated position, reach sideways to an elevated
position), shoulder rotation (reach sideways to an elevated position) and shoulder
abduction (hand to mouth and down).
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Significant differences in maximum range of movement in children with and without
cerebral palsy were established using 3D motion analysis for the variables of interest
for each task analysed on the Melbourne Assessment. Differences were established
for trunk flexion (reach forward, reach forward to an elevated position and hand to
mouth and down), shoulder flexion (reach forward, reach forward to an elevated
position and hand to mouth and down), shoulder abduction (hand to mouth and
down), elbow extension (reach forward, reach forward to an elevated position and
reach sideways to an elevated position), elbow pronation (reach forward to an
elevated position and reach sideways to an elevated position), elbow supination
(supination / pronation) and wrist extension (hand to mouth and down). During the
development of the Melbourne Assessment, items were selected that were of
particular difficulty for children with cerebral palsy (Randall et al. 1999). The data
suggests that the tasks chosen were of particular difficulty for children with cerebral
palsy and supports the selection of these items as part of the Melbourne
Assessment.
A significant difference was established between children with and without cerebral
palsy for total range of thorax flexion (all five tasks assessed); lateral flexion (reach
sideways to an elevated position, hand to mouth and down and pronation /
supination) and rotation (reach sideways to an elevated position, hand to mouth and
down and pronation / supination). The scoring criterion of the Melbourne
Assessment for the task supination / pronation is based solely on the maximum
range of movement of supination (Randall et al. 1999). Using 3D motion analysis a
significant difference was established in total range of movement at the thorax
(flexion / extension, U = 14.0, p <.001, lateral flexion / extension, U = 24.0, p < .001,
rotation, U = 18.0, p < .001) between children with and without cerebral palsy.
Children with cerebral palsy used a compensatory pattern of the thorax (flexion,
lateral flexion to the unaffected side and forward rotation of the affected side) to
supinate their forearm. Surgery and therapy aim to promote function and minimise
compensatory movements. Without including range of movement at the thorax in the
task supination / pronation, these compensatory movements used to achieve
supination cannot be measured using the Melbourne Assessment.
For the shoulder, a significant difference in children with and without cerebral palsy
was established in maximum shoulder flexion for the tasks reach forwards to an
elevated position and hand to mouth and down. For the same tasks no significance
98
was established for the total range of shoulder flexion / extension. This suggests that
children without cerebral palsy start and finish the movement in greater shoulder
flexion. A significant difference was established between children with and without
cerebral palsy for maximum elbow pronation for the tasks reach forwards to an
elevated position, reach sideways to an elevated position and hand to mouth and
down. For the same subjects and same tasks, no significant difference was
established for total range of movement in forearm rotation. This suggests that
children without cerebral palsy start and finish the movement in greater pronation
than children with cerebral palsy.
A significant difference between children with and without cerebral palsy was
established for the total range of radial/ ulna deviation for the tasks reach forwards (U
= 46.0, p <.001), reach forwards to an elevated position (U = 56.0, p < .001), reach
sideways to an elevated position (U = 39.0, p <.001) and supination / pronation (U =
51.0, p <.001). Ulna / radial deviation is not included in any range of motion sub-skill
on the Melbourne Assessment and yet it clearly differentiates between children with
and without cerebral palsy.
It has been recommended that if arm motion analysis is to become routinely used for
diagnosis or rehabilitation then a set of discriminating or functional tasks should be
established (Anglin & Wyss, 2000). Tasks from the Melbourne Assessment are
related to functional tasks and aim to be representative of the most important
components of upper limb function (Randall et al. 1999). This research has
established that the Melbourne Assessment can discriminate range of movement and
total range of movement between children with and without cerebral palsy and
consequently may be appropriate standard activities of the upper limb for motion
analysis.
The Melbourne Assessment is a criterion-referenced assessment which provides
information about a child’s actual upper limb performance and skill development
(Dunn, 2001; Randall et al., 1999). The Melbourne Assessment bases this
performance on accepted standards of competency (Stein & Cutler, 2000). These
operational performance standards outlined in the scoring criteria of the Melbourne
Assessment are based on ‘typical’ movement. This research has demonstrated
through 3D motion analysis that the operational performance standards that guide
the sub-skill range of motion do not always reflect typical movement. The research
supports the choice of the inclusion of the items reach forwards, reach forwards to an
99
elevated position, reach sideways to an elevated position hand to mouth and down
and pronation / supination as part of the Melbourne Assessment. This research has
also identified other variables of interest (compensatory movement of the thorax for
the task supination / pronation and ulna and radial deviation for all tasks) that are
shown to be of particular difficulty for children with cerebral palsy. This research has
also provided a quantitative measure of the way children with cerebral palsy achieve
upper limb tasks and adapt to compensate for musculoskeletal pathology. With this
knowledge therapists and surgeons can base their intervention and evaluate the
impact of the intervention on performance.
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CHAPTER 5 A Randomised Control Trial of Lycra® Arm Splints in Children with Cerebral Palsy Across all Levels of the International Classification of Functioning Disability
and Health
Abstract This study aimed to investigate the efficacy of the short term (1 hour), long term (3
months), short term carryover (1 hour) and long term carryover (3 months) effects of
wearing lycra® arm splints in children with cerebral palsy across all levels of the
International Classification of Functioning Disability and Health (ICF). Eighteen
participants aged between 6 years 2 months and 14 years 11 months (M = 11.12, SD
= 2.44) with a diagnosis of cerebral palsy were recruited. A randomised cross-over
research design was employed, with all participants tested using the following
assessments; The Melbourne assessment of unilateral upper limb function, passive
and active range of motion, Functional Independence Measure for Children, ICF
Checklist, Goal Attainment Scale, Parent questionnaire, Teacher questionnaire and
Child questionnaire.
No significant mean difference was found in the scores on The Melbourne
assessment of unilateral upper limb function and passive and active range of motion
across all treatment conditions. No significant difference was established for the
Functional Independence Measure for Children at baseline, at 3 months of splint
wear and 3 months post splint wear. After 3 months of splint wear the mean T-score
for the Goal Attainment Scale was greater than 50 indicating children had achieved
their goals. Descriptive statistics were used to analyse the Teacher, Parent and
Child Questionnaire as well as the ICF Checklist. The lycra® arm splint was shown
to have a statistically significant impact at the level of participation after 3 months of
wear (measured by the Goal Attainment Scale), whereas no significant difference
was observed at the levels of impairment and activity (measured by The Melbourne
assessment of unilateral upper limb function, passive and active joint range of motion
as measured using a goniometer and the Functional Independence Measure for
Children).
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Introduction Cerebral palsy is a non-progressive permanent neurological disorder caused by
damage to the immature brain (Mayston, 2001; Stanley et al., 2000). Neurological
splinting is commonly utilised in the management of children with cerebral palsy-
spasticity (Reid, 1992a). Splints are devices added to the body to support, position,
or immobilise a part; to prevent contractures and deformities; to assist weak muscles
and restore function or to reduce spasticity (Trombly, 1989).
Lycra® arm splints are designed and fabricated in Australia by Second Skin™ (see
Figure 5.1). The splints are individually tailored and consist of lycra stitched together
to produce tension in the area where the splint is worn. The fabric alignment is
related to the desired direction of pull of the associated muscles (Gracies et al.,
2000). The effects of neutral warmth, circumferential pressure and a low force
resisting the spastic muscle are believed to contribute to the modification of spasticity
(Wilton, 2003). Lycra® the splinting aims to impact on tone, posture, pattern of
movement and promote function (Second Skin, 2000).
Figure 5.1: Lycra® arm splint
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In an adult population with no known neurological condition, from a neutral position
lycra supination arm splints were found to supinate the forearm of all 10 subjects,
while pronator garments pronated the forearm in eight out of the 10 subjects (Gracies
et al., 1997). Lycra arm and hand splints have also been shown to reduce swelling in
the distal limb, improve wrist posture and reduce wrist and finger spasticity in a
population of adults with hemiplegia (Gracies et al., 2000).
The effect of lycra splints in children with cerebral palsy has been investigated by
Blair et al. (1995), Brownlee et al. (2000), Corn et al. (2003), Edmondson et al.
(1999), Knox (2003), Nicholson et al. (2001) and Scott-Tautum (2003). None of
these studies randomly allocated subjects to groups and the majority were case
series with outcomes measured before and after splinting.
Blair et al. (1995) obtained outcomes from three concurrent studies; a descriptive
study, a four-period crossover trial and a recipient-control study. They found
immediate improvements in postural stability and reduction in involuntary movement,
increased confidence to attempt motor tasks and improved dynamic function
following wearing of lycra® Upsuits. The results of these studies have been criticised
by other researchers and clinicians for failing to control a number of threats to
internal validity and for not being sufficiently impartial (Nicholson et al., 2001). Harris
(1996) stated Blair et al. (1995) failed to employ a valid crossover design, lacked
examiner blinding and used subjective measures.
Knox (2003) evaluated the effect of wearing lycra garments in eight children with
cerebral palsy. A repeated measures design was used with participants tested using
the Gross Motor Function Measure (GMFM – Russell et al., 2002) and the Quality of
Upper Extremity Skills Test (QUEST – DeMatteo et al., 1993). However statistical
power of this study was low as 50% of participants withdrew from the study. Of the
remaining four, improvements in either the QUEST or GMFM were reported.
Nicholson et al. (2001) evaluated upper limb function in 12 children with cerebral
palsy wearing lycra garments using 3D motion analysis, the Paediatric Evaluation of
Disability Index (PEDI – Haley et al., 1992) and a parental or carer questionnaire.
The authors found that all children made improvements in at least one of the
functional scales of the PEDI and scores for the whole group showed significant
gains. The 3D measures used require further examination before confidence is given
103
to these findings. The normative data used to validate movements of the upper limb
during the reaching task were based on one 31-year old male subject and may not
be representative of normative movement in children (Attfield et al., 1998).
Edmonson et al. (1999) investigated the efficacy of Camp (Camp International Inc,
Canada, Ontario) lycra garments in 15 children aged 2 to 12 years with a diagnosis
of cerebral palsy. An unpublished assessment, which examined gross motor skills,
balance and fine motor function was administered pre and post splinting. A range in
functional change was found with children with athetosis, ataxia and hypotonia
showing marked improvement.
Brownlee et al. (2000) evaluated hand and gauntlet splints for 10 children with
hemiplegia and whole body suits for 10 children with quadriplegia. A non-
standardised hand function assessment and the GMFM were used to obtain a base
line measure and again after splinting. Six out of the 10 children with hemiplegia
showed functional improvements in hand skill testing after eight weeks. No change
was seen in children with quadriplegia on the GMFM.
Blair et al. (1995) identified compliance as a major issue in lycra garment prescription
studies. Difficulties with donning and doffing garments have also been reported
(Edmonson et al., 1999; Knox 2003; Nicholson et al., 2001; Rennie, Attfield, Morton,
Polak & Nicholson, 2000). Nicholson et al. (2001) found that even though children
improved it did not necessarily outweigh the disadvantages associated with wearing
and removing the suit. Blair et al. (1995) suggested that lycra® splinting applied only
to the limbs may broaden the use of this approach to splinting. Lycra® arm splints
overcome many of the practical problems of full body lycra® suits.
Corn et al. (2003) employed a single subject research design to investigate the
effects of lycra® splints in four children with neurological deficits. Using the
Melbourne Assessment (Randall et al., 1999) as the measurement tool, one child
had a slight decline in upper limb function, one had an initial improvement and two
showed no significant change between baseline and intervention phases (Corn &
Timewell, 2003; Corn et al., 2003). It was suggested that as the Melbourne
Assessment was a relatively new tool further investigation was required regarding its
sensitivity to change (Corn & Timewell, 2003).
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A pre-test / post-test study of 40 participants (23 adults and 17 children) with
movement difficulties aimed to evaluate the functional gains of the upper limb and
trunk associated with dynamic lycra splinting. A variety of outcome measures were
used including the Canadian Occupational Performance Measure (COPM), Modified
Ashworth scale, Tardieu scale, Office of Population Censuses and Surveys (OPCS)
disability scale, a questionnaire, resting limb posture and Chailey sitting ability scale.
Significant differences were found related to the use of lycra splints as measured by
the COPM, Modified Ashworth scale, Tardieu scale (certain muscle groups), OPCS
disability scale and resting posture (Scott-Tatum, 2003).
These seven studies provide limited evidence to justify the expense and feasibility
associated with prescribing, fitting and training children with Second Skin™ lycra®
arm splints. There is a need for continued research to understand the benefits and
limitations of these splints and to build evidence to support splinting practices in this
area. The aim of this study is to investigate the effectiveness of Second Skin lycra®
arm splints in children with cerebral palsy using outcome measures at all levels of the
ICF.
The ICF is part of the World Health Organisation family of International
Classifications. It defines different domains for a person with a given health condition
from the perspective of the physical body, individual and society. These health
domains or health related domains are described as body functions and structures,
activities and participation (AIHW, 2003). Impairments are problems in body function
or structure. Activity limitations are defined as difficulties an individual may have in
executing activities and participation restrictions are problems an individual may
experience in involvement in life situations (WHO, 2001a). The ICF recognises the
importance of environmental factors in facilitating function or creating barriers for
people with a disability (WHO, 2000). Cerebral palsy can affect individuals in one or
several of the ICF domains. To achieve a complete and useful understanding of the
intervention, evaluation is required of as many different domains as possible.
Outcomes also need to address the effects of intervention in terms that are
meaningful to the child and the family (Boyd & Hays, 2001).
105
This research commenced with the following hypothesises, which are written in null
format due to the lack of literature in the area.
1.1 At the impairment level there is no significant difference in quality of unilateral
upper limb motor function (as measured using the Melbourne Assessment) in a
population of children with cerebral palsy at
• Baseline
• Initial lycra® splint wear
• 3 months of wearing a lycra® splint
• Immediate splint removal
1.2 At the impairment level there is no significant difference in passive and / or
active range of motion of the elbow (measured with a goniometer) in a population of
children with cerebral palsy at
• Baseline
• Initial lycra® splint wear
• 3 months of wearing a lycra® splint
• Immediate splint removal
1.3 There is no significant difference in scores on the WeeFIM (UDSMR, 1998)
representing the ICF domain of activity when children with cerebral palsy wear a
lycra® arm splint for 3 months.
1.4 There is no significant difference in GAS (Kiersuk et al., 1994) scores
representing the ICF domain of participation when children with cerebral palsy wear a
lycra® arm splint for 3 months.
No hypothesis has been developed for the parental, teacher and child questionnaire
as descriptive statistics will be used to analyse these data. The ICF Checklist
(Version 21a Clinician Form, WHO 2001b) was used to provide a functional profile of
the children in the study, as well as to identify environmental and contextual factors
that may have impacted on the outcome of the study (Appendix R).
106
Method Subjects were recruited through advertisements in a local newspaper and community
newsletters. Children between the ages of 5 and 15 with a diagnosis of cerebral
palsy and who could follow two-step instructions were considered for inclusion in the
study. Children who had previously received upper limb botulinum –A toxin injections
or surgery were excluded from the study as were children who had worn a lycra®
arm splint in the past two years. Withdrawal criteria following commencement of the
study included withdrawal of consent or development of adverse reactions to the
splint during the period of the study.
From the initial pool of 29 subjects only 18 subjects fulfilled the inclusion criteria for
the study. This was the largest possible sample available in the community. A
compromise power analysis calculated the power of the study as .799 with the
following degrees of freedom; alpha (.20), effect size (.80), beta/alpha ratio (1), and
sample size (n=9, n=9) (Faul & Erdfleder, 1992). No subject withdrew from the study
thus allowing data analysis of the full 18 subjects.
The age of the subjects ranged from six years two months to 14 years 11 months (M
= 11.12, SD = 2.44). Ten of the subjects were male and eight were female. All
children had a diagnosis of cerebral palsy with 14 having a distribution of hemiplegia,
three of quadriplegia and one child had a diagnosis of ataxia. The severity of
spasticity in children with hemiplegia and quadriplegia ranged from mild to severe.
Informed consent to participate in the study was obtained from each child’s legal
guardian as required by the University of Western Australia ethics committee for
compliance with the Declaration of Helsinki (see appendix A). Anonymity was
preserved by assigning a unique identifying code to each participant. Confidentiality
was maintained by storing and archiving all information recorded in a secure location
and disclosing identify material only with the subject’s permission.
A randomised counterbalanced cross-over single factor design was used to structure
the lycra® arm splint as the independent variable. Subjects in Group 1 wore the
lycra® arm splint for three months and then subjects in Group 2 wore the lycra® arm
splint for the same time frame. The wearing regime for the lycra® arm splint was
Monday to Friday (9:00 am – 3:00pm). Subjects were randomly allocated to groups.
Figure 5.2 is a diagrammatic representation of the study design using the notation
107
introduced by Campbell and Stanley (1963). Extraneous variables were controlled
by requesting subjects continue with normal levels of therapy and activity, not take up
any new activity and maintain current levels of medication.
108
Baseline 3 month 3 month
O1 X1 X2 O2 O3 O4 (Group 1) R
O1 O2 O3 X1 X2 O4 (Group 2)
Key: X – Experimental intervention (arm splint) X1 – Arm splint (after 1 hour of wear) X2 – Arm splint (after 3 months of wear) O – Measurement of the dependent variable R – Subjects randomly assigned to group (Campbell & Stanley, 1963)
Figure 5.2: Study design
In conjunction with wearing the lycra® arm splint children participated in a goal
directed upper limb training program, while wearing the splint. This involved
incorporating specific upper limb activities into the daily routine of the child (see
appendix N and Q). The goals for this training were taken from the goals developed
for the GAS. The home environment was identified as the primary environment to
work on the goals. The procedure followed for embedding the child’s goals into
everyday routine was taken from ‘Using the Opportunity’ (Cerebral Palsy Association,
CPA, 1999). Both Groups commenced goal directed training at baseline (O1).
The dependant variable at the impairment level was quality of upper limb movement
measured by the Melbourne Assessment (Randall et al., 1999) and passive and
active range of motion of the elbow measured using a goniometer. Range of motion
was measured according to the protocol developed by Clarkson and Gilewich (1989).
The Melbourne Assessment (Randall et al., 1999) is a criterion-referenced test for
children with neurological impairment between the ages of 5 and 15 years. The
assessment is designed to measure a child’s unilateral upper limb motor function
based on 16 items involving; reach, grasp, release and manipulation (Johnson, et al.,
1994). Preliminary studies have indicated that the Melbourne Assessment is a
reliable and valid tool for measuring the quality of upper limb movement in children
with cerebral palsy (Bourke-Taylor, 2003; Randall et al., 2001). The Melbourne
Assessment has previously been used in one study investigating lycra splints (Corn
et al., 2003). Knox (2003) investigated lycra splints using the GMFM and QUEST
and proposed that the Melbourne Assessment may be more suitable for subsequent
trials of lycra splints. The Melbourne Assessment has also been used to investigate
outcomes from upper limb botulinum-toxin-A (Boyd et al., 2004; Wallen et al., 2004).
The dependant variable at the activity level is performance of daily functional skills
across the domains of self-care, mobility and cognition as measured by the WeeFIM
(UDSMR, 1998). The WeeFIM (UDSMR, 1998) builds on the organisational format
of the Functional Independence Measure (FIM) for adults and aims to measure
changes in function over time to assess the burden of care (type and amount of
assistance) in terms of physical, technological and financial resources (Braun 1991,
Granger et al., 1986). A minimal data set is used to track outcomes over a number of
settings (Msall, DiGaudio & Rogers et al., 1994). The WeeFIM (UDSMR, 1998) has
not previously been used to determine the efficacy of lycra splints, however the FIM
has been implemented in one study investigating the role of botulinum toxin-A in the
upper limb (Hurvitz et al., 2000).
The dependant variable at the participation level was measured using the Goal
Attainment Scale (GAS – Kiersuk et al., 1994). This scale is an individualised
criterion referenced measure that can be used to assess qualitative changes and
small but clinically important improvements in motor development and function
(Palisano, 1993). The primary strength of the GAS is its ability to evaluate
individualised change over time (Ottenbacher & Cusick, 1990). Palisano (1993)
investigated the validity of the GAS in infants with motor delays. The results
supported content validity and the responsiveness of the GAS to detect clinically
significant change. Mitchell and Cusick (1998) used the GAS as a method of
evaluating a paediatric rehabilitation program. They found that the GAS provided a
systematic approach in the evaluation of treatment outcomes for individual clients in
relevant environments. The GAS has not previously been used to measure the
intervention of lycra splints. It has however been used to assess functional outcomes
following botulinum toxin-A administration (Boyd et al., 2003; Wallen et al., 2004).
In this study the GAS procedure developed by the Cerebral Palsy Association (CPA,
2003) and Tobell and Burns (1997a & 1997b) was followed by a senior occupational
therapist with clinical experience in the area of paediatric neurology and training in
the GAS. Goals were set in collaboration with the family, child, an occupational
109
therapist from Second Skin™ and an occupational therapist on the research team.
Three goals were developed for each child following the criteria developed by King et
al. (1999). Each goal was scaled from -2 (current level of performance) through 0
(desired level of performance) to +2 (much greater than expected level of outcome).
For Group 1 the scores from goals achieved were summed and converted to a T-
score at 3 months after splint wearing and at three months following splint removal.
For Group 2 scores were obtained at 3 months prior to splint application and 3
months following splint wear. A T-score of 50 indicated that on average goals were
achieved (Wallen et al., 2004). A goal monitoring committee comprising an
independent occupational therapist and physiotherapist assessed each goal’s
relevance and realism (see appendix O). The committee made an assessment
between the clinical problems observed on video, case notes and the treatment goals
and expected level of outcome selected for the study.
The ICF checklist was used to collect information about environmental and personal
factors. The ICF checklist version 2.1A (WHO, 2001b) is a practical tool to elicit and
record information on the functioning and disability of an individual. It is designed to
be used by clinicians or health care professionals and information is collected from
written records, primary respondents, other informants and direct observation. Past
research has shown the ICF to be applicable, reliable and strongly correlated with
established scales for children with cognitive, motor and complex disabilities
(Battagalia et al., 2004). However some components of activity and participation
may not fully identify the developmental nature of children (Battagalia et al., 2004;
Ogonowski, Kronk, Rice & Feldman, 2004).
The Parent, Teacher and Child Questionnaire was originally used in a descriptive
clinical trial of lycra garments (Knox, 2003). The child Questionnaire comprises three
questions and the Parent and Teacher section has six questions with the first three
the same as for the Child (see appendix M). The response from the participants
guides what level of the ICF is addressed. Internal reliability of the questionnaire was
established in this study by comparing the responses of parents and teachers as well
as comparing the responses of the same parents over time. A Mann-Whitney U test
(two-tailed, α.05) found no statistically significant difference between the responses
from the group of parents and teachers for questions 1 (p = .76), 3 (p = .61), 5 (p =
.40) and 6 (p = .83). A significant difference was established for question 4 “How
long does it take you to put the splint on?” (p = .012). Teachers on average took
longer to put the splint on the child (M = 6.0 minutes SD = 2.17) than parents (M =
110
2.73 minutes, SD = 1.92). This could be related to the minimal amount of practice
and training received by teachers compared with the parents in the application of the
lycra® splint. Due to the open nature of question 2 “What difference does it make”
no analysis was performed on the relationship of the responses from parents and
teachers. An intraclass correlation coefficient (alpha) found an acceptable to perfect
relationship (1.00, 0.87, 0.98 & 1.00) between responses of parents (to questions
one, four, five and six respectively) on two separate occasions. A low intraclass
correlation coefficient (0.67) was established for question two “What do you think
about wearing the arm splint?”
These findings support the internal reliability of the questionnaire. Interviews were
conducted face to face with parents and children and over the telephone for
teachers. Interview time ranged between 12 and 33 minutes, were highly structured
and controlled such that the same questions and prompts were given to all
participants. Interviews were audiotaped and additional observational notes were
also taken during the interview.
Prior to the first formal testing session all children were assessed using the
Melbourne Assessment. With parental permission all videos from the Melbourne
Assessment were sent to Second Skin™ to assist with the individual design of the
participants lycra® arm sleeves. Participants were then contacted by Second
Skin™ and attended separate appointments to;
i. measure and design the splint
ii. fit their splint one week prior to data collection.
All assessments took place at the motion analysis laboratory at the School of Human
Movement and Exercise Science, University of Western Australia. During testing
children sat in a sitting position of hips flexed at 90 degrees and knees flexed to 90
degrees with feet flat on the floor. One child sat in their wheelchair with postural
supports, two children sat in a high backed chair and the remaining 15 children sat
on a stool for all testing sessions. The table height was adjusted so that the child's
elbows could rest on the table in a comfortable position of approximately 90 degrees
elbow flexion. Baseline assessment was completed with the sleeve off.
Assessments after one hour of splint wear (X1) and three months of splint wear (X2)
were performed, while the splint was still on the arm. All children completed a full
Melbourne Assessment (Randall et al., 1999) which was administered by a qualified
occupational therapist, according to the procedures outlined in the manual.
111
Anthropometric and anatomical measurements including weight, height, wrist and
elbow widths, upper limb segment length and total arm length were recorded. The
ICF Checklist (WHO, 2001b), WeeFIM (USMDR, 1998) and GAS were administered
after the Melbourne Assessment and range of motion. Data were collected through a
combination of the primary respondent (child), other informants (parent or carer) and
direct observation. The test protocol for the Melbourne Assessment and range of
motion was carried out twice, within a day.
Data analysis A one-way analysis of variance (ANOVA) was used to compare the means of active
and passive range of motion as well as scores on the Melbourne Assessment during
baseline (O1), one hour after splint wearing (X1), 3 months after splint wearing (X2)
and immediately after splint removal (Group 1 O2 and Group 2 O4). A ShapiroWilks
test was used to check for population normality and Levene statistic employed to
determine whether variances were equal. Parametric testing was determined
appropriate as data are normally distributed (Thomas, Nelson & Thomas, 1999).
Employing parametric testing also enables a direct comparison with the data of other
clinical upper limb studies (Boyd et al., 2003; Wallen, et al., 2004).
For the WeeFIM test motor scores at baseline and 3 months after splint wear were
analysed using a dependant t-test. WeeFIM motor scores comprise the domains of
self-care and mobility. Motor scores were chosen for analysis over total scores
(domains of; self-care, mobility and communication) as lycra® arm splints do not aim
to impact on communication. A two-tailed dependant sample t-test was used to
analyse the long term carry-over effects of the lycra® arm splints through comparison
of the means of Group 1 at baseline and 3 months post splint on the Melbourne
Assessment and WeeFIM. Post-hoc analysis was not used as no significance
difference was found with the Melbourne Assessment and range of motion.
Percentage scores were used in the analysis of the ANOVA for the Melbourne
Assessment.
To establish the effects of fatigue and learning associated with multiple testing
percentage scores from the Melbourne Assessment of Group 2 baseline assessment
(O1 and O2) and Group 1 testing after 3 months post splint wearing (O3 and O4) were
analysed. A two-tailed t-test for dependant samples indicated that there was no
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significant difference between the scores for Group 2 at baseline O1 (M = 55.13, SD =
12.43), and baseline O2 (M = 52.66, SD = 10.34), t (7) = 1.549 p<.05. No
significance was established for Group 1 at 3 months post splint wear O3 (M = 55.22,
SD = 18.64) and O4 (M = 55.64, SD = 17.52), t (7) = -0.493, p >.05, indicating that
fatigue and learning did not significantly affect Melbourne Assessment variables
across testing sessions.
Equivalence of the groups was also established by comparing the Melbourne
Assessment scores for Group 1 at Baseline (O1) and Group 2 at baseline (O1) using
an independent t-test (two-tailed). Results established that there was no
significance difference between the Melbourne scores for Group 1 (M = 56.17, SD =
17.76) and Group 2 (M = 55.12, SD = 12.43) with a t (7) score of 0.14, p >.05.
The intra-rater reliability of the examiner scoring the Melbourne Assessment was also
established to strengthen the measurement accuracy of the data (see appendix U).
To determine if the examiner was able to score consistently the same performance
by the same child on the Melbourne Assessment the strength of agreement of repeat
scorings of the same video tape were examined. Twenty children with cerebral palsy
were included in the study (18 children from this splinting study were included as well
as two additional children that did not meet the inclusion criteria at the initial
screening as both had received upper limb botulinum-A toxin). Intra-class correlation
estimate of inter-rater reliability was 0.97. Previously a reliability of 0.96 was used to
indicate that the measurement error standard deviation of a single rating is about
one-fifth of the population standard deviation of the scores and suggests that the
score may be useful for individual patient assessment, (Randall et al., 2001).
Responses from the Parent, Teacher and Child Questionnaire were transcribed into
text and a summary sheet drafted. Descriptive codes were assigned to each unit of
meaning. Codes were created from data collected in a pilot study investigating
lycra® arm splints from the perspective of the consumer (see Appendix J) and
relevant literature. The coding system developed was derived from the ICF
framework. All perceived benefits and disadvantages of the splint were viewed in
context of body functions and body structures, activities and participation. The ICF
further divides these components into a number of domains of classification. Eight
themes at each level of the ICF were derived from the responses of parents, children
and teachers and coded accordingly (see Table 5.1). Three of these themes were
from the component body function (mental functions, sensory function and pain and
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neuromuscular and movement related functions). The remaining five (mobility, self-
care, domestic life, major life areas and community, social and civic life) were from
the component activity limitations and participation requirements (AIHW, 2003; WHO,
2001d).
Component Domains
Body Function • Mental functions e.g. memory, attention, perception, sleep
• Sensory functions and pain e.g. vestibular, pain, seeing
• Neuromuscular and movement related functions e.g. muscle tone,
muscle power, involuntary movements
Activity Limitations
and Participation
Restrictions
• Mobility e.g. lifting and carrying objects, fine hand use, walking,
moving around equipment
• Self care e.g. washing oneself, toileting, dressing, eating
• Domestic life e.g. preparation of meals, doing housework
• Major life areas e.g. school education
• Community, social and civic life e.g. recreation and leisure
(AIHW, 2003;WHO, 2001a)
Table 5.1: Themes for questionnaire using the ICF framework
Credibility for the coding system was established through a reliability study whereby
three qualified occupational therapists coded 50 responses from a randomised
sample of parents and children. The percentage of agreement between the raters
was 96% (see Appendix Q). With modifications to the coding through the inclusion of
an additional category of ‘sensory motor’ the agreement between the three raters
increased to 99.33%.
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Results Range of motion
An ANOVA was performed on passive range of motion of the elbow (flexion,
extension and supination) at baseline (O1), initial splint application (X1), three months
after splint wear (X2) and initial removal of the splint (O2). No statistically significant
change was found for passive elbow supination F (3, 68) = 0.002, p>.05, passive
elbow flexion F (3, 68) = 0.19, p > .05, or passive elbow extension F (3, 68) = 0.004,
p > .05 across all conditions of the independent variable (Table 5.2). The ANOVA
performed on active range of motion at the elbow (flexion, extension and supination)
across the same levels of the independent variable was not significant for active
elbow supination F(3,68) = 0.007, p > .05, active elbow flexion F(3,68) = 0.006, p >
.05 and active elbow extension F(3,68), p > .05 (see table 5.3 for specific results).
Baseline (O1)
Immediate splint wear
(X1)
3 months of splint wear (X2)
Immediate splint
removal
Fobs
M -4.27 -4.47 -4.12 -4.52 Passive Elbow
Extension SD 6.64 6.66 6.75 7.17
.004
M 145.83 146.33 146.11 146.11 Passive Elbow
Flexion SD 7.08 5.73 6.07 5.94
.019
M 69.73 69.94 69.88 69.72 Passive Elbow
Supination SD 11.77 11.49 11.87 11.69
.002
Table 5.2: Passive range of motion of the elbow across all treatment conditions
Baseline (O1)
Immediate splint
wear (X1)
3 months of splint wear (X2)
Immediate splint
removal
Fobs
M -7.00 -7.11 -7.33 -7.05 Active
Elbow
Extension
SD 9.02 9.21 8.82 8.95
.005
M 141.83 142.16 141.89 141.722 Active
Elbow
Flexion
SD 10.79 10.38 10.87 10.57
.006
M 62.17 62.89 62.94 62.78 Active
Elbow
Supination
SD 17.84 18.04 17.66 17.80
.007
Table 5.3: Active range of motion of the elbow across all treatment conditions
115
Melbourne Assessment
An ANOVA was performed on the participant’s percentage scores at baseline, O1 (M
= 56.18, SD = 14.18), initial splint application, X1 (M = 57.78, SD = 14.38), after three
months of splint wear, X2 (M = 55.05, SD = 14.35) and immediately after splint
removal, O2 (M = 56.14, SD = 13.74). This ANOVA revealed no significant mean
difference, F (3, 68) = 0.130, p >.05 at any level of the independent variable (see
Figure 5.3). The authors of the Melbourne Assessment recommended that a
percentage score change must be greater or equal to 12 % to be considered a ‘true’
change’ (Randall et al., 1999). In relation to the assessments criteria, no change in
unilateral upper limb function was found in any participant in the study at any level of
the independent variable. No significant difference was established for Group 1,
between baseline (M = 56.17, SD = 17.76) and 3 months post splint wear (M = 55.63,
SD = 17.52), t (7) = .410, p > .05.
Melbourne Assessment
0
20
40
60
80
100
Baseline Initial splintw ear
3 monthssplint w ear
Immediatesplint
removal
Perc
enta
ge
Melbourne Assessment % score
Figure 5.3: Melbourne Assessment scores across all treatment conditions
WeeFIM
A two-tailed t-test for dependant samples indicated that there was no significant
difference in WeeFIM motor scores for participants at baseline (M = 71.50, SD =
21.82) and after wearing the lycra® splint for three months (M = 71.75, SD = 21.82), t
(15) = -2.236, p > .05. Using the same test no significant difference was established
for Group 1 at baseline (M = 74.12, SD = 19.04) and 3 months post splint wear (M =
73.75, SD = 18.66), t (7) = .893, p >.05.
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Goal Attainment Scale
Group 1 mean T-scores was 53.20 (SD= 5.04) at 3 months of splint wear and 48.41
(SD =4.10) 3 months post splint wear. Eight out of nine subjects achieved a T-score
of 50 or above, immediately after splint wear. The mean T-score for Group 2 was
35.17 (SD = 6.79) at the 3 month period before wearing the splint and 53.99 (SD =
3.81) after wearing the splint for 3 months. All subjects in Group 2 achieved an
average T-score of greater than 50 (see Figure 5.4).
Goal Attainment Scale Scores Group 1
20253035404550556065
1 2 3 4 5 6 7 8Subjects
T-Sc
ore
Immediatly after splint wear 3 months post splint wear
Goal Attainment Scale Scores Group 2
20
30
40
50
60
70
1 2 3 4 5 6 7 8Subjects
T-Sc
ore
3 months pre splint wear Immediatly after splint wear
Figure 5.4: Goal Attainment Scale scores for Group 1 and 2
The most frequent categories of goals selected (total, 54) were self care (29.63%),
domestic life (19.23%), mobility (17.31%), community, social and civic life - recreation
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(32.69%). The GAS was employed in the study to measure change at the level of
participation. Due to the client centred individual nature of goal setting not all goals
developed by the child and the family were at the participation level. The majority
74%, (39 goals) of the goals focussed on increasing the child’s involvement in life
situations (participation) with 20% (11 goals) addressing improving a specific task or
action of the child (activity) and 7% (4 goals) focussing on problems of body functions
and structures (impairment).
Parent, Teacher and Child Questionnaire
Children (72.72%), parents (85.1%) and teachers (85.1%) felt that the application of
the splint made an overall difference (see Figure 5.5).
Do you think the splint makes a difference?
0102030405060708090
Yes No Unsure
Perc
enta
ge
Child Parent Teacher
Figure 5.5: Parent, teacher and child response to question 1 on the questionnaire
“Do you think the splint makes a difference?”
Neuromuscular and movement related functions were seen as the greatest benefit by
children (15 comments), parents (23 comments) and teachers (21 comments).
Benefits in this area included;
• “Her arm seems much straighter” (parent report)
• “My arm moves a bit more” (child report)
• “Much more control over what she is doing” (teacher report)
Perceived disadvantages in the neuromuscular and movement related function
domain included “no physical difference” (teacher report) and “arm still seems really
stiff” (parent report).
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Parents (15 comments), teachers (14 comments) and children (5 comments)
reported benefits of the lycra® arm splint in the areas of sensory functions and pain.
The majority (85.29%) of the responses in this area reported that the child was more
aware of their affected side or arm. Two parents reported that the lycra® arm splints
helped reduce pain (shoulder for one child and elbow for the other). Disadvantages
in the area of sensory functions and pain included “not making him more aware of his
arm” (parent report), “very tight and child complained it made her sore” (teacher
report).
Benefits in the area of mental functions included “willing to use left arm more”
(parent), and “trying to use left arm more” (teacher report). In the area of mobility no
disadvantages were reported. Benefits of lycra® arm splints in the domain of mobility
included;
• “Child could drive their wheelchair better as their wrist was straighter”
• “His balance was better and he fell less in the playground”
Perceived benefits by parents in the area of self care included;
• “Child was able to put her hair into a ponytail”
• “She held her plate when eating”
Teachers (18 comments) observed more benefits in the area of education than
parents and children. Some of the benefits included “holding onto their paper when
writing”, “holding paper when cutting” and “neater writing”. A disadvantage of the
splint was that “he missed out on painting as we did not want to get the splint dirty”
(teacher). Benefits in the area of recreation included;
• “I am great at skipping now” (child report)
• “Better at moving games and balls” (parent report)
• “Child can turn on and off her music with a switch next to her tray” (parent
report)
Figure 5.6 is a graphical representation of the perceived benefits and disadvantages
of the lycra® arm splints from the perspective of the parent, teacher and child.
119
Benefits and disadvantages of the splint
-10-505
10152025
Pare
nt
Teac
her
Chi
ld
Pare
nt
Teac
her
Chi
ld
Pare
nt
Teac
her
Chi
ld
Pare
nt
Teac
her
Chi
ld
Pare
nt
Teac
her
Chi
ld
Pare
nt
Teac
her
Chi
ld
Pare
nt
Teac
her
Chi
ld
Pare
nt
Teac
her
Chi
ld
SensoryFunction
Neuromuscular& movement
related functions
Mental functions Mobility Self Care Domestic Life Education Recreation
Num
ber o
f res
pons
es
Positive Responses Negative Responses
Figure 5.6: Benefits and disadvantages of the splint from the perspective of the
parent, teacher and child
When asked what they thought about wearing the splint 44.44% of the children felt
they did not mind, 11.11% of the children liked wearing it, 5.55% of children did not
like wearing it and 38.88% of children were unsure. Parents reported that 22.22% of
the children liked wearing the splint and 66.66% of the children did not mind wearing
the splint (see Figure 5.7).
What do you think about wearing the splint?
0
10
20
30
40
50
60
70
I like it I don't mind it I don't like it Unsure
Per
cent
age
Parent Teacher Child
Figure 5.7: Parent, teacher and child response to question 3 on the questionnaire
“What do you think about wearing the splint?”
120
Parents (total 18) were asked if they would consider getting a new arm splint for their
child at the end of the study. The majority of parents (14) would definitely consider a
new arm splint, two parents reported they would possibly consider a new arm splint,
one parent was unsure and one parent would not consider a new arm splint.
The most common wearing regime established through the questionnaire was five
days per week (parents, 55.55%, teachers 50%), eight hours per day (parents
44.45%, teachers 44.45%). Table 5.4 outlines the actual wearing regime for
participants in the study, as reported by parents and teachers.
Days per week of splint wear Hours per day of splint wear
Days Parents Teachers Hours Parents Teachers
4 0% 5.55% 6 0% 5.5%
5 55.55% 50% 7 38.88% 38.88%
6 16.67% 11.11% 8 44.44% 44.45%
7 27.78% 33.33% 9 16.67% 11.11%
Table 5.4: Intervention, actual splint wearing regime, as identified by parents and
teachers
ICF Checklist
Environmental, contextual and health related information was analysed at baseline
(O1) and after 3 months of splint wear (X2). Environmental factors were coded from
the perspective of the parent. Changes in these domains from baseline to after 3
months of splint wear are recorded in Table 5.5.
121
Environmental Factors – Domains
Products and technology [3] e110 – New medication for ADHD (+2)
[5] e110 – New diet to promote attention and concentration (+3)
[1] e115 – New powered wheelchair (+4)
[4] e115 – Outgrew walker (3)
[1] e125 – Return of communication device to loan library (3)
Support and relationships [2] e310 – Grandparents left after extended stay with family (2)
[12] e310 – Foster family change (1)
[6] e320 – Close friend move away (2)
[3, 11] e340 – New personal assistants (3, +1)
[All participants except 2 & 12] – At least one new health professional (0, +1, +2, 2, 3, 1, 0, 0,
2, +1, 0, 0, 0, 2, 0, 3, 0)
[16,2,3,5,7,1,9,18] e360 – New teacher (+1, +1, 0, 0, 2, 0, +1, -1)
Attitudes [5, 11] e425 – teased by peers about lycra® arm splint
Personal factors –
[4] – chickenpox (unwell for 6 days)
[13] – virus (unwell for 4 days) Qualifiers in environment 0 No barriers 0 No facilitators 1 Mild barriers +1 Mild facilitators 2 Moderate barriers +2 Moderate facilitators 3 Severe barriers +3 Substantial facilitators 4 Complete barriers +4 Complete facilitators [ ] Participant number e110 ICF environmental factor code Table 5.5: Environmental Factors
Discussion This study describes a family-centred assessment procedure that measures the
efficacy of lycra® arm splints at the level of body functions and structures, activities
and participation. An important part of this research was to investigate whether
lycra® arm splints, which are cost prohibitive and require increased carer assistance
result in meaningful changes for the child and family.
There were positive results in support of lycra® arm splints effecting meaningful
changes in children’s abilities to participate in life tasks. The majority of children
made meaningful gains according to the Parent, Teacher and Child questionnaire
and the Goal Attainment Scale providing positive indicators of the efficacy and
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acceptability of the lycra® arm splint. In particular 14 of the 18 respondents would
definitely consider wearing a lycra® arm splint again, and actual wearing time
exceeded (8 hours – 44.45%, 7+days – 100%) or equalled (7 hours – 55.55%) the
requested wearing regime for the study. From the point of view of the consumer
(parent, teacher and child) lycra® arm splints were seen as beneficial (178 positive
responses) in the areas of body functions, activity and participation. Only 14
negative comments (total comments = 192) were reported and these were all in the
areas of sensory functions and pain and education.
On average GAS goals were achieved for children in both groups as indicated by a
mean T-score of greater than 50. The most frequent categories of goals selected
(total, 54) were from the area of self care and community, social and civic life
(leisure). The importance of self care and leisure as reflected in GAS goals for
children and their families was reported by Wallen et al. (2004) in a study of
functional outcomes of botulinum toxin in children with cerebral palsy. This finding
highlights the importance of addressing areas of participation that are meaningful to
both the child and family when working with children who have cerebral palsy.
The improvement measured by the GAS was maintained by Group 1 after 3 months
of splint removal (this is when the mechanical effects of the splint would have worn
off) as indicated by no significance in the two-tailed test for dependant sample t (7) =
2.390, p>.05. No measure was taken for Group 2 due to the nature of the cross over
design. The mean GAS T-score (35.17) for Group 2 taken before splint wear, helps
establish that extraneous factors (i.e., learning and fatigue) had minimal influence on
the outcomes of the GAS. A significant difference for Group 2 after three months of
wear (t (7) = -8.00, p <.05), indicates the goals were achieved.
The quality of unilateral upper limb movement did not change when measured by the
Melbourne Assessment. This is similar to findings by Corn et al. (2003) and Wallen
et al. (2004) who used the Melbourne Assessment to investigate change in upper
limb function in children with cerebral palsy with an intervention of lycra® splinting
and botulinum toxin – A, respectively. Both these studies concluded that either
quality of upper limb function was not responsive to the intervention or the Melbourne
Assessment was not sensitive enough to measure change in children with cerebral
palsy (Corn et al., 2003; Wallen et al., 2004).
123
For change on the Melbourne Assessment to be considered true and exclude
measurement error the percentage score change must be greater or equal to 12 - 14
% (Randall et al., 1999). This suggests that only large improvements in quality of
movement will be identified (Corn et al., 2003). The original sensitivity of the
Melbourne Assessment was established for a population of children at early stages
of acquired cerebral insult (Randall et al., 1999). Due to spontaneous recovery from
brain lesions these children are likely to improve rapidly over a short period of time
(Frackowiak, 2001; Randall et al., 1999). Randall et al. (1999) did not include
children with cerebral palsy in the study of the sensitivity of the Melbourne
Assessment as “they often show very slow rates of change” (p.8). Further studies
are required regarding the responsiveness of the Melbourne Assessment to detect
small but clinically significant change in the quality of upper limb function in children
with cerebral palsy.
No significant change was established for active supination, flexion and extension
and range of motion at the elbow, which supports the findings of Gracies et al. (2000)
in their study on the effects of lycra splints in an adult population with hemiplegia.
While consistent with the findings of one upper limb botulinum toxin study (Wallen et
al., 2004) this result does differ from the findings of Corry et al. (1997), who reported
an increase in elbow extension. In the present study change was established in
activity and participation (measured by the GAS, parent, child and teacher
questionnaire) but not in active range of motion. This may be attributed to the fact
that goniometric measurements only measure end range and may not reflect the
required range of motion for functional activities (Wallen et al., 2004).
No change in passive range of motion at the elbow were recorded. This is consistent
with findings of a study that measured the effects of botulinum toxin in children with
cerebral palsy (Fehlings et al., 2000; Wallen et al., 2004) and data of Gracies et al.
(2000) who stated that the lack of change of passive range of motion may be related
to absence of underlying contractures in the sample.
Significant changes were established for the GAS, parent, child and teacher
questionnaire although range of motion and Melbourne Assessment results did not
change over time. Children may have been completing functional activities
(evaluated positively in the GAS) without using more normal movement patterns, and
by incorporating change in range of motion not present at end ranges.
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No significant difference was found for the WeeFIM at baseline and after three
months of splint wear. During the period of splint wearing nine children went from
‘complete independence’ with upper body dressing to ‘supervision’ or ‘set-up’ with
upper body dressing as the splint was applied for the child (see Appendix S). This
reduction in overall motor score may mask other functional gains made by the
children on the WeeFIM.
While studies have investigated changes in care-giver assistance after wearing
lycra® splints, no studies have used the WeeFIM. Nicholson et al. (2001) found
results similar to this study using the PEDI to investigate the effects of lycra splints.
Improvements found on the functional skills scale of the PEDI, in a population of 12
children with cerebral palsy were minor and unrelated to the type of motor problem.
Nicholson et al. (2001) also found that some children needed more help due to the
difficulties in taking off the garment for toileting. In a study investigating lycra splints
in a population of adults and children with movement disorders, a positive and
significant effect on the level of assistance needed with tasks was established for the
OPCS disability scale (Scott-Tautum, 2003). The Functional Independence Measure
(FIM) has been used in past research to investigate change in a 16 year old child
with cerebral palsy after botulinum toxin injections (Hurvitz et al., 2000). Hurvitz et al.
(2000) reported results similar to this study with no change established for the FIM.
Experience from this study has provided insight into the necessity for further studies
investigating the efficacy of lycra® arm splints to employ measures with greater
sensitivity to clinically significant change, at the level of impairment. Three
dimensional motion analysis has the capacity to measure the range of motion of
joints during activity (unlike goniometric measures) and has been shown to reveal
subtle changes in motor performance often undetectable using clinical evaluation
(Hurvitz et al., 2000; Ramos, Latash, Hurvitz & Brown, 1997). Measures of
movement sub-structures have also been demonstrated to measure change at the
level of impairment pre-intervention and post-intervention (Kluzik et al., 1990;
McPherson et al., 1991; Teng & Kamm, 2002).
As disability affects individuals at all levels of the ICF framework, employing
measures from the domains of body functions and structures, activity and
participation has enabled a comprehensive and holistic understanding of the effects
of lycra® arm splints in a population of children with cerebral palsy. The
incorporation of the GAS and questionnaires also enables documentation of
125
outcomes in terms that are meaningful to the child and the family. Further research
is recommended using measures with greater sensitivity at the level of body
functions and structures as well as incorporating family centred measures at the ICF
level of activity and participation.
126
CHAPTER 6 A Randomised Controlled Trial of the Effects of
Lycra® Arm Splints on Movement Substructures during Functional Tasks in Children with Cerebral
Palsy
Abstract The purpose of this study was to measure the changes in movement substructures
(in addition to movement time) and upper limb motor function following the wearing of
a lycra® splint by children with cerebral palsy. Measures made at baseline, initial
lycra® splint application, 3 months after lycra® splint wear, on immediate lycra®
splint removal and 3 months post lycra® splint wear were compared. The study also
explored the efficacy of lycra® splints in the cerebral palsy sub-populations of spastic
and dystonic hypertonia and tested the sensitivity of the Melbourne Assessment of
Unilateral Upper Limb Function (Melbourne Assessment - Randall, 1999).
Three-dimensional upper limb and trunk kinematic data were recorded using a seven
camera Vicon (Oxford Metrics Ltd, Oxford, U.K.) motion analysis system.
Movement substructures during tasks taken from the Melbourne Assessment were
analysed from calculations of the 3D movement of the wrist joint centre. A full
Melbourne Assessment was also completed across all treatment conditions.
Sixteen children with cerebral palsy (hypertonia) aged between 8.9 years and 14.11
years with a mean age of 11.48 (SD 2.23) were recruited. A randomised cross over
research design was employed with Group 1 wearing the lycra® splint for three
months and then Group 2 wore the lycra® splint for the same period of time. A
significant difference was established between baseline and 3 months after lycra®
splint wear for the movement substructures; movement time, percentage of time and
distance in primary movement, jerk index, normalised jerk and percentage of jerk in
primary and secondary movements. These substructures moved closer to the motor
behaviour of children without cerebral palsy at 3 months after lycra® splint wear. No
significant difference was established for; directness index, peak velocity as a
percentage of distance in the primary movement, normalised jerk in the secondary
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movement and unilateral upper limb function across all treatment conditions. The
strength of the difference in normalised jerk and the percentage of jerk in the primary
movement from baseline to 3 months after lycra® splint wear was greatest in the
sub-population of children with dystonic hypertonia. The investigation into the
sensitivity of the Melbourne Assessment and the 3D movement characteristic of
normalised jerk indicated that the Melbourne Assessment was not able to identify
small but clinically significant changes in motor function in this population of children
with cerebral palsy, whereas normalised jerk detected the effects of intervention.
This research demonstrates that movement sub-structures (including movement
time) can be quantified and are amenable to change with intervention if appropriate
testing methodologies are used.
Introduction Cerebral palsy is an umbrella description for a group of persistent but not unchanging
motor disorders due to a defect or lesion of the immature brain (Bax, 1964; Stanley &
Watson, 1992). Of every 1000 live births in Western Australia 2.0 – 2.5 children will
be diagnosed with cerebral palsy by the age of 5 years (Stanley & Blair, 1991). This
rate is similar to findings in Sweden (Hagberg et al., 2001), Finland (Riikonen,
Raumavirta, Sinivouri & Sepala, 1989) and England (Jarvis, Holloway & Hey, 1985;
Pharoah, Cooke, Cooke & Rosenbloom, 1990).
Hypertonia occurs secondary to central nervous system damage. Hypertonia is an
increased resistance to passive movement due to dynamic and static components.
The dynamic component of hypertonia has both a neural – the tonic muscle
contraction (reflexive) and non-neural interaction (mechanical factors) (Copley &
Kuipers, 1999; Wilton, 2003). Functionally hypertonia results in reduced voluntary
motion, which can impact on participation in age-appropriate occupational tasks
(Wilton, 2003). Hypertonia presents as velocity-dependant (spastic), non-velocity
dependant (rigid) and extrapyramidal (dystonic) hypertonia. Children with each of
these presentations of hypertonia have different patterns of movement and postural
reactions (Scrutton, 2000). Dyskinesia is another type of motor impairment and is
often found in conjunction with hypertonia. It is characterised by unwanted
movements which may be athetoid (writhing) and / or dystonic (rigid) (Stanley et al.
2000).
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Lycra® splints are semi-dynamic splints that are individually prescribed and
fabricated (Copley & Kuipers, 1999). They have been used in a wide range of clinical
populations, including children with cerebral palsy (Blair et al.,1995; Brownlee et al.,
2000; Corn et al., 2003; Edmonson et al., 1999; Hylton & Allen, 1997; Knox, 2003;
Nicholson et al., 2001) and adults post burns (Kennedy, Peck & Stone, 2000;
Williams, Knapp & Wallen, 1998) or with rheumatoid arthritis (Murphy, 1996) or
neurological impairment (Barnes, 2001; Gracies et al., 2000).
Lycra® arm splints extend from the wrist to the axilla and have a zip to assist with
application (Second Skin, 2000). The garments comprise circumferential lycra
segments that are stretched in the orientation appropriate to produce the chosen
direction of pull and then sewn together (Gracies et al., 1997). The two designs of
lycra® arm splints fabricated by Second Skin™ include the pronation-flexion and
supination-extension arm splints (Second Skin, 2002). In an investigation of 10
adults without spasticity, supinator garments have been demonstrated to supinate
the forearm in all participants, whereas the pronator garment pronated the forearm in
eight out of 10 participants when assessed from an anatomical position (Gracies et
al., 1997). In a population of 16 adults with hemiplegia, who wore lycra arm splints in
combination with lycra gloves, a differential effect on spasticity was found in two
(wrist and finger flexors) out of the 10 muscle groups analysed (Gracies et al., 2000).
Neutral warmth, circumferential pressure, tension and line of pull of the fabric
creating a low force to resist the spastic muscle are thought to contribute to the
modification of spasticity (Wilton, 2003). Lycra splints are able to provide support to
joints and may encourage the maintenance of a position that the person can partially
assume (Copley & Kuipers, 1999). It can be viewed that increased joint pressure will
provide greater stimuli to joint receptors. A reduction in spasticity may also provide
afferent impulses in the muscle with a more accurate signal of the change in muscle
force and length. This increased joint pressure and reduction in spasticity may
enable improved feedback to the somatosensory system (Kandel, Schwartz &
Jessell, 1995).
Measures at the level of body functions and structures used in previous studies
investigating the efficacy of lycra splints include the Melbourne Assessment of
Unilateral Upper Limb Function (Melbourne Assessment - Corn et al., 2003; Randall
et al.,1999), the Quality of Upper Extremity Skills Test (QUEST - DeMatteo, et al.,
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1993; Knox, 2003), Modified Ashworth Scale (Scott-Tautum, 2003.), Tardieu scale
(Scott-Tautum, 2003), motion analysis – variation of the movement (Nicholson et al.,
2001), abdominal and grip strength (Blair et al., 1995), respiratory function (Blair et
al., 1995), active and passive range of motion (see Chapter 5) and a range of
unpublished assessments developed for individual studies (Brownlee et al., 2000;
Edmonson, et al., 1999; Blair, et al., 1995). Research has indicated that some of
these measures may not be sensitive enough to detect clinically significant change.
Two studies using the newly developed Melbourne Assessment found no significant
difference in unilateral upper limb function pre and post lycra® splinting. Both studies
concluded that the assessment needed further research regarding its responsiveness
to change (Corn et al., 2003; see Chapter 5). The findings of Wallen et al. (2004)
were similar when they employed the Melbourne Assessment to investigate the
outcomes of Botulinum Toxin-A in children with cerebral palsy. In the investigation
that used the QUEST, two out of the four participants showed improved scores post
intervention. However, due to the small sample size the sensitivity of the QUEST
was unable to be examined. In a study investigating the efficacy of lycra® splints in a
population of children with cerebral palsy no significant difference was found for
active and passive range of motion using a goniometer to measure end of range
angles. It was suggested that the lack of change in passive range of motion was
related to the sample not having significant underlying contractures. Changes in
active range of motion may not have been at end range and thus not detected by
goniometric measurement (see Chapter 5). Wallen et al. (2004) also found no
change in passive or active range of motion in a study investigating the outcomes of
Botulinum Toxin-A.
Smoothness of reach was employed as one variable of interest in five children with
cerebral palsy, who were part of an eight week lycra splinting program (Nicholson et
al., 2001). Smoothness of movement was measured distally and proximally using
the root mean square error (RMSE) as the indication of movement variance.
Nicholson et al. (2001) viewed a greater variation in the movement to indicate less
stability and decreased smoothness of movement. Current research has identified
that the complexity of upper extremity movement permits the same goal to be
achieved using many different techniques (Rau et al., 2000; Schmidt et al., 1999).
This inherent variability is highlighted in the upper extremity by the number of
degrees of the freedom at different joints and range of motion, as well as the variety
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and complexity of the tasks performed. Consequently RMSE does not necessarily
reflect smoothness of a wave but discrete point to point variability of movement.
Qualitative measures of smoothness of movement in the literature include movement
units, movement elements, jerk, normalised jerk and fluency. Movement units or
movement elements have been used to measure quality of upper limb movements in
adults with neurological impairment (McPherson et al., 1991; Trombly, 1992; Wu et
al., 1998), children with cerebral palsy (Kluzik et al., 1990; Teng & Kamm, 2002),
normally developing infants (Fetters & Todd, 1987; Thelen et al., 1996) and children
with a minor neurological dysfunction (Schellekens et al., 1983). A movement unit is
defined as an oscillating pattern of an acceleration followed by a deceleration
(Fetters & Todd, 1987). The lower the number of movement units the greater the
control of the reaching task (Kluzik et al., 1990). The velocity trace for a reaching
task for adults without a neurological impairment consisted of a single movement
unit, whereas people with neurological impairment had multiple movement units
during reaching tasks (Bernhardt et al., 1998; Kluzik et al., 1990).
The working definition of the movement unit includes a preset threshold, which is not
consistently employed in the literature. The threshold has been given as increasing
temporal values for at least 20 ms and followed by decreasing values for at least 20
ms (Michaelsen et al., 2001), as well as a speed maximum between two minima
where the difference between the maximum speed and both minima exceed 1 cm/s
(Thelen et al., 1996). As this pre-set threshold is difficult to define, the variables of
jerk and normalised jerk have been used to describe movement smoothness
(Thomas et al., 2000).
Jerk is the rate of change of acceleration or the third time derivative of position and
has been used to describe upper limb movement smoothness by Feng & Mak (1997),
Flash & Hogan (1985), Hogan & Flash (1987) and Novak, Miller, Baker & Houk,
(1996). In comparison to subjects without spasticity, subjects with spasticity exhibit
greater average jerk (Feng & Mak, 1997).
Jerk measures are affected by the size and duration of the movement and therefore
must be normalised to enable a comparison of coordination difficulties in patterns of
different shapes, sizes and durations (Teulings et al., 1997). Absolute jerk may not
be suitable for children’s movements that are considerably different in terms of length
and duration (Yan, Hinrichs et al., 2000). Kitazawa et al. (1993) normalised the
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integrated jerk by distance and duration and applied it to reaching movements before
and after lesioning of the cerebella nuclei in cats. The influence of movement length
or duration was removed from the jerk measure by dividing the time integral of
square jerk (length² / duration5) by the length² / duration5 of the movement (Kitazawa
et al., 1993).
Normalised jerk has since been used to quantify fine motor coordination in patients
with Parkinson’s disease (Stelmach, 1997; Teulings et al., 1997), developmental
characteristics of young girls over arm throwing techniques (Yan, Hinrichs et al.,
2000), developmental features of rapid aiming arm movements across the lifespan
(Yan, Thomas et al., 2000) and to investigate changes in movement substructures as
a function of practice (Thomas et al., 2000).
Smoothness of movement has been shown as a variable of interest in the Melbourne
Assessment (Randall et al., 1999). Fluency is a sub-skill in eight of the Melbourne
Assessment test items and is defined as the ‘ability of the movement to flow smoothly
and freely without jerkiness or tremor’ (Randall et al., 1999 p. 45).
To date all measures of the smoothness of movement employed in clinical outcome
studies have been two dimensional (2D). Movement difficulties in children with
cerebral palsy are not limited to the sagittal plane (Ỏunpuu et al., 2000). Abnormal
transverse plane rotations, which are common in children with cerebral palsy can
result in significant errors in sagittal plane results if collected with a 2D system (Davis
& DeLuca, 1996). Consequently to get a true and accurate understanding of the
movement sub-structures in children with cerebral palsy a 3D system is preferred.
Other sub-structures of movement that have been shown to discriminate between
people with and without neurological impairment include movement time (Trombly,
1992; Flash, 1995; Wu, et al., 1998), directness (Feng & Mak, 1997), percentage of
distance and time in the primary movement (Schellekens et al., 1983), normalised
jerk in primary and secondary movement, percentage of jerk in primary and
secondary movement and peak velocity as percentage of distance in the primary
movement (see Chapter 3).
The primary aim of this study was to determine if motor behaviour in children with
cerebral palsy is closer to the motor behaviour of children without cerebral palsy at
initial lycra® splint application, 3 months after lycra® splint wear and on immediate
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lycra® splint removal compared to baseline. It was hypothesised that when
comparing all treatment conditions to baseline:
1.1 movement time would be reduced
1.2 directness index would move closer to unity
1.3 percentage of time and distance in the primary movement would
increase
1.4 jerk index and normalised jerk would decrease
1.5 normalised jerk in the secondary movement would decrease
1.6 peak velocity would increase
1.7 percentage of jerk in the primary movement would increase
1.8 percentage of jerk in the secondary movement would decrease
1.9 total percentage score on the Melbourne Assessment would increase
The second aim of the study was to investigate the long term carry-over effects of the
lycra® splint. It was hypothesised that:
2.1 there would be no significant difference in sub-movements
(normalised jerk and percentage of time in the primary movement) and
unilateral upper limb function between 3 months lycra® splint wear
and 3 months post lycra® splint wear.
2.2 there would be a significant difference in sub-movements (normalised
jerk and percentage of time in the primary movement) and unilateral
upper limb function between baseline and at 3 months post lycra®
splint wear.
The third aim of the study was to investigate the effects of lycra® arm splints on the
sub-populations of children with dystonic and spastic hypertonicity. It was
hypothesised that:
3.1 there will be a significant difference in normalised jerk in children with
dystonic and spastic hypertonicity at baseline
3.2 there will be a significant difference in the percentage of time in the
primary movement in children with dystonic and spastic hypertonicity
at baseline
3.3 there will be a significant difference in normalised jerk at baseline and
after 3 months of splint wear in children with dystonic hypertonicity
3.4 there will be a significant difference in percentage of time in the
primary movement at baseline and after 3 months of splint wear in
children with dystonic hypertonicity
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3.5 there will be a significant difference in normalised jerk at baseline and
after 3 months of splint wear in children with spastic hypertonicity
3.6 there will be a significant difference in percentage of time in the
primary movement at baseline and after 3 months of splint wear in
children with spastic hypertonicity
The fourth aim of the study was to investigate the sensitivity of the measures
employed at the level of impairment to detect small, but clinically significant, changes
in motor function. It was hypothesised that:
4.1 the sub-skill of fluency from the Melbourne Assessment will detect
small but clinically significant change (as determined by the Goal
Attainment Scale) in unilateral upper limb fluency pre and post
intervention of lycra® arm splints
4.2 total percentage scores from the Melbourne Assessment will detect
small but clinically significant change (as determined by the Goal
Attainment Scale) in unilateral upper limb motor function pre and post
intervention of lycra® arm splints
4.3 normalised jerk will detect small but clinically significant change (as
determined by the Goal Attainment Scale) in unilateral upper limb
motor function pre and post intervention of lycra® arm splints
Methods Participants
Children aged between 5 and 15 years with a diagnosis of cerebral palsy
(hypertonia) were considered for inclusion in the study. Children who had previously
received upper limb botulinum – A toxin were excluded from the study as were
children who had worn a lycra® arm splint in the past two years. Subjects had to be
able to follow two-step instructions and have upper limb hypertonia, as determined by
the resistance of the biceps to passive stretch. Withdrawal criteria included
withdrawal of consent or development of adverse reactions to the splint or testing
procedures during the period of the study.
Volunteers for the study were sought through newspaper advertisements and internal
advertising through local hospitals and therapy centres. Twenty-nine families
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attended an initial screening appointment where information was provided about the
intervention and assessment procedures for the study. Children were tested using a
full Melbourne Assessment and parents completed a brief questionnaire. With
parental permission the videotape of the Melbourne Assessment was sent to Second
Skin™ to assist with the individual design of the lycra® arm splints. After the initial
appointment two families declined to participate and 10 children did not meet the
inclusion criteria. All 17 children who met the criteria were included in the study.
The youngest child in the study (6 years 2 months) did not complete the final testing
session as he developed a physiological anxiety response to the application and
removal of markers. Data were analysed for eight male and eight female children
with cerebral palsy (hypertonia), who had a mean age of 11.48 years (SD = 2.23
years). Three children had quadriplegia and 13 had hemiplegia (Table 6.1 contains
descriptive details of the sample). The dominant characteristic of hypertonicity in the
children was spastic (n= 11), dystonic (n = 5) and rigid (n = 1). All legal guardian’s
signed consent forms including the Declaration of Helsinki as required by the
University of Western Australia Ethics Committee.
Participant Number
Age (y.m) Sex Arm
assessed Type of cerebral
palsy Hypertonia Group
1 11.9 Male Left Quadriplegia Dystonia 1 2 14.11 Female Left Quadriplegia Dystonia 2 3 14.8 Female Right Quadriplegia Spastic 1 4 9.1 Female Left Hemiplegia Spastic 2 5 10.7 Female Right Hemiplegia Spastic 1 6 14.6 Male Left Hemiplegia Dystonia 2 7 14.7 Male Right Hemiplegia Spastic 2 8 8.9 Male Left Hemiplegia Spastic 2 9 12.8 Male Left Hemiplegia Spastic 1
10 10.9 Female Left Hemiplegia Rigid 1 11 9.2 Male Right Hemiplegia Spastic 2 12 10.6 Female Left Hemiplegia Spastic 1 13 10.1 Female Left Hemiplegia Spastic 2 14 9.11 Female Left Hemiplegia Dystonia 1 15 13 Male Right Hemiplegia Dystonia 2 16 9.1 Male Left Hemiplegia Spastic 2
Table 6.1: Descriptive details of participants in the study
It has been suggested that a beta = .20 with a corresponding power of 80% provides
reasonable protection against making a Type II error (Portney & Watkins, 2000). A
one-tailed compromised power analysis (effect size = .80 (large), beta / alpha ratio =
1) with a sample size of n1 = 8 and n2 = 8 obtained a desired power of .785 (Faul &
Erdfelder, 1992).
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Due to the variability of upper limb movement a single trial may not be representative
of the typical response, subsequently a method for multiple trial analysis has been
proposed by Bates, Dufek & Davis, (1992). Bates et al. (1992) has shown that if trial
size is increased the required sample size decreases at a proportionally greater rate.
They suggested that for a statistical power of 90% trial sizes of 10, 5 and 3 should be
used for a sample size of 5, 10 and 20 respectively. Using the general linear
relationship outlined by Bates et al. (1992) the statistical power for this study (16
children, 3 trials) is greater than 70% as shown above.
Design
A counterbalanced cross-over single factor design was used to structure the
investigation of the independent variable, the lycra® splint. Subjects in Group 1 wore
the lycra® splint for 3 months and then subjects in Group 2 wore their lycra® splints
for the same time period. Due to the nature of the cross over design, Group 1 had
one baseline measure and two measures at 3 months post splint removal, whereas
Group 2 had three baseline measures and no measures at 3 months post splint
removal. Figure 6.1 is a diagrammatic representation of the study design using the
notation introduced by Campbell and Stanley (1963). The wearing regime for the
lycra® arm splint was Monday to Friday (9:00 am – 3:00pm). Subjects were randomly
allocated to groups. Extraneous variables were controlled by requesting subjects
continue with normal levels of therapy and activity, not take up any new activity and
maintain current levels of medication.
Baseline 3 month 3 month
O1 X1 X2 O2 O3 O4 (Group 1) R
O1 O2 O3 X1 X2 O4 (Group 2)
Key: X – experimental intervention (arm splint)
X1 – Arm splint (after 1 hour of wear) X2 – Arm splint (after 3 months of wear) O – Measurement of the dependent variable R – Subjects randomly assigned to group (Campbell & Stanley, 1963)
Figure 6.1: Study design
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Measures
The Melbourne Assessment (Randall et al., 1999) is a criterion-referenced test for
children with neurological impairment between the ages of 5 and 15 years. The
assessment is designed to measure a child’s unilateral upper limb motor function
based on 16 items involving; reach, grasp, release and manipulation (Johnson et al.,
1994). Preliminary studies have indicated that the Melbourne Assessment is a
reliable and valid tool for measuring the quality of upper limb movement in children
with cerebral palsy (Bourke-Taylor, 2003; Randall et al., 2001).
A seven-camera Vicon 370 (Oxford Metrics, Oxford, U.K.) motion analysis system
operating at 50 Hz was used to record the 3D marker positions and movements
during a static trial and each of the four tasks taken from the Melbourne Assessment.
Three 2D video footage cameras were placed in the fontal (anterior and posterior)
and sagittal planes. Due to the variability of upper extremity movement the selection
of more than one task is necessary for analysis (Rau et al., 2000). Four motion
analysis tasks; reach forwards, reach forwards to an elevated position, reach
sideways to an elevated position and hand to mouth and down (while holding a
biscuit) were adopted from the Melbourne Assessment (Randall et al., 1999). These
tasks were chosen as they related to functional activities, focussed on motor abilities
and included important components of elbow motion that lycra® splints aimed to
influence.
The marker sets used were the static calibration marker set (see Figure 6.2) and the
functional movement marker set - a subset of the static set. The 3D positions of the
markers were reconstructed in the static and functional movement trials using a
customised model in Vicon Workstation Software (Oxford Metrics Ltd, Oxford, U.K.).
A kinematic model of the head, trunk, upper arm, forearm and hand was created
using BodyBuilder ® (Oxford Metrics Ltd, Oxford, U.K.) software to analyse the 3D
movement of the wrist joint centre throughout the functional tasks. The outward
movement for each trial was used for jerk analysis to be consistent with the
Melbourne Assessment. Three trials for each dynamic task were selected for
analysis. When there were more than three available, selecting trials was done by
eliminating those furthest away from the average (elbow flexion / extension) for the
child for that task. Selecting the best trials would have violated the assumption of
uncorrelated error variance (Mullineaux et al., 2001).
137
Figure 6.2: Static marker set, (yellow circles on the right section of the figure
represent markers and the red circle represents the wrist joint centre).
The wrist joint centre was defined as the mid-point between the ulna and radial
styloid processes, as identified by anatomical markers in the static trial and
reconstructed relative to forearm markers during dynamic trials. Once the position of
the wrist joint centre was determined, the data were filtered using a Woltering spline
with a mean standard square error (MSSE) of 20 in the Vicon Workstation ®
software. A MSSE of 20 was determined by residual analysis based on a sample of
children without a neurological condition (Appendix H). Movement substructures
were analysed for the 3D wrist joint centre using custom written ‘Jerk Analysis’
computer software (Labview, National Instruments Inc, Texas, U.S.A.). This ‘Jerk
Analysis’ software was modified from the 2D software used by Thomas et al. (2000).
Movement start and finish were identified from the 3D kinematic data as well as 2D
video footage. Movement start was defined as movement of the wrist joint away from
the marked position and movement end was defined as the initial point of sustained
contact with the target or initial point when the child sustains contact between the
mouth and the biscuit and the mouth / face. These definitions are consistent with the
guidelines for the Melbourne Assessment (Randall et al., 1999).
All assessments took place at the Motion Analysis laboratory at the School of Human
Movement and Exercise Science, University of Western Australia. During testing
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children adopted a sitting position with hips flexed at 90 degrees and knees flexed to
90 degrees with feet flat on the floor. One child sat in their wheelchair with postural
supports, two children sat in a high backed chair and the remaining 13 children sat
on a stool for all testing sessions. The table height was adjusted so that the child's
forearms rested on the table in a comfortable position of approximately 90 degrees
elbow flexion, such that their assessed hand was on the table (midline of body and a
forearms distance from the body). This is referred to as the marked position in the
Melbourne Assessment (Randall et al., 1999) and was employed for consistency.
Research has shown that movement performance of the upper limb is influenced by
start position (Yang et al., 2002a).
Baseline assessment was completed with the lycra® splint off. Assessments after
one hour of splint wear and three months of daily splint wear were performed while
the splint was still on the arm. The splint was applied by a qualified occupational
therapist according to the guidelines by Second Skin™. All children completed a full
Melbourne Assessment which was administered by a qualified occupational therapist
according to the procedures outlined in the manual. The test protocols for the
Melbourne Assessment and 3D motion analysis were carried out twice, within a day.
Children were also assessed using the Functional Independence Measure for
Children (UDSMR, 1998), Goal Attainment Scale (GAS – Kiresuk et al., 1994),
International Classification of Functioning Disability and Health Checklist (Version
21a Clinician From, WHO 2001b) at baseline and 3 months after lycra® splint wear.
The parent, teacher and child questionnaire (Knox, 2003) was administered at 3
months after splint wear (see Chapter 5).
As part of the lycra® splinting intervention children participated in goal directed upper
limb training while wearing the lycra® splint. This training involved active practice in
task specific activities related to the child’s functional goals (as recorded by the
GAS). Training was done during the child’s daily routine and generally took a total of
20 to 30 minutes each weekday (CPA, 1999).
Dependant variables were defined as;
• Movement time - time taken from the initial hand movement to end position
(Yan & Thomas et al., 2000). The lower the score of movement time the
faster the movement speed (Thomas et al., 2000).
• Directness index - ratio between the actual path of the hand and the
theoretical shortest path of the hand (Bernhardt et al., 1998). The more direct
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a subject’s movement, the closer the directness index is to unity (Teng &
Kamm, 2002).
• Jerk index - rate of change of acceleration or the third time derivative of
position (Feng & Mak, 1997; Flash & Hogan 1985; Hogan & Flash 1987;
Kitazawa et al., 1993; Thomas et al., 2000).
• Normalised jerk – jerk that has been normalised for different movement
durations and sizes by dividing integrated squared jerk by length2/ duration5
per movement (Kitazawa et al., 1993; Teulings et al., 1997; Thomas et al.,
2000; Yan & Thomas et al., 2000).
• Primary movement – the initial ballistic movement determined by calculating
the maximum slope on the acceleration curve and adjusting it to the minimum
slope on the velocity curve. The identification of the primary movement was
then confirmed by manually viewing the acceleration, velocity, displacement
traces and 3D graph of the movement.
• Percentage of jerk in primary movement – jerk in the primary sub-movement
divided by overall movement jerk (Thomas et al., 2000).
• Percentage of time in the primary movement – portion of the movement time
beginning at the start of the movement to the start of the secondary
movement divided by movement time (Thomas et al., 2000). Percentage of
distance in the primary movement was calculated using the same procedure.
Data analysis To reduce experimental bias the investigators analysing the 3D motion analysis and
‘Jerk Analysis’ data were blinded to group assignment, level of the independent
variable being tested and order of testing sessions. Past research has shown that
participants can increase their primary sub-movement and decrease jerk as a result
of practice (Thomas et al., 2000). To establish the effects of practice associated with
testing a dependant t-test was used to compare the variables normalised jerk and
percentage of time in primary movement for Group 2 at baseline one and baseline
two. No significance was established for normalised jerk at baseline one (M =
284.96, SD = 492.30) and two (M = 265.64, SD = 486.88) t (95) = 1.542 (two-tailed) p
> 0.05, or for the percentage of time in the primary movement at baseline one (M =
53.80%, SD = 20.96) and baseline two (M = 52.24%, SD = 19.62) t (95) = 0.670 (two-
tailed) p > .05. This indicates that practice was not a significant factor across testing
sessions during this study.
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To determine equivalence between groups, normalised jerk and percentage of time
in primary movement was compared for Group 1 and 2 at baseline. A two-tailed t-
test for independent samples found no significance difference in normalised jerk t
(190) = 0.201 p > .05 and percentage of time in primary movement t (190) = 1.762 p
> .05. This indicates that at baseline there was no significant between group
difference in the sub-movements normalised jerk and percentage of time in the
primary movement.
Each independent variable had four levels (k = 4), baseline, immediate splint wear, 3
months after splint wear and immediate splint removal. A one way repeated
measures analysis of variances (ANOVA) was used to compare across treatment
conditions between subjects. The assumptions of normality, homogeneity of
variance and sphericity were met for all independent variables. The level of
significance was adjusted using a Bonferroni correction to protect against Type 1
error. A planned comparison of 10 independent variables was established. To
ensure a Type 2 error was not the level of significance was adjusted to .01 for these
comparisons (Portney & Watkins, 2000).
Due to the nature of the cross over design only Group 1 received follow-up
assessment at 3 months after splint removal. A dependant samples t-test was used
to compare the means for normalised jerk and total percentage scores from the
Melbourne Assessment for Group 1 at baseline and 3 months following splint wear
and at 3 months after splint wear and 3 months post splint removal.
Nonparametric techniques were used to analyse the data investigating the effects of
lycra® arm splints in sub-populations due to the unequal sample sizes and violations
of normality and homogeneity of variance of the distributions.
Responsiveness of the Melbourne Assessment and ‘Jerk Analysis’ software was
examined using change in scores at baseline and 3 months following splint wear.
Total percentage scores and fluency sub-skills from the Melbourne Assessment and
normalised jerk at points of clinically important change were statistically analysed
using a 2-tailed t-test for dependant samples. Fluency sub-skill scores were
calculated by the sum of eight fluency sub-skills on the Melbourne Assessment.
Clinically important change was determined using the Goal Attainment Scale (GAS –
Kiresuk et al., 1994). The GAS is an individualised client centred outcome measure
141
that represents possible levels of goal attainment following therapeutic intervention
(Brown et al., 1998). GAS scores were calculated for this sample (see Chapter 5).
GAS mean T-scores were greater than 50 (Group 1 M = 53.20, SD = 5.04; Group 2
M =53.99, SD = 3.81) after 3 months of splint wear. A T-score of 50 indicates that
goals on average were achieved (McLaren & Rodgers, 2003).
Results Table 6.2 displays means and standard deviations for all the movement variables
analysed at baseline, initial splint wear, 3 months after splint wear and immediate
splint removal.
Independent variable
Baseline Initial splint wear
3 months after splint wear
Immediate splint removal
F
Movement time
M 57.03s SD 23.18s
M 51.56s SD 22.10s
M 48.76s SD 21.44s
M 51.03s SD 22.68s
5.06
Directness Index
M 1.68 SD 1.36
M 1.62 SD 1.31
M 1.51 SD 1.06
M 1.53 SD 0.94
0.94
Percentage of time in primary movement
M 48.76% SD 21.44%
M 51.56% SD 22.10%
M 57.10% SD 23.04%
M 52.32% SD 20.93%
5.15
Percentage of distance in primary movement
M 56.67% SD 23.16%
M 62.30% SD 23.35 %
M 64.41% SD 24.33%
M 61.83% SD 25.99%
3.91
Jerk Index M 67827 SD 127374
M 60352 SD 278163
M 19135 SD 39073
M 29579 SD 89950
4.09
Normalised Jerk
M 308.71 SD 338.27
M 269.63 SD 398.69
M 191.68 SD 229.87
M 219.19 SD 350.96
5.052
Normalised Jerk in secondary movement
M 3049.82 SD 35942.58
M 173.51 SD 418.99
M 228.98 SD 706.44
M 567.18 SD 3217.73
1.112
Percentage of Jerk in secondary movement
M 43.60% SD 30.18%
M 42.76% SD 27.03%
M 32.86% SD 27.27%
M 40.40% SD 28.66%
5.813
Percentage of Jerk in primary movement
M 56.40% SD 30.18%
M 57.24% SD 27.03%
M 67.14% SD 27.27%
M 59.60% SD 28.66%
5.813
Peak velocity as percentage of distance in primary movement
M 84.08% SD 76.24%
M 74.49% SD 51.47%
M 68.19% SD 68.65%
M 87.79% SD 116.87%
2.391
Unilateral upper limb function
M 54.40% SD 14.57%
M 54.20% SD 15.96%
M 55.84% SD 13.52%
M 55.88% SD 14.81%
0.781
Table 6.2: Descriptive statistics of sub-movements across all treatment conditions
142
Movement time
A one-way repeated measures ANOVA was performed on movement time across
each level of the experimental condition. This ANOVA revealed a significant main
effect (baseline M = 57.03 s, SD = 23.18; initial splint wear M = 51.56 s, SD = 22.10;
3 months after splint wear, M = 48.76 s, SD = 21.44; and immediate splint removal M
= 51.03 s, SD = 22.68), F (2.96, 565.33) = 5.056, p <.01. A Bonferroni post hoc
analysis established significant differences between; baseline and immediate splint
application, baseline and 3 months after splint wear and baseline and immediate
splint removal.
Directness Index
No significant main effect was established for directness index F (2.96, 565.33) =
0.94, p >.01. A trend was evident for the directness index baseline mean score (M =
1.68, SD = 1.36) being further away from unity and thus less direct then the mean
score after 3 months of splint wear (M = 1.51, SD = 1.06).
Percentage of time and distance in primary movement
A significant main effect was established for the percentage of time F (2.96, 565.33)
= 5.149, p <.01, and percentage of distance F (2.96, 565.33) = 3.906, p <.01 in the
primary movement. Using a Bonferroni post-hoc analysis a significant difference was
established between the percentage of time in the primary movement at baseline (M
= 48.75%, SD = 21.44%) and 3 months after splint wear (M = 57.10%, SD =
23.04%), (see Figure 6.3). Using the same post hoc analysis a significant difference
was established between the percentage of distance in the primary movement at
baseline (M = 56.66%, SD = 23.16%) and 3 months after splint wear (M = 64.41%,
SD = 24.33%).
143
Percentage of time in primary movement
3035404550556065707580
Baseline Initial splintwear
3 monthsafter splint
wear
Immediatesplint
removal
Nor
mal
ised
jerk
Childrenwith CP
Childrenwithout CP
Figure 6.3: Percentage of time in primary movement across all treatment conditions
Normalised jerk and jerk index
The ANOVA revealed a significant main effect for normalised jerk F (2.79, 523.62) =
5.05, p <.01 and jerk index F (1.58, 302.25) = 4.09, p <.01. The Bonferroni post hoc
analysis established significant differences in normalised jerk between; baseline (M =
308.70, SD = 338.266) and 3 months of splint wear (M = 191.68, SD = 229.87),
baseline and splint removal (M = 219.19, SD = 350.96) and between initial splint
wear (M = 269.63, SD = 398.69) and 3 months after splint wear (see Figure 6.4).
Normalised jerk
0
50
100
150
200
250
300
350
Baseline Initialsplint wear
3 monthsafter splint
wear
Immediatesplint
removal
Nor
mal
ised
jerk
Childrenwith CP
Childrenwithout CP
Figure 6.4: Percentage of jerk in primary movement across all treatment conditions
144
A significant difference was also established for the jerk index between baseline (M
= 67827, SD = 127374) and 3 months of splint wear (M = 19135, SD = 39073),
baseline and splint removal (M = 29579, SD = 89950) and initial splint wear (M =
60350, SD = 278163) and 3 months after splint wear. Figure 6.5A displays a typical
3D trajectory for a child with cerebral palsy at baseline, initial splint application, 3
months after splint wear and immediate splint removal, for the task reach sideways to
an elevated target. Figure 6.5B displays a typical displacement, velocity,
acceleration and jerk trace for one child with and without cerebral palsy completing
the Melbourne Assessment task ‘reach sideways to an elevated position’. Traces at
baseline, initial splint wear, 3 months after splint wear and on immediate splint
removal are displayed for a child with cerebral palsy.
X
Y
Z
X
Y
Z
i. Baseline ii. Initial splint wear
X
Y
Z
X
Y
Z
iv. Immediate splint removal iii. 3 months of splint wear
145Figure 6.5A: 3D trajectory for a child with cerebral palsy at i. baseline, ii. initial splint wear, iii. 3 months of splint wear and iv. immediate splint
l
Jerk Acceleration Velocity
Velocity Acceleration Jerk
Initial splint wear
-1E+08
4E+08
9E+08
1.4E+09
Time
Child without cerebral palsy
0
500
1000
1500
Time
mm
.s-1
Child without cerebral palsy
-5000
0
5000
Time
mm
.s-2
Child without cerebral palsy
01E+092E+093E+094E+095E+09
Time
Baseline
0
500
1000
1500
Time
mm
.s-1
Baseline acceleration
-10000-500005000
10000
Time
mm
.-2
Baseline jerk
01E+102E+103E+104E+105E+10
Time
Initial splint wear
0
500
1000
Time
mm
.s-1
Initial splint wear
-5000
0
5000
Time
mm
.s-2
3 months splint wear
0
500
1000
1500
Time
mm
.s-1
3 months splint wear
-5000
0
5000
Time
mm
.s-2
Immediate splint removal
0
5E+08
1E+09
1.5E+09
Time
Immediate splint removal
0
500
1000
Time
mm
.s-1
Immediate splint removal
-5000
0
5000
Time
mm
.s-2
3 months splint wear
0
5E+08
1E+09
1.5E+09
Time
Children with cerebral palsy
Figure 6.5B: Velocity, acceleration and jerk trace for child with (baseline, initial, 3
months and initial off) and without cerebral palsy (reach sideways)
146
Percentage of jerk in primary and secondary movements
A significant main effect was established for percentage of jerk in the primary F (2.93,
559.88) = 5.81, p <.01 and secondary F (2.93, 559.88) = 5.813, p < .01 movements.
A significant difference was established for percentage of jerk in the primary
movement between; baseline (M = 56.39%, SD = 30.18%) and 3 months after splint
wear (M = 67.14%, SD = 27.27%), initial splint wear (M = 57.24%, SD = 27.03%) and
3 months after splint wear and between 3 months after splint wear and immediate
splint removal (M = 59.60%, SD = 28.67%), (see Figure 6.6). A significant difference
was also found for percentage of jerk in the secondary movement between; baseline
(M = 43.60%, SD = 30.18%) and 3 months after splint wear (M = 32.86%, SD = 27.27
%), p <.05, initial splint wear (M = 42.76%, SD =27.03 %) and 3 months after splint
wear p < .05 and between 3 months after splint wear and immediate splint removal
(M = 40.40%, SD = 28.66%), p < .05.
Percentage of jerk in primary movement
30405060708090
100110
Baseline Initialsplint wear
3 monthsafter splint
wear
Immediatesplint
removal
Nor
mal
ised
jerk
Childrenwith CP
Childrenwithout CP
Figure 6.6: Percentage of jerk in primary movement across all treatment conditions
Peak velocity as a percentage of distance in the primary movement
No significant main effect was established for peak velocity as a percentage of
distance in the primary movement F (2.30, 438.54) = 2.391 p >.01. A trend was
evident with peak velocity as a percentage of distance in the primary movement
being larger at baseline (M = 84.08%, SD = 76.24) than at 3 months (M = 68.18%,
SD = 68.66).
147
Unilateral upper limb function
An ANOVA was performed on total percentage Melbourne Assessment scores at
baseline, initial splint wear, 3 months after splint wear and immediate splint removal.
No significant main effect (F (3, 45) = 0.781 p > .01) was established.
3 months post splint removal
A two-tailed t-test for dependant samples indicated that normalised jerk for Group 1
was significantly higher at 3 months post splint removal (M = 267, SD = 246.50) than
at 3 months after splint wear (M = 195.96, SD = 248.33) t (96) = 2.113, p <.05. In
Group 1 percentage of time in the primary movement was significantly reduced at 3
months post splint removal (M = 53.64, SD = 18.36) compared with 3 months post
splint wear (M = 64.20, SD = 24.22), t (96) = 3.260, p < .05. In Group 1 a two-tailed
t-test for dependant samples indicated no significant difference for total percentage
Melbourne Assessment scores at 3 months after lycra® splint wear and 3 months
post splint wear t (7) = 0.223, p > .05. No significant difference was established for
normalised jerk t (96) = 1.83, p > .05, percentage of time in primary movement t (96)
= 1.10, p > .05, and total percentage scores on the Melbourne Assessment t (7) =
0.639, p > .05, at baseline and 3 months after splint removal
Sub-movements in sub-populations
Five children in the study had dystonic hypertonicity (60 trials across 4 movement
tasks) and ten had spastic hypertonicity (120 trials across 4 movement tasks). A
Mann-Whitney U-test was employed to determine if there was a significant difference
in normalised jerk and percentage of time in the primary movement in the two
independent samples of children with dystonic and spastic hypertonicity. A two-tailed
Mann-Whitney U-test established a significant difference in normalised jerk at
baseline p < .001, for children with dystonic (M = 468.65, SD = 446.26) and spastic
(M = 258.81, SD = 287.16) hypertonicity.
A Mann-Whitney U-test was also employed to determine if there was a significant
difference in percentage of time in the primary movement in children with dystonic
and spastic hypertonicity at baseline. This test revealed no significant difference in
percentage of time in primary movement at baseline p =.788, p >.05 in children with
dystonic (M = 48.09, SD = 21.88) and spastic (M = 49.05, SD = 21.31) hypertonicity.
148
A two-tailed Wilcoxon signed-ranks test was used to test relative differentiations in
children with dystonic and spastic hypertonicity at baseline and 3 months after
wearing a lycra® splint. A significant difference between baseline and 3 months was
established for the percentage of time in the primary movement for children with
dystonic hypertonicity .001, p<.05 and for children with spastic hypertonicity p =.048,
p<.05. The same test was used to test the relative differentiations for the movement
variable normalised jerk and a significant difference was established between
baseline and 3 months for children with dystonic hypertonicity p <.001, and for
children with spastic hypertonicity p = .016, p<.05 (See Figure 6.7).
Normalised jerk in subpopulations
0
100200
300400
500
Baseline 3 months
Nor
mal
ised
jerk
Dystonic Spastic Rigid Children without cerebral palsy
Percentage of time in primary movement in subpopulations
304050607080
Baseline 3 months
Per
cent
age
of ti
me
in
prim
ary
mov
emen
t
Dystonic Spastic Rigid Children without cerebral palsy
Figure 6.7: Normalised jerk and percentage of time in primary movement in
subpopulations of children with cerebral palsy
Sensitivity of measures
A two-tailed t-test for dependant samples indicated that there was no change in
fluency sub-skill scores t (1l5) = .00 p > .05 and total percentage Melbourne
Assessment scores t (15) = 1.032 p > .05 at baseline and 3 months after lycra® splint
149
wear. A significant difference was established at baseline (M = 308.71, SD = 338.27)
and 3 months after splint wear (M = 191.68, SD = 229.87) for normalised jerk t (191)
= 4.34, p < .05 (2-tailed).
Discussion After children with cerebral palsy wore the lycra® splint for 3 months less corrective
movements were required, movement was faster, more efficient and under greater
central control. This was evident by the significant difference established for
movement time, normalised jerk, jerk index, percentage of time and distance in
primary movement and percentage of jerk in the primary and secondary movement
from baseline to 3 months after splint wear.
The data supported the hypothesis that movement time would reduce from baseline
to initial splint wear, 3 months of splint wear and immediate removal. This is similar
to the findings of Kluzik et al. (1990) who established movement time decreased in a
sample of children with cerebral palsy following neurodevelopmental treatment. The
data revealed large variability in intra-subject movement time. This may have been
due to the lack of time constraints included in the task, variety of tasks, the lack of
homogeneity of a sample of children with cerebral palsy. Intra-subject movement
time has also been reported to be large in adults (Jeannerod, 1984) and in infants
(Fetters & Todd, 1987). Movement time across all levels of the independent variable
was longer than movement time reported for children without cerebral palsy (Chapter
3). Movement time was significantly reduced from baseline to immediate splint
application indicating that the arm splint has an influence on movement time
independent of any goal directed training. A significant difference was established
between baseline and immediate splint removal supporting the short term (1 hour)
carry-over effect of the splint.
The data did not support the hypothesis that the directness index would move closer
to unity. This is consistent with Kluzik et al. (1990) who found that the length of the
path the hand travelled did not change pre and post neurodevelopmental treatment.
In this study a change was evident in movement time but not in the directness index
consequently it could be viewed that there may have been a change in the speed of
muscle activation but not a change in the pattern of muscle activation.
150
Children with cerebral palsy spend a shorter percentage of time and distance in the
primary movement compared to children with out cerebral palsy (Chapter 3). The
data supported the hypothesis that the percentage of time and distance in the
primary movement would increase at 3 months after splint wear compared to
baseline. The primary movement is considered to be under central control while the
secondary movement relies on sensory feedback (Thomas et al., 2000). At baseline
children pre-program only a short initial portion of the movement (as represented by
the small percentage of time and distance in the primary movement) with several
corrective adjustments during the remainder of the movement (secondary
movement). At 3 months of splint wear the percentage of time and distance in the
primary movement increases suggesting performance improves as more of the
movement is under central control. This increase in the primary movement after
intervention is similar to the findings of Kluzik et al. (1990) who identified the duration
of the first movement unit relative to the total movement time increased after
neurodevelopmental treatment suggesting a more controlled reach.
An increase in the percentage of time and distance in the primary movement may be
related to the reduction in jerk and spasticity and increased sensory feedback
provided by the splint. A reduction in jerk may increase the neuromotor noise ratio
consequently enabling a greater true signal of muscle length and force transmitted.
A reduction in spasticity promotes greater accuracy in force variability so force
recruitment for a task is modulated as extra force is not required to overcome the
spasticity. A reduction in spasticity at 3 months after splint wear is supported in the
data through the interrelation of jerk, movement time and velocity. Spasticity and jerk
are velocity dependant. At 3 months after splint wear movement time decreases. If
there was no reduction in spasticity an increase in normalised jerk could be predicted
with a corresponding decrease in movement time. As normalised jerk has decreased
and a greater percentage of overall jerk is in the primary movement, spasticity may
have decreased. This improved input from the reduction in jerk and spasticity as well
as from the sensory (proprioceptive and tactile) feedback from the splint promotes
feedback about the body’s interaction with the environment via the somatosensory
system, enabling movement to be under greater central control.
A difference in the percentage of time and distance in the primary movement was not
evident between baseline and initial splint wear, however there was a difference at 3
months. This highlights the importance of incorporating goal directed training into the
lycra® splinting program for maximum benefits. A statistically significant reduction in
151
the percentage of time and distance in the primary movement at immediate splint
removal indicates that effects of the splint cause the change in the sub-movements
not other external variables.
After wearing the splint for 3 months movement time decreases and the length of the
primary movement increases. A movement with a larger primary sub-movement is
more efficient as it relies less on feedback. Increased movement time at baseline
may be related to the increased time required to make corrective actions in the
secondary movement to reach the target.
Normalised jerk and jerk index across all levels of the independent variable were
higher for children without cerebral palsy compared with children with cerebral palsy
(Chapter 3). The hypothesis that normalised jerk and jerk index would decrease at 3
months was supported by the data. This reduction in jerk, pre and post treatment, is
consistent with the findings of Kluzik et al. (1990) who employed movement units as
a measure of smoothness and demonstrated that the number of movement units per
reach decreased significantly following neurodevelopmental treatment in children
with cerebral palsy. A significant difference was established between initial splint
wear and 3 months after splint wear, again supporting the inclusion of goal directed
training. A difference was established between baseline and immediate splint
removal supporting the short-term (1 hour) carry-over effects of the splints.
Normalised jerk has been shown to reflect smoothness of movement and movement
efficiency (Yan & Thomas et al., 2000). It could be suggested that in children with
cerebral palsy (hypertonicity) movement is smoother and more efficient after wearing
a lycra® arm splint for 3 months.
The data supported the hypothesis that at 3 months of splint wear the percentage of
jerk in the primary movement would increase and the percentage of jerk in the
secondary movement would decrease. The percentage of jerk in the primary
movement is greater for children without cerebral palsy compared with children with
cerebral palsy and the inverse is true for the secondary movement (Chapter 3). A
significant difference was established for both the percentage of jerk in the primary
and secondary movement between initial splint application and 3 months after splint
wear. This again supports the inclusion of goal directed training to maximise the
effects of lycra® arm splints. A significant difference was established between 3
months of splint wear and immediate splint removal. This does not support the short
term carry over effect of the splint but does support the notion that changes in
152
percentage of jerk in primary and secondary movements is directly related to the
lycra® arm splint and not extraneous factors.
A long term carry-over effect was not supported by analysis of sub-movements
(normalised jerk and the percentage of time in the primary movement) or unilateral
upper limb function. This research was restricted to a 3 month time frame for splint
wear. Further research is required to investigate if an increase is splint wear will
impact on the long-term carry over effect of the splint.
The data supported the hypothesis that there was a significant difference in
normalised jerk in children with dystonic and spastic hypertonicity at baseline. This is
comparable to the clinical presentation of children with dystonic hypertonicity as their
movement is characterised by unwanted, clumsy, uncoordinated movements during
activity (Bax & Brown, 2004). The hypothesis that there was a significant difference
in the percentage of time in the primary movement in children with dystonic and
spastic hypertonicity was not supported.
The data supported the hypothesis that there would be a significant difference in
normalised jerk (.001, p<.05) and percentage of time in the primary movement (.001,
p<.05) for children with dystonic hypertonicity at baseline and 3 months after splint
wear. This is similar to the results of Nicholson et al. (2001) who found lycra
garments increased movement smoothness for children with athetosis and ataxia.
Edmonson et al. (1999) also reported marked improvement in children with athetosis,
ataxia and hypotonia after wearing lycra splints. Brownlee et al. (2000) identified that
the children who benefited the most from lycra garments had ataxia or dystonic types
of motor disorders.
Children with dystonic hypertonia tend to use extremes of inner and outer range
postures and find middle-range control a problem (Scrutton, 2000). Joint receptors
provide feedback on end of range movement, whereas muscle spindles provide
feedback information in middle-ranges (Kandel et al., 1995). It could be viewed that
the proprioceptive input provided by the splint to the joint receptors impacts on the
feedback to the somatosensory system and consequently motor control in children at
extremes of range of motion. The data support this assumption with the strength of
the significance in the reduction of normalised jerk in children with dystonic
hypertonia compared with children who have spastic hypertonia pre and post
splinting.
153
The data also supported the hypothesis that there would be a significant difference in
normalised jerk (.016, p<.05) and percentage of time in the primary movement (.048,
p<.05) in children with spastic hypertonicity. The strength of this finding was not as
strong compared with children with dystonic hypertonicity. Conversely Nicholson et
al. (2001) reported that for children with spasticity the lycra garments result in an
increase in movement jerkiness, although this did not limit functional improvements.
Both the Melbourne Assessment and ‘Jerk Analysis’ software measure change at the
ICF level of body functions and structures. This study has demonstrated that the
movement substructure normalised jerk is responsive to clinically significant change
as a result of lycra® splints. The data further suggest that the Melbourne
Assessment was not sensitive to this change over time.
In a research setting the Melbourne Assessment may not be the most suitable tool to
assess the effectiveness of intervention techniques in a population of children with
cerebral palsy due to a lack of sensitivity. This is similar to the findings of Wallen et
al. (2004), who investigated functional outcomes of botulinum toxin in the upper limb
of children with cerebral palsy. These researchers reported GAS T-scores of 42 and
47 at 3 and 6 months respectively and no significant changes in the Melbourne
Assessment. The scoring of the Melbourne Assessment consists of 3, 4 or 5 point
scales according to the success of the quality of movement (Bourke-Taylor, 2003).
The precision of the scoring of the Melbourne Assessment is restricted by the
accuracy of observational sub-movements and kinematics of the examiners and the
2D video footage, which forms the basis of these observations. Although therapists
have been shown to be able to accurately and reliably judge kinematics (jerkiness,
hand path indirectness and peak movement speed) of performance during
observational assessment (Bernhardt et al., 1998) there is currently no data on the
precision of these observations. Scoring from 2D video footage reduces the
examiners ability to effectively measure rotational components of movement.
The benefit of analysing 3D sub-movements however needs to be considered in
context of its clinical utility. Unlike the Melbourne Assessment, 3D upper limb motion
analysis is not currently readily available to clinicians, is costly, requires additional
training for clinicians and is not easy to administer (Law & Baum, 2001).
154
This study provides doctors and therapists with the highest level of evidence to base
clinical decisions about lycra® splinting in children with cerebral palsy. It is original
as it is the first intervention study to employ 3D sub-movements as an outcome
measure. Past research into the efficacy of lycra® splints has been compromised
due to the lack of sensitivity of measures to detect clinically significant change in
motor function. This research has provided unique information about the change in
motor function in children with cerebral palsy as a result of lycra® splinting. It is
clinically important in more areas other than paediatric neurology, as 3D analysis has
the potential to be applied to a wide range of intervention studies such as Parkinson’s
disease, multiple sclerosis and stroke.
155
CHAPTER 7 A Randomised Controlled Trial of the Effects of
Lycra® Arm Splints on Trunk and Upper Limb Angular Kinematics in Children with Cerebral Palsy
Abstract Lycra® arm splints are designed to promote upper limb function in children with
cerebral palsy by addressing postural and tonal issues impacting on the elbow. The
objective of this study is to investigate the three dimensional angular kinematics
(thorax, shoulder and elbow) in children with cerebral palsy at initial lycra® arm splint
wear, after 3 months of splint wear, immediately after splint removal and 3 months
post splint wear compared with baseline. Sixteen children with cerebral palsy
(hypertonicity) aged between 9 and 14 years took part in a randomised cross-over
trial. Three dimensional joint kinematic data of the upper limb and trunk were
acquired with a seven camera Vicon motion analysis system. All participants had
five movement tasks analysed from the Melbourne Assessment of Unilateral Upper
Limb Function analysed (Randall et al., 1999).
Results of the study demonstrated that for the tasks reach sideways to an elevated
position and reach forwards to an elevated position, maximum elbow extension
increased between baseline and 3 months after splint wear although the total range
of elbow flexion / extension did not change. For the reach forwards to an elevated
position and hand to mouth and down tasks, maximum pronation and range of elbow
pronation / supination moved closer to that of children without cerebral palsy after 3
months of splint wear compared with baseline. A significant difference was
established for maximum elbow supination for the task pronation / supination.
Effects of lycra® arm splints on the shoulder and compensatory movements of the
thorax were examined and significant differences established for these variables in
some of the tasks. Long-term (3 months) carry-over effects are established for the
thorax but not at the elbow and shoulder. This research shows that lycra® arm
splints when worn for 3 months, can make a quantifiable, change to maximum range
of movement and total range of movement during functional tasks at the elbow and
shoulder joints and thorax segment in children with cerebral palsy.
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Introduction Cerebral palsy is the most common physical disability in childhood, occurring in 2.0
to 2.5 per 1000 live births (Reddihough & Collins, 2003). The condition is a disorder
of movement and posture due to a deficit or lesion of the immature brain (Bax &
Brown, 2004). These disorders manifest early in life and are permanent and non-
progressive although the musculoskeletal effects do change with time (O’Flaherty &
Waugh, 2003; Stanley & Watson, 1992).
Impairments present in children with cerebral palsy occur as a direct result of the
brain injury or indirectly to compensate for underlying problems including; abnormal
muscle tone, limited variety of muscle synergies, contractures, altered biomechanics,
weakness and lack of fitness, loss of speed of movement, associated and mirror
movements, with the net result being limited functional ability (Brown & Walsh, 2000;
Mayston, 2001). The most common posture of the upper limb in children with
cerebral palsy is a flexed posture at the elbow, wrist and fingers, together with
internal rotation at the shoulder and pronation of the forearm. This pronation - flexion
synergy pattern limits functional performance of the hand and arm (Second Skin,
2002). The trunk on the unaffected side is flexed to accommodate functionally
shortened limbs on the affected side due to fixed contractures (see Figure 7.1).
Intervention to minimise impairments include therapy (splinting, strengthening,
positioning), selective surgery and pharmacology (O’Flaherty & Waugh, 2003).
Figure 7.1: Upper limb posture of a child with cerebral palsy - right hemiplegia
157
Lycra® arm splints are circumferential, semi-dynamic splints, designed and
fabricated by Second Skin™ and extend from the wrist to the axilla (see Figure 7.2).
They comprise of a series of lycra segments sewn together in an orientation
appropriate to produce a low force to resist the spastic muscles, while also facilitating
the antagonist muscles (Gracies et al., 2000; Wilton, 2003). The splints are designed
to facilitate functional movement by impacting on tone, posture and patterns of
movement. The supination-extension lycra® arm splint addresses the pronation
flexion synergy pattern of movement of the upper limb by promoting active supination
and extension (Second Skin, 2002). The mechanical properties of lycra arm splints
have been established in patients without neurological involvement (Gracies et al.,
1997). In adults with hemiplegia lycra arm and hand splints were shown to
significantly improve resting posture at the wrist, reduce wrist and finger flexion
spasticity and reduce swelling in patients with swollen limbs (Gracies et al., 2000).
Figure 7.2: Lycra® arm splint
To date two studies have investigated the impact of lycra® arm splints on children
with neurological dysfunction. Corn et al. (2003) employed a multiple single subject
experimental design to investigate the impact of lycra® arm and hand splints on the
quality of upper limb movement. The outcome measure used was the Melbourne
Assessment (Randall et al., 1999). Corn et al. (2003) reported that one long-term
user declined in performance, one new user demonstrated initial improvement in his
quality of upper limb movement while the other two participants showed no significant
change. This thesis employed measures at all levels of the International
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Classification of Functioning Disability and Health (WHO, 2001a) to investigate
lycra® arm splints and found no significant difference at the level of impairment
using the Melbourne Assessment and for passive and active range of motion
(Chapter 5). Both studies concluded that either the measures employed were not
sensitive enough to identify any change that did occur or that lycra® arm splint did
not result in significant changes to the quality of unilateral upper limb movement.
Three dimensional (3D) motion analyses can provide valuable information about
compensatory and actual movement used by children with cerebral palsy at the level
of impairment. It is a powerful assessment of movement in all degrees of freedom
(Rau et al., 2000). Vicon 370 (Oxford Metrics Ltd, Oxford, U.K.) is a 3D commercial
motion analysis system that employs a passive optical marker system to provide a
visual record of body segment positions (Anglin & Wyss, 2000). Testing has shown
that the Vicon 370 (Oxford Metrics Ltd, Oxford, U.K.) system can measure the
average distance between two markers within 1 mm of the actual value (RMS error =
0.062 cm, Richards, 1999) and demonstrated the capability of measuring an absolute
angle within 1.5° of the actual value (RMS error = 1.421°, Richards, 1999). Reid et
al. (2004) determined the repeatability of elbow motion using the measure of the
average coefficient of multiple correlations (CMCs) in typically developing children in
all planes of movement using the above system. The repeatability was found to be
good to excellent (flexion / extension CMC = 0.92, abduction / adduction CMC =
0.77, supination / pronation CMC = 0.82, See Appendix K).
Upper limb 3D kinematic analysis has been successfully employed in the past in
children with cerebral palsy to investigate the extent to which movement limitations
are taken into account when planning and performing sequences (Mutsaarts et al.,
2004). It has also been applied to a comparative study of children with and without
cerebral palsy (Chapter 4).
This study was performed to evaluate lycra® arm splints in children with cerebral
palsy and address the following hypotheses:
1.1 Maximum elbow extension will increase during functional tasks that
require elbow extension (reach forwards, reach forwards to an
elevated position, reach sideways to an elevated position) at initial
lycra® splint application, following 3 months of splint wear and on
immediate splint removal compared with baseline.
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1.2 Total range of elbow flexion / extension will increase during functional
tasks that require elbow extension (reach forwards, reach forwards to
an elevated position, reach sideways to an elevated position) at initial
lycra® splint application, following 3 months of splint wear and on
immediate splint removal compared with baseline.
1.3 Maximum elbow pronation will move in a direction closer to that of
children without cerebral palsy during functional tasks that require
elbow pronation (reach forwards to an elevated position, reach
sideways to an elevated position and hand to mouth and down) at
initial lycra® splint application, following 3 months of splint wear and
on immediate splint removal compared with baseline.
1.4 Total range of elbow pronation / supination will move in a direction
closer to that of children without cerebral palsy during functional tasks
that require elbow pronation (reach forwards to an elevated position,
reach sideways to an elevated position and hand to mouth and down)
at initial lycra® splint application, following 3 months of splint wear and
on immediate splint removal compared with baseline.
1.5 Maximum elbow supination will increase in the pronation / supination
task at initial lycra® splint application, following 3 months of splint
wear and on immediate splint removal compared with baseline.
1.6 Total range of elbow supination / pronation will increase in the
pronation / supination task at initial lycra® splint application, following
3 months of splint wear and on immediate splint removal compared
with baseline.
1.7 Maximum shoulder flexion will increase in the tasks reach forwards,
reach forwards to an elevated position and hand to mouth and down
at initial lycra® splint application, following 3 months of splint wear and
on immediate splint removal compared with baseline.
1.8 Total range of shoulder flexion / extension will increase in the tasks
reach forwards, reach forwards to an elevated position and hand to
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mouth and down at initial lycra® splint application, following 3 months
of splint wear and on immediate splint removal compared with
baseline.
1.9 Maximum shoulder abduction will increase in the tasks reach
sideways to an elevated position at initial lycra® splint application,
following 3 months of splint wear and on immediate splint removal
compared with baseline.
1.10 Total range of shoulder abduction / adduction will increase in the tasks
reach sideways to an elevated position at initial lycra® splint
application, following 3 months of splint wear and on immediate splint
removal compared with baseline.
1.11 Compensatory movements of the thorax (thorax flexion) will reduce in
the tasks reach forwards, reach forwards to an elevated target and
hand to mouth and down at initial lycra® splint application, following 3
months of splint wear and on immediate splint removal compared with
baseline, as measured by the maximum recorded angle and total
range of movement.
1.12 Compensatory movements of the thorax (thorax lateral flexion) will
reduce in the tasks supination / pronation and reach sideways to an
elevated target at initial lycra® splint application, 3 months of splint
wear and on immediate splint removal compared with baseline, as
measured by the maximum recorded angle and total range of
movement.
1.13 Compensatory movements of the thorax (thorax rotation) will reduce in
the tasks supination / pronation, reach sideways to an elevated target
and reach forwards to an elevated target at initial lycra® splint
application, following 3 months of splint wear and on immediate splint
removal compared with baseline, as measured by maximum recorded
angle and total range of movement.
The long term carryover effects of the lycra® arm splint will be investigated guided by
the following hypotheses:
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2.1 No significant difference will be found following 3 months of lycra®
splint wear and 3 months post lycra® splint wear in:
• maximum elbow extension for the tasks reach forwards to an
elevated position and reach sideways to an elevated position
• maximum elbow supination for the task pronation / supination
• maximum shoulder flexion for the task reach forwards to an
elevated position
• maximum trunk flexion for the task hand to mouth and down.
2.2 A significant difference will be found at baseline and 3 months post
lycra® splint wear in:
• maximum elbow extension for the tasks reach forwards to an
elevated position and reach sideways to an elevated position
• maximum elbow supination for the task pronation / supination
• maximum shoulder flexion for the task reach forwards to an
elevated position
• maximum trunk flexion for the task hand to mouth and down.
Methods Children aged between 5 and 15 years with a diagnosis of cerebral palsy
(hypertonia) were considered for inclusion in the study. Children who had previously
received upper limb botulinum – A toxin were excluded from the study as were those
who had received a lycra® arm splint in the past two years. Subjects had to be able
to follow two-step instructions and have upper limb hypertonia, as determined by the
resistance of the biceps to passive stretch. Withdrawal criteria included withdrawal of
consent or development of adverse reactions to the splint or testing procedures
during the period of the study.
Participants were recruited using a variety of methods including advertorials in the
local paper (see Appendix G), presentations to local occupational therapists and
parent groups in the region and mail outs to occupational therapists working with
school aged children with physical disabilities. Any family who responded was sent
an information sheet about the study (see Appendix A). This was followed up five
days later by a phone call and an initial meeting was scheduled with the family.
Twenty-nine families attended an initial screening appointment, where information
162
was provided about the intervention and assessment procedures for the study.
Children were tested using a full Melbourne Assessment and parents completed a
brief questionnaire. After the initial appointment two families declined to participate
and 10 children did not meet the inclusion criteria. All 17 children who met the
criteria were included in the study. With parental permission the videotape of the
Melbourne Assessment for these 17 children was sent to Second Skin™ to assist
with the individual design of the lycra® arm splints.
The youngest child in the study (6 years 2 months) did not complete the final testing
session as he developed a physiological anxiety response to the application and
removal of markers and his data were not analysed. Data were analysed for eight
male and eight female children with cerebral palsy, (hypertonia) aged 9 to 14 years
(M = 11.48, SD = 2.23 years). Three children had a diagnosis of quadriplegia and 13
had a diagnosis of hemiplegia (see Table 7.1). All legal guardians signed consent
forms including the Declaration of Helsinki as required by the University of Western
Australia Ethics Committee (see Appendix A).
Child Number
Type of cerebral palsy
Hypertonia Group Aim of splint
1 Quadriplegia Dystonia 1 Ext rotation, elbow extension, supination
2 Quadriplegia Dystonia 2 Ext rotation, reduce hyperextension, supination
3 Quadriplegia Spastic 1 Ext rotation, elbow extension, supination
4 Hemiplegia Spastic 1 Ext rotation, elbow extension, supination
5 Hemiplegia Dystonia 1 Ext rotation, elbow extension, supination
6 Hemiplegia Dystonia 1 Ext rotation, elbow extension, supination
7 Hemiplegia Spastic 2 Ext rotation, elbow extension, supination
8 Hemiplegia Spastic 1 Ext rotation, neutral elbow, supination 9 Hemiplegia Spastic 2 Ext rotation, elbow extension,
supination 10 Hemiplegia Rigid 2 Ext rotation, elbow flexion, pronation 11 Hemiplegia Spastic 2 Ext rotation, elbow extension,
supination 12 Hemiplegia Spastic 1 Ext rotation, elbow extension,
supination 13 Hemiplegia Spastic 1 Ext rotation, elbow extension,
supination 14 Hemiplegia Spastic 2 Ext rotation, elbow extension,
supination 15 Hemiplegia Dystonia 2 Ext rotation, elbow extension,
supination 16 Hemiplegia Spastic 2 Ext rotation, elbow extension,
supination Table 7.1: Descriptive details of the sample of children in the study
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The 16 children were randomly assigned to Group 1 (n = 8) and Group 2 (n = 8). It
has been suggested that a beta = .20 with a corresponding power of 80% provides
reasonable protection against making a Type II error (Portney & Watkins, 2000). A
one-tailed compromised power analysis (effect size = .08 (large), beta / alpha ratio =
1) with a sample size of n1 = 8 and n2 = 8 provided a power of .785 (Faul &
Erdfelder, 1992).
Due to the variability of upper limb movement a single trial may not be representative
of typical movement patterns, subsequently a method for multiple trial analysis has
been proposed by Bates et al. (1992). Bates et al. (1992) has shown that if trial size
is increased the required sample size decreases at a proportionally greater rate.
They suggested that for a statistical power of 90% trial sizes of 10, 5 and 3 should be
used for a sample size of 5, 10 and 20 respectively. Using the general linear
relationship outlined by Bates et al. (1992) the statistical power for this study (16
children, 3 trials) was shown to be greater than 70% as shown above.
A counterbalanced cross-over single factor design was used to structure the
investigation of the independent variable, the lycra® splint. Subjects in Group 1 wore
the lycra® splint for 3 months and then subjects in Group 2 wore their lycra® splints
for the same time period. Both subjects started a goal directed training program at
baseline (O1). Due to the nature of the cross-over design, Group 1 had one baseline
measure (O1) and two measures at 3 months post splint removal (O3, O4). Group 2
had three baselines (O1, O2, O3), however the cross-over design did not permit any
assessments at 3 months post splint removal. Figure 7.3 provides a diagrammatic
representation of the study design using the notation introduced by Campbell and
Stanley (1963). The wearing regime for the lycra® arm splint was 9:00 am – 3:00pm,
Monday through to Friday and was monitored by parents and teachers during this
time. Extraneous variables were controlled by requesting subjects continue with
normal levels of therapy and activity, not take up any new activity and maintain
current levels of medication.
164
165
Baseline 3 month 3 month
O1 X1 X2 O2 O3 O4 (Group 1) R
O1 O2 O3 X1 X2 O4 (Group 2) Key: X – experimental intervention (arm splint)
X1 – Arm splint (after 1 hour of wear) X2 – Arm splint (after 3 months of wear) O – Measurement of the dependent variable R – Subjects randomly assigned to group (Campbell & Stanley, 1963)
Figure 7.3: Study design
Baseline equivalence of the Groups was determined by comparing the mean
maximum elbow extension for the task reach forwards to a high target and the mean
maximum supination for the task pronation / supination at baseline for both Groups at
testing session O1. A two-tailed independent sample t-test found no significant
difference between Group 1 (M = 134.9°, SD = 14.49) and Group 2 (M = 138.3°, SD
= 17.65), t (47) = 0.718, p > .05, for maximum elbow extension for the task reach
forward to a high target at baseline. No significant difference was established
between Group 1 (M = 2.2°, SD = 23.6) and Group 2 (M = 0.8°, SD = 9.9), t (47) =
0.285, p > .05 for maximum supination for the task pronation / supination. This
indicates that for these selected variables Group 1 and Group 2 were equivalent.
At baseline O1 both Groups commenced goal directed upper limb training. The
training continued for the whole 6 month period of the study (from O1 to O4). This
training involved active practice in task specific activities related to the child’s
functional goals. Goals were developed in conjunction with the research team,
Second Skin™, the child and the family. Training was incorporated into the child’s
daily routine and generally took a total of 20 to 30 minutes each weekday (Cerebral
Palsy Association, 1999). Training was individualised according to the needs of the
child and their functional goals. Appendix X is an example of a goal directed training
program from one child in the study.
Children in Group 2 started goal directed training at baseline O1 and continued until
baseline O3 without wearing a lycra® arm splint. Children in Group 1 continued their
goal directed training program for 3 months from baseline O2 after wearing a splint for
3 months to baseline O3 without wearing a splint. To establish the effects of goal
directed training without a lycra® splint a two-tailed t -test for dependant samples
was used to compare the means for maximum elbow supination and maximum elbow
extension for the task reach forwards to an elevated position for Group 2 between
baseline O1 and baseline O3 . No significant difference was established for maximum
pronation, t (20) = .102, p > .05 or maximum elbow extension t (20) = .511, p > .05
indicating there was no change of these variables when children were involved in
goal directed training alone.
A seven-camera Vicon 370 (Oxford Metrics, Oxford, U.K.) motion analysis system
operating at 50 Hz was used to record the 3D marker positions and movements
during a static trial and each of the five tasks taken from the Melbourne Assessment.
Figure 7.4 outlines the camera configuration used. Additionally three, 2D digital
cameras were placed in the frontal (anterior and posterior) and sagittal planes.
Figure 7.4: Camera configuration, for 3D motion analysis
Due to the variability of upper-extremity movement the selection of more than one
task is necessary for analysis (Rau et al., 2000). Five motion analysis tasks; reach
forwards, reach forwards to an elevated position, reach sideways to an elevated
position, supination/ pronation and hand to mouth and down (while holding a biscuit)
166
were adopted from the Melbourne Assessment (Randall et al., 1999). These tasks
were chosen as they; relate to functional activities, focus on motor abilities and
include important components of elbow motion that lycra® splints aim to influence.
Reaching tasks have also been employed previously in 3D motion analysis by Yang
et al. (2002a, 2002b). The test items were administered by a qualified occupational
therapist using the standard guidelines outlined in the Melbourne Assessment
manual. Subjects were instructed to perform each task a minimum of three
consecutive times at their self selected speed.
The marker sets used were the static calibration marker set (see Figure 7.5) and the
functional movement marker set - a subset of the static set. Twenty-one light weight
spherical retroflective markers with a diameter of 10 mm were placed at anatomical
landmarks on the subject’s trunk and upper limb based on research of Schmidt et al.
(1999) and Lloyd et al. (2000). Two markers defined the hand (first and fifth
metacarpal heads) and two markers defined the wrist joint (ulna and radius styloid
processes). A three marker triad was placed on the forearm and another triad on the
upper arm to identify 3D movements for these segments. Markers used to define the
shoulder joint centre included the acromion and anterior and posterior sites (see
Figure 7.5, posterior sites can not be seen). The trunk was defined using C7, clavicle
and sternum, with markers placed at all three sites. The opposite shoulder was also
marked at the acromion to provide an indication of shoulder alignment and finally the
head was identified with four markers (left and right front of head and left and right
back of head).
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Figure 7.5: Static marker set, showing a re-creation of the markers (pink) on the left
and photographically on the right
Before commencement of the Melbourne Assessment dynamic tasks, static trials
were recorded to establish joint centres and anatomical frames of reference. These
static trials included two ‘pointer’ trials, whereby a standardised pointer rod (see
Figure 7.6) was used to ‘point’ at the medial and lateral epicondyle landmarks. This
alternative method of calculating the epicondyle sites and elbow axis was used in an
effort to reduce errors associated with excessive skin movement over bony
landmarks.
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Figure 7.6: Static ‘pointer’ trial, identifying the left lateral epicondyle
The dynamic marker set is a sub-set of the original static marker set. The markers
used in the calculation of the wrist and shoulder joint centres were removed from the
static marker set, as they were only required for the initial joint definition static trials.
All assessments took place at the Motion Analysis laboratory at the School of Human
Movement and Exercise Science, University of Western Australia. During testing
children adopted a sitting position with hips and knees flexed at 90 degrees with feet
flat on the floor. One child sat in her wheelchair with postural supports, two children
sat in a high backed chair and the remaining 13 children sat on a stool for all testing
sessions. The table height was adjusted so that the child's forearms rested on the
table in a comfortable position of approximately 90 degrees elbow flexion and their
assessed hand was on the table. All tasks started and finished with the hand on a
marked position, as research has shown that movement performance of the upper
limb is influenced by start position (Yang et al., 2002b). The marked position
defined as the midline of body, a forearm’s distance from the body, is consistent with
that used in the Melbourne Assessment and was employed for consistency.
Baseline assessment was completed with the lycra® splint off. Assessments after
one hour of splint wear and three months of daily splint wear were performed with the
splint on the arm. The splint was applied by a qualified occupational therapist
according to the guidelines by Second Skin™. The test protocol for 3D motion
analysis was carried out twice, within a day. Children were also assessed using the
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Functional Independence measure for children (WeeFIM, Guide 1993), the
Melbourne Assessment (Randall et al., 1999), Goal Attainment Scale (GAS – Kiresuk
et al., 1994), International Classification of Functioning Disability and Health
Checklist (Version 21a Clinician From, World Health Organisation 2001b) at baseline
and 3 months after lycra® splint wear. The parent, teacher and child questionnaire
(Knox, 2003) was administered 3 months after splint wear. These results from the
above tests are presented in Chapter 5).
Data analysis To reduce experimental bias the investigators analysing the 3D motion analysis data
were blinded to group assignment, level of the independent variable being tested and
order of testing sessions. Three trials for each dynamic task were selected for
analysis. When there were more than three available trials selecting the appropriate
three was done by eliminating the trials furthest away from the average (elbow
extension – for reaching tasks, elbow supination for pronation / supination task and
elbow supination for the task hand to mouth and down) for the child for that task.
Selecting the best trials violates the assumption of uncorrelated error variance
(Mullineaux et al., 2001).
As displayed in Table 7.1 the designs of the children’s splints were individualised
according to their unique postural and movement patterns. For 13 out of the 16
children the aim of the splint was to externally rotate the shoulder, extend the elbow
and supinate the forearm. Child 10 had a design feature incorporated into her splint
to promote forearm pronation. Her data were removed when analysing forearm
supination / pronation as the goal of her splint in respect to forearm rotation was
different from the 15 other subjects. Consequently each task involving elbow
supination / pronation was conducted with 45 trials (15 subjects x 3 trials). The aim
of the splint for 13 out of the 16 participants was to increase elbow extension. The
goal of the splint at the elbow for Child 2 was to reduce hyperextension, Child 8 had
a neutral elbow design, as he had no functional difficulties in the flexion / extension
elbow plane. The goal of the splint for child 10 was to increase elbow flexion.
Accordingly data were analysed for elbow flexion / extension for 39 trials (13 subjects
x 3 trials) for each of the tasks. During the data collection Child 3 sat in a high
backed wood foam insert (bilateral thoracic and pelvic supports) with a head-rest and
harness in her wheelchair. Data for this child were not included in the data analysis
170
for the thorax, subsequently thorax data were conducted for 45 trials (15 subjects x 3
trials) for each of the five tasks.
Each independent variable had four levels (k = 4); baseline, immediate splint wear, 3
months after splint wear and immediate splint removal. A one way repeated
measures analysis of variance (ANOVA) was used to compare across treatment
conditions between subjects. The assumptions of normality, homogeneity of
variance and sphericity were met for all independent variables. The level of
significance was adjusted using a Bonferroni correction to .01 to protect against the
possibility of making a Type I error, while not making a Type II error.
Due to the nature of the cross-over design only Group 1 received follow-up
assessment at 3 months after splint removal. To investigate the long term carryover
effects of the lycra® arm splint a dependant sample t-test was employed to compare
the group means for maximum elbow extension (reach forwards to an elevated
position and reach sideways to an elevated position), maximum elbow supination
(supination / pronation task), maximum shoulder flexion (reach forwards to an
elevated position) and maximum thorax flexion (hand to mouth and down). The
means were compared at baseline (O1) and 3 months post splint wear (O3) and again
between 3 months of splint wear (X2) and 3 months post splint wear (O3) (Figure 7.3).
Movement start and finish were identified from the 3D kinematic data as well as 2D
video footage. Movement start was defined as the first movement of the wrist joint
away from the marked position and movement end was defined as the initial point of
sustained contact with the target, initial point when the child sustained contact
between the mouth and the biscuit and the mouth / face or point of maximum
supination. These definitions are consistent with the guidelines for the Melbourne
Assessment (Randall et al., 1999).
A kinematic model of the upper limb and trunk was created using Vicon
BodyBuilder® Software (Oxford Metrics Ltd, Oxford, U.K.) and used to analyse the
3D joint angles of the thorax segment and shoulder and elbow joints during functional
tasks. Analysis of the kinematics included thorax (3 df = flexion / extension, lateral
flexion / extension and rotation), shoulder (3 df = abduction / adduction, internal /
external rotation and flexion / extension) and elbow (2 df = flexion / extension and
supination / pronation). In the Melbourne Assessment the scoring criteria is
individually defined for each test item (Randall et al., 1999). The range of motion
171
sub-skills served as a guide for the 3D variables to be analysed for each task
captured using 3D motion analysis.
The shoulder joint centre is identified as the centre of the three shoulder markers
placed at the acromion and at the posterior and anterior shoulder sites. The shoulder
joint centre is defined in relation to the triad of markers placed on the upper arm and
is reconstructed relative to the position of the upper arm triad in dynamic trials. The
elbow axis is defined as the line connecting the medial and lateral epicondyles as
identified in the pointer trials, the centre of which is defined as the elbow joint centre.
The medial and lateral epicondylar sites are reconstructed relative to the upper arm
triad during dynamic trials. The wrist joint is defined in a similar manner to the elbow
joint centre. The ulna and radial styloid process’ markers act to define the joint axis,
the centre of which is the joint centre, these markers are reconstructed relative to the
forearm triad markers.
The upper arm segment is defined by the upper arm triad with the origin at the elbow
joint centre, while the forearm segment is defined by the forearm triad with the origin
at the wrist joint centre. The hand segment is defined by the hand markers and the
wrist joint centre with the origin lying between the two hand markers (see Figure 7.7).
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Shoulder Wing
Head
y
x z
y
x z
y
x z
y
x z
Upper Arm
Forearm
Hand
Thorax
Torso
y
x z
y
x z
y
x z
Figure 7.7: Joint centres (red) and coordinate systems are displayed on
the left figure and marker placement (grey) on the right figure.
The shoulder angles are defined as the relative movement of the upper arm segment
about the shoulder wing segment acting through the shoulder joint centre. The
shoulder wing is defined as the plane connecting the mid thorax (between C7 and
clavicle), acromion and the shoulder joint centre (see Figure 7.8). This definition of
the shoulder joint is a more functional representation of shoulder movement
compared with the movement of the upper arm segment relative to the thorax. The
method of defining shoulder angles in relation to the shoulder wing is of particular
importance in the population of children with cerebral palsy as their trunk position
during functional tasks (often flexed, laterally flexed to the unaffected side and
rotated to the affected side) impacts on the accurate calculations of the shoulder joint
angle when calculated from the thorax.
Figure 7.8: The shoulder wing is highlighted in green, it is the plane connecting the
mid thorax, acromion and the shoulder joint centre.
Elbow angles are identified as the relative movement of the forearm segment with
reference to the upper arm segment acting about the elbow joint centre. The wrist
angles are described as the movement of the hand segment about the forearm
segment acting through the wrist joint centre. Torso rotation, and lateral flexion data
are adjusted for left and right differences to enable comparison of the total sample of
children with and without cerebral palsy.
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To enable a comparison with the results from the range of movement sub-scale on
the Melbourne Assessment, angular conversions to the data from Vicon
BodyBuilder® were made to assist with clinical interpretation. Consequently elbow
extension, wrist extension, elbow pronation and elbow supination were converted to
the Melbourne Assessment angular convention (see Table 7.2).
Melbourne Assessment Vicon Body Builder Conversion of Vicon BodyBuilder
Elbow extension Minimum elbow flexion 180° - minimum elbow
flexion
Wrist extension Minimum wrist extension Change negative to
positive
Forearm pronation (start
position of forearm mid-position ) Maximum pronation (start
position at the anatomical position) Maximum pronation - 90°
Forearm supination (start
position of forearm mid-position ) Minimum supination (start
position at the anatomical position) 90° - minimum elbow
supination
Table 7.2: Conversions of Vicon BodyBuilder Data
The data were filtered using a Woltering spline with a mean standard square error
(MSSE) of 20 in the Vicon Workstation ® software. A MSSE of 20 was determined
by residual analysis based on a sample of children without a neurological condition
(see appendix H).
Results An analysis of variance (ANOVA) was performed on range of elbow flexion –
extension at baseline, initial splint wear, 3 months after splint wear and immediate
splint removal. This ANOVA revealed no significant main effect for the tasks reach
forwards F (3,114) = 1.261, p >.05, reach forwards to an elevated position F (3,114)
= 1.117, p > .05 and reach sideways to an elevated position F (3,114) = 1.243, p >
.05. As seen in Table 7.3 a trend of increased range of flexion / extension at 3
months of splint wear compared with baseline is evident for all tasks that require
elbow extension.
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Task Angle Baseline Initial
splint wear 3 months splint wear
Immediate splint removal
F value
Maximum
extension
M 123.3 SD 19.3
M 124.6 SD 8.6
M 127.3 SD 11.9
M 124.2 SD 13.3
1.181 (3,114)
Reach forwards
Range flexion
/ extension
M 38.3 SD 22.5
M 41.6 SD 25.7
M 45.3 SD 21.6
M 44.6 SD 22.6
1.261 (3,114)
Maximum
extension
M 118.8 SD 16.8
M 125.3 SD 21.1
M 126.1 SD 16.5
M 118.2 SD 13.6
3.491 (3,114)
Reach forwards to an elevated position
Range flexion /
extension
M 42.8 SD 25.2
M 41.5 SD 24.9
M 46.9 SD 25.3
M 46.4 SD 29.9
1.117 (3,114)
Maximum
extension
M 120.7 SD 21.8
M 125.7 SD 15.5
M 130.1 SD 15.8
M 125.2 SD 20.5
3.729 (3,114)
Reach sideways to an elevated position
Range flexion /
extension
M 42.1 SD 22.3
M 48.9 SD 37.3
M 48.8 SD 24.7
M 47.6 SD 21.7
1.243 (3,114)
Table 7.3: Maximum and total range of elbow extension (degrees) across all
treatment conditions
An ANOVA was performed on maximum elbow extension across all levels of the
independent variable for the same tasks. Maximum elbow extension was greater 3
months after splint wear (M = 126.1°, SD =16.5) compared with baseline (M = 118.8°,
SD = 16.8, p = .060) and at 3 months after splint wear compared with immediate
splint removal (M = 118.2.80°, SD = 13.6 p = .030), for the task reach forwards to an
elevated position F (3,114) = 3.491 p < .05 (see Figure 7.9). For the task reach
sideways to an elevated position a significant main effect was established F (3,114) =
3.729, p < .05 between baseline (M = 120.7°, SD = 21.8) and 3 months after splint
wear (M = 130.1°, SD = 15.8 p =.029). The main effect of maximum elbow extension
was not significant for the task reach forwards F (3,114) = 1.181, p > .05, however a
trend was evident of increased elbow extension at 3 months after splint wear (M =
127.3°, SD = 11.9) compared with baseline (M = 123.3°, SD = 19.3) (see Figure
7.10).
175
Reach forwards to an elevated position
0
20
40
60
80
100
120
Time
Ang
le
Flexion
Extension
Legend ▀ Children without cerebral palsy ▀ 3 months splint wear ▀ Baseline ▀ Immediate splint removal ▀ Initial splint wear
Figure 7.9: Reach forwards to an elevated position, (elbow flexion / extension) for
children without cerebral palsy and for children with cerebral palsy at baseline, initial
splint wear, 3 months after splint wear and immediate splint removal.
176
Reach fowards
121
122
123
124
125
126
127
128
baseline initial splintw ear
3 months splintw ear
immediate splintremoval
Elbo
w e
xten
sion
Reach forwards to an elevated position
90
95
100
105
110
115
120
125
130
baseline initial splintw ear
3 months splintw ear
immediate splintremoval
Elbo
w e
xten
sion
Reach sideways to an elevated position
114
116
118
120
122
124
126
128
130
132
baseline initial splintw ear
3 months splintw ear
immediate splintremoval
Elbo
w e
xten
sion
Figure 7.10: Mean maximum elbow extension for the three reaching tasks
177
A significant difference was established for maximum pronation for the task reach
forwards to an elevated position F (3,132) = 9.14, p < .05. For this task maximum
pronation moved closer to the maximum pronation of children without cerebral palsy
(M = 51.7°, SD = 9.0) at 3 months of splint wear (M = 52.7°, SD = 30.4, p = .002) and
on immediate splint removal (M = 44.3°, SD = 20.8, p = .007) compared with baseline
(M = 27.3°, SD = 34.8). A significant difference was also established for maximum
pronation for this task between initial splint wear (M = 35.9°, SD = 23.44, p = .019)
and 3 months after splint wear. No significant difference was established for
maximum pronation for the task reach sideways to an elevated position F (3,132) =
0.996, p > .05 (see Table 7.4). A significant difference was established for maximum
pronation for the task hand to mouth and down, F (3, 132) = 5.305, p < .05. The
difference was established between baseline (M = 23.1°, SD = 20.6) and 3 months of
splint wear (M = 36.9°, SD = 18.22) and between baseline and immediate splint
removal (M = 35.8°, SD = 23.9).
A significant difference was established for total range of elbow pronation / supination
for the task reach forwards to an elevated position, F (3,132) = 5.843, p < .05. This
difference was at 3 months after splint wear (M = 20.5°, SD = 15.5) compared with
baseline (M = 31.1°, SD = 19.6) and between 3 months of splint wear and immediate
splint removal (M = 30.6°, SD = 16.9). No significant difference was established for
the total range of pronation / supination for the task reach forwards to an elevated
position F (3,132) = 2.128, p > .05. A significant difference was established for the
total range of pronation / supination for the task hand to mouth and down F (3,132) =
4.867, p < .05. A difference was established between baseline (M = 33.7°, SD =
16.9) and initial splint wear (M = 23.1°, SD = 15.9) and between baseline and 3
months after splint wear (M = 24.3°, SD = 18.2).
178
Task Angle Baseline Initial
splint wear 3 months splint wear
Immediate splint removal
F value
Maximum
pronation
M 27.3 SD 34.8
M 35.9 SD 23.4
M 52.7 SD 30.4
M 44.3 SD 20.8
9.14 (3,132)
Reach forwards to an elevated position
Range
pronation /
supination
M 31.1 SD 19.6
M 22.3 SD 15.7
M 20.5 SD 15.5
M 30.6 SD 16.9
5.843 (3,132)
Maximum
pronation
M 42.9 SD 40.5
M 42.0 SD 41.1
M 39.5 SD 41.3
M 45.3 SD 49.8
0.996 (3,132)
Reach sideways to an elevated position
Range
pronation /
supination
M 27.2 SD 15.2
M 34.0 SD 21.4
M 37.2 SD 26.2
M 33.7 SD 19.1
2.128 (3,132)
Maximum
pronation
M 23.1 SD 20.6
M 29.4 SD 21.2
M 36.9 SD 18.2
M 35.8 SD 23.9
5.305 (3,132)
Hand to mouth and down Range
pronation /
supination
M 33.7 SD 16.9
M 23.1 SD 15.9
M 24.3 SD 18.2
M 27.5 SD 18.8
4.867 (3,132)
Table 7.4: Maximum and total range of elbow pronation (degrees) across all
treatment conditions
The pronation / supination task was the only movement that required supination of
the forearm. A significant main effect was established for maximum elbow supination
for this task F (3,132) = 3.034, p < .05 (see Table 7.5). Using a Bonferroni test to
compare the main effect no statistically significant difference was found between
baseline (M = -13.41°, SD = 54.03), initial splint application (M = -28.9°, SD = 53.97),
3 months after splint wear (M = -1.5°, SD = 50.74) and immediate splint removal (M =
-17.2°, SD = 28.69) (see Figure 7.11).
179
Task Angle Baseline Initial splint wear
3 months splint wear
Immediate splint removal
F value
Maximum
supination
M -13.41 SD 54.0
M -28.9 SD 53.9
M -1.5 SD 50.7
M -17.2 SD 28.6
3.034 (3,132)
Supination/
Pronation
Range
pronation /
supination
M 29.5 SD 13.4
M 28.5 SD 22.0
M 36.5 SD 32.0
M 32.2 SD 16.4
1.171 (3,132)
Table 7.5: Maximum and total range of elbow supination (degrees) across all
treatment conditions
Supination / pronation task
0
20
40
60
80
100
120
140
160
180
Time
Ang
le
Supination
Pronation
Legend ▀ Children without cerebral palsy ▀ 3 months splint wear ▀ Baseline ▀ Immediate splint removal ▀ Initial splint wear
Figure 7.11: Supination / pronation task (elbow angle, supination / pronation), for
children without cerebral palsy and for children with cerebral palsy at baseline, initial
splint wear, 3 months after splint wear and immediate splint removal
180
The total range of shoulder flexion / extension increased from baseline (M = 39.0°,
SD = 17.3) to 3 months after splint wear (M = 56.4°, SD = 31.5, p = .035) and from
baseline to immediate splint removal (M = 55.4°, SD = 30.4, p = .028) with a
significant main effect of F (3,141) = 4.704, p < .05, for the task reach forwards to an
elevated position. A significant main effect was also established for maximum
shoulder flexion for the same task F (3,141) = 5.731, p < .05. The difference was
identified as between baseline (M = 48.9°, SD = 18.4) and 3 months of splint wear (M
= 62.1°, SD = 17.2, p = .007) and between baseline and initial splint wear (M = 61.3°,
SD = 19.9, p = .007).
Maximum shoulder flexion for task reach forwards revealed a significant main effect
F, (3,141) = 9.374, p < .05. For this task maximum shoulder flexion increased from
baseline (M = 45.3°, SD = 14.0) to 3 months of splint wear (M = 57.2°, SD = 13.3),
from initial splint wear (M = 50.4°, SD = 16.6) to 3 months of splint wear and reduced
from 3 months of splint wear to immediate splint removal (M = 49.4°, SD = 16.9).
The main effect for total range of shoulder flexion / extension for the task reach
forwards was not significant, F (3,141) = 1.783, p > .05 (see Table 7.6).
Task Angle Baseline Initial
splint wear 3 months splint wear
Immediate splint removal
F value
Maximum
flexion
M 45.3 SD 14.0
M 50.4 SD 16.6
M 57.2 SD 13.3
M 49.4 SD 16.9
9.374 (3,141)
Reach forwards
Range flexion /
extension
M 33.9 SD 27.2
M 44.0 SD 30.5
M 44.5 SD 24.3
M 44.5 SD 30.2
1.783 (3,141)
Maximum
flexion
M 48.9 SD 18.4
M 61.3 SD 19.9
M 62.1 SD 17.2
M 58.0 SD 21.6
5.731 (3,141)
Reach forwards to an elevated position
Range flexion /
extension
M 39.0 SD 17.3
M 47.7 SD 27.8
M 56.4 SD 31.5
M 55.4 SD 30.4
4.704 (3,141)
Maximum
flexion
M 38.2 SD 16.3
M 35.3 SD 14.9
M 36.5 SD 14.9
M 38.1 SD 15.3
0.673 (3,141)
Hand to mouth and down Range flexion /
extension
M 24.5 SD 14.8
M 27.1 SD 11.8
M 29.5 SD 15.0
M 25.9 SD 17.4
1.289 (3,141)
Table 7.6: Maximum and total range of shoulder flexion (degrees) across all
treatment conditions
181
No significant main effect was established for total range of shoulder flexion /
extension, F (3,141) = 1.289, p > .05 or maximum shoulder flexion, F (3,141) = 0.673,
p > .05 for the task hand to mouth and down (see Table 7.6).
A significant main effect was established for maximum shoulder abduction for the
task reach sideways to an elevated position, F (3,141) = 2.755, p > .05. The
difference was found between baseline (M = 64.8°, SD = 10.2) and 3 months of splint
wear (M = 75.7°, SD = 12.3). A significant main effect was not established for total
range of shoulder abduction / adduction (see Table 7.7).
Task Angle Baseline Initial splint
wear 3 months splint wear
Immediate splint removal
F value
Maximum
abduction
M 64.8 SD 10.2
M 81.3 SD 46.5
M 75.7 SD 12.3
M 68.0 SD 43.3
2.755 (3,141)
Reach sideways to an elevated position
Range
abduction /
adduction
M 36.73 SD 27.0
M 44.0 SD 18.5
M 43.6 SD 17.1
M 41.7 SD 27.2
1.143 (3,141)
Table 7.7: Maximum and total range of shoulder abduction (degrees) across all
treatment conditions
Maximum thorax flexion decreased from baseline (M = 39.5°, SD = 10.1) to 3 months
after splint wear (M = 32.7°, SD = 7.3) and from initial splint wear (M = 38.0°, SD =
12.5) to 3 months after splint wear, F (3,132) = 4.977, p < .05, for the task reach
forwards to an elevated position. A significant main effect was also established for
maximum thorax flexion for the task hand to mouth and down, F (3,132) = 7.334, p <
.05. Thorax flexion reduced from baseline (M = 39.0°, SD = 11.9) to 3 months after
splint wear (M = 34.2°, SD = 7.1), from baseline to immediate splint removal (M =
32.4°, SD = 8.0) and from initial splint wear (M = 38.4°, SD = 12.8) to immediate
splint removal. No significant main effect was established for maximum thorax
flexion for the task reach forwards, F (3,132) = 1.904, p > .05 (see Table 7.8). No
significant main effect was established for total range of thorax flexion / extension for
the tasks reach forwards, F (3.132) = 0.469, p > .05, reach forwards to an elevated
position, F (3,132) = 0.895, p > .05 and hand to mouth and down, F (3,132) = 0.768,
p > .05 (see Table 7.8).
182
Task Angle Baseline Initial
splint wear 3 months splint wear
Immediate splint removal
F value
Maximum
flexion
M 46.8 SD 11.3
M 45.7 SD 8.5
M 43.9 SD 8.5
M 43.6 SD 10.9
1.904 (3,132)
Reach forwards
Range flexion /
extension
M 13.2 SD 10.3
M 11.8 SD 5.3
M 11.2 SD 9.1
M 11.9 SD 9.6
0.469 (3,132)
Maximum
flexion
M 39.5 SD 10.1
M 38.0 SD 12.5
M 32.7 SD 7.3
M 35.8 SD 10.0
4.977 (3,132)
Reach forwards to an elevated position
Range flexion /
extension
M 13.0 SD 10.4
M 12.3 SD 7.0
M 10.1 SD 8.3
M 11.6 SD 12.6
0.895 (3,132)
Maximum
flexion
M 39.0 SD 11.9
M 38.4 SD 12.8
M 34.2 SD 7.1
M 32.4 SD 8.0
7.334 (3,132)
Hand to mouth and down Range flexion /
extension
M 9.6 SD 9.4
M 9.1 SD 9.9
M 7.5 SD 5.0
M 8.5 SD 5.9
0.768 (3,132)
Table 7.8: Maximum and total range of thorax flexion (degrees) across all
treatment conditions
No significant main effect was established for maximum thorax lateral flexion for the
task pronation / supination, F (3, 132) = 0.616, p > .05 and the task reach sideways
to an elevated position, F (3,132) = 1.887, p > .05 (see Table 7.9). The main effect
for total range of thorax flexion / extension was not significant for the tasks pronation
/ supination, F (3,132) = 0.594, p > .05 and reach sideways to an elevated position, F
(3,132) = 1.804, p > .05 (see Table 7.9).
183
Task Angle Baseline Initial
splint wear
3 months splint wear
Immediate splint removal
F value
Maximum
lateral flexion
M -14.4 SD 11.9
M -12.5 SD 11.7
M -12.4 SD 12.6
M -11.4 SD 10.3
1.887 (3,132)
Reach sideways to an elevated position
Range lateral
flexion
M 19.7 SD 8.1
M 21.8 SD 8.7
M 18.1 SD 8.2
M 19.9 SD 12.9
1.804 (3,132)
Maximum
lateral flexion
M -2.0 SD 11.9
M -2.5 SD 9.9
M -0.6 SD 10.5
M -0.4 SD 11.8
0.616 (3,132)
Pronation / supination
Range lateral
flexion
M 11.6 SD 10.1
M 11.5 SD 8.8
M 11.6 SD 9.8
M 13.6 SD 10.4
0.594 (3,132)
Table 7.9: Maximum and total range of lateral thorax flexion (degrees) across all
treatment conditions
A significant main effect was established for total range of thorax rotation for the task
reach forwards to an elevated position, F (3,132) = 2.796, p > .05. The total range of
thorax rotation decreased from baseline (M = 15.14°, SD = 9.55) to 3 months after
splint wear (M = 11.04°, SD = 6.94). No significant main effect was established for
total range of thorax rotation for the tasks supination / pronation, F (3,132) = 1.736, p
> .05 and reach sideways to an elevated position F (3,132) = 0.515, p > .05 (see
Table 7.10). No significant main effect was established for maximum thorax rotation
for the tasks supination / pronation, F (3,132) = 1.640, p > .05, reach forwards to an
elevated position, F (3,132) = 1.640, p > .05 and reach sideways to an elevated
position, F (3,132) = 1.706, p > .05.
184
Task Angle Baseline Initial
splint wear
3 months splint wear
Immediate splint removal
F value
Maximum
rotation
M -8.1 SD 11.2
M -11.5 SD 8.7
M -11.1 SD 9.8
M -9.2 SD 13.0
1.640 (3,132)
Reach forwards to an elevated position
Range of
rotation
M 15.14 SD 9.55
M 13.27 SD 8.88
M 11.04 SD 6.94
M 13.13 SD 9.77
2.796 (3,132)
Maximum
rotation
M -17.8 SD 19.5
M -14.5 SD 12.
M -15.5 SD 10.4
M -12.7 SD 15.7
1.706 (3,132)
Reach sideways to an elevated position
Range of
rotation
M 22.2 SD 9.4
M 24.5 SD 10.6
M 22.5 SD 10.3
M 23.1 SD 10.6
0.515 (3,132)
Maximum
rotation
M -8.15 SD 11.27
M -11.51 SD 8.72
M -11.17 SD 9.85
M -9.21 SD 13.06
1.640 (3,132)
Supination / Pronation
Range of
rotation
M 6.82 SD 7.80
M 7.30 SD 5.51
M 6.75 SD 4.63
M 9.28 SD 7.63
1.736 (3,132)
Table 7.10: Maximum and total range of lateral thorax rotation (degrees) across all
treatment conditions Due to the nature of the cross over design, only Group 1 was assessed at 3 months
post splint wear. A one-tailed dependant t-test was employed to investigate the
difference in Group 1 at baseline and 3 months post splint wear and 3 months of
splint wear and 3 months post splint wear. A one-tailed t-test for dependant samples
indicated that for the task reach forwards to an elevated position, maximum elbow
extension was greater at 3 months of splint wear (M = 143.6°, SD = 20.5) than at 3
months post splint wear (M = 130.8°, SD = 14.9), t (20) = 2.89, p < .05. For the same
task no significant difference was established for maximum elbow extension at
baseline (M = 135.8°, SD = 18.8) and 3 months post splint wear, t (20) = 1.195, p >
.01. A one-tailed t-test for dependant samples indicated a significant difference in
maximum elbow extension for the task reach sideways to an elevated position at 3
months of splint wear (M = 133.7°, SD = 9.8) and 3 months post splint wear (M =
127.2°, SD = 11.0), t (20) = 2.408, p < .05. No significant difference was established
between baseline and 3 months post splint wear for maximum elbow extension for
the task reach sideways to an elevated position, t (20) = 0.790, p > .05.
A one-tailed t-test for dependant samples indicated that for the task pronation /
supination, maximum elbow supination was greater at 3 months of splint wear (M =
185
18.9°, SD = 26.4) than at 3 months post splint wear (M = -2.3°, SD = 27.4), t (23) =
3.317, p < .05. For the same task no significant difference was established between
baseline (M = 2.2°, SD = 23.6) and 3 months post splint wear t (23) = 1.023, p > .05.
No significant difference between 3 months of splint wear and 3 months post splint
wear was established for maximum shoulder flexion for the task reach forwards to an
elevated position, t (23) = 1.44, p > .05. A trend was evident for children at 3 months
of splint wear to have greater shoulder flexion (M = 59.3°, SD = 18.2) than at 3
months post splint wear (M = 52.9°, SD = 20.0). No significant difference was
established between baseline and 3 months post splint wear, t (23) = 1.437, p > .05.
A one-tailed t –test for dependant samples indicated that for the task hand to mouth
and down there was no significant difference in maximum thorax flexion at 3 months
of splint wear and 3 months post splint wear, t (20) = .417, p > .05. At baseline
children used greater maximum trunk flexion (M = 42.7°, SD = 12.5) than at 3 months
post splint wear (M = 35.9°, SD = 8.2), t (20) = 2.956, p < .05.
Discussion: Lycra® arm splints are designed to facilitate functional use of the arm by impacting
on tone and posture (Second Skin, 2002). The splints are dynamic in nature, hence
children wearing them need to move and play to the best of their abilities to achieve
maximum benefit. In the study the majority of children wore a supination / extension
arm splint designed to impact on the pronation flexion synergy pattern of movement
by promoting active elbow extension and supination. Active elbow extension and
supination were promoted at 3 months of splint wear in some of the tasks.
The data supported the hypothesis that maximum elbow extension increases at 3
months of splint wear compared with baseline for the tasks reach forwards to an
elevated position and reach sideways to an elevated position. In the task reach
forwards to an elevated position, maximum elbow extension moved closer to the
movement achieved by children without cerebral palsy (M = 136.1°) at 3 months after
splint wear (M = 126.1°) compared with baseline (M = 118.8°) (Chapter 4). For the
task reach forwards to an elevated position a significant difference was found
between 3 months of splint wear and immediate splint removal indicating that the
increase in maximum elbow extension is directly related to the effect of the splint and
not other external variables. For the task reach sideways to an elevated position
maximum elbow extension moved closer to the maximum elbow extension achieved
186
by children without cerebral palsy (M = 156.6°) at 3 months after splint wear (M =
130.2°) compared to baseline (M = 120.7°) (Chapter 4).
No difference was established in maximum elbow extension between baseline and
initial splint wear for any reaching tasks. This is consistent with the findings by
Gracies et al. (2000) who investigated short-term (3 hour) effects of lycra splints in
adults with hemiplegia. Gracies et al. (2000) found no significant difference in the
mean of active range of movement with and without splints. This increase in
maximum extension at 3 months and not at initial splint wear, supports the
assumption that children need to move, work and play in their splint for the splints to
be of most benefit. The benefit of incorporating goal directed training into the
splinting program was also supported.
The data did not support the hypothesis that total range of elbow flexion / extension
will increase during the tasks reach forwards, reach forwards to an elevated position
and reach sideways to an elevated position. This suggests that, as there was a
change in maximum elbow extension at 3 months, a shift occurs for the whole range
of movement into more extension at 3 months of splint wear, compared with baseline
(children start with less elbow flexion and end with more elbow extension).
The supination-extension lycra® arm splint aims to promote active supination.
Supination is important for common daily activities such as wiping oneself after
toileting, combing / brushing hair, washing your face, putting a fork to your mouth and
opening a door (Chao, An, Askew & Morrey, 1980; Morrey, Askew, An & Chao, 1981;
Zuckerman & Matsen, 1989; Romilly, Anglin, Gosine, Hershler & Raschke, 1994).
The hypothesis that maximum elbow supination will increase in the pronation –
supination task was supported in this research. A significant main effect was
established for maximum elbow supination, however, the Bonferroni test to compare
main effects did not established any differences among the four independent
variables. A trend of moving closer to the movement of children without cerebral
palsy (M = 72.9°) for maximum elbow supination was evident at 3 months of splint
wear (3 months of splint wear, M = -1.5°; baseline, M = -13.41). This is consistent
with the findings by Gracies et al. (2000) who identified a trend of increased elbow
supination when the lycra garment was worn.
Although children with cerebral palsy still have a significant impairment in active
supination, the mean increase (14.9°) might be important to their success with
187
functional tasks. At baseline (M = -13.4°) children on average did not have enough
supination to rise from a chair (M = -10°) or read a newspaper (M = -7°). At 3 months
of splint wear (M = -1.5°) they had on average enough supination to achieve both
these functional tasks (Zuckerman & Matsen, 1989).
The hypothesis that maximum pronation will move in a direction closer to that of
children without cerebral palsy at 3 months and on immediate splint removal during
the tasks reach forwards to an elevated position and hand to mouth and down was
supported by the data. A difference was found between baseline and 3 months of
splint wear and on immediate splint removal. This suggests the lycra® arm splint has
a short –term (1 hour) carry-over effect on maximum pronation. It could also suggest
that an increase in maximum pronation at immediate splint removal is attributed to
the goal directed training program but such a program without lycra® splinting has
been shown to have no relationship to maximum pronation (Group 2 at O1 and O2, t
(20) = .102, p > .05).
A significant difference was established between immediate splint wear and 3
months after splint wear for maximum elbow pronation for the task reach forwards to
an elevated position. This indicates that on immediate splint wear maximum
pronation does not move closer to that of children without cerebral palsy but after 3
months of splint wear, and goal directed training, maximum pronation does move in
that direction. A statistically significant difference was not established for maximum
pronation for the task reach sideways to an elevated position.
It is proposed that lycra® splints reduce hypertonicity through the properties of
circumferential pressure, neutral warmth and by altering the sensitivity to stretch of
the muscle spindles through maintained stretch of the hypertonic muscle (Copley &
Kuipers, 1999). The supination – extension lycra® splints aim to provide a prolonged
stretch to selected arm muscles including pronator quadratus and pronator teres. A
force is created in the direction of supination along the line of pull of these muscles to
provide a prolonged force and reduce hypertonicity. The increase in pronation
through wearing the splint cannot be attributed to the stretch of muscle spindles (as
the force is being created in the opposite direction). The increase must therefore be
related to the reduction of hypertonicity through the properties of circumferential
pressure and neutral warmth. These properties may also be attained through the
application of an accurately measured elastic tubular bandage (AllegroMedical, 2004)
and may have a role in the reduction of hypertonicity of children with cerebral palsy.
188
Further research is required to determine the difference in angular kinematics of
children with cerebral palsy wearing lycra® splints and a commercially available
elastic tubular bandage.
At 3 months of splint wear maximum forearm pronation for the tasks reach forwards
to an elevated position (M = 52.7°), reach sideways to an elevated position (M =
39.5°) and hand to mouth and down (M = 36.9°) moved closer to the maximum
pronation required for functional activities of daily living. Past research shows that
most activities of daily living can be accomplished with 50° of pronation (Chao et al.,
1980; Morrey et al., 1981, Zuckerman & Matsen, 1989).
Children without cerebral palsy have a smaller total range of pronation / supination
than children with cerebral palsy for the tasks reach forwards to an elevated position,
reach sideways to an elevated position and hand to mouth and down (see Chapter
4). The hypothesis that the total range of pronation / supination will move in a
direction closer to that of children without cerebral palsy was supported for the tasks
reach forwards to an elevated position and hand to mouth and down but not for the
task reach sideways to an elevated position. The difference for the task reach
forwards to an elevated position was established between baseline and 3 months of
splint wear and between baseline and immediate splint removal. This again supports
the immediate short-term carry-over effects of the splint. For the task hand to mouth
and down a significant difference was established between baseline and 3 months of
splint wear and between baseline and immediate splint wear. This indicates that the
lycra® arm splints have an immediate effect on total range of pronation / supination
and that the 3 month goal directed training may not have impacted on the change in
the total range of movement.
Lycra® splints were demonstrated to have a positive effect on shoulder flexion and
abduction. The hypothesis that maximum shoulder flexion will increase in the task
reach forwards and reach forwards to an elevated position was supported by the
data. For the task reach forwards the range increased at 3 months of splint wear (M
= 57.2°) and at immediate splint removal (M = 49.4°) compared with baseline (M =
45.3°). A difference was also established between initial splint wear and 3 months of
splint wear further highlighting the importance of goal directed training as part of the
lycra® splinting program.
189
For the task reach forwards to an elevated position a significance was established in
maximum shoulder flexion between baseline (M = 48.9°) and 3 months of splint wear
(M = 62.1°) and between baseline and initial splint wear (M = 61.3°). At initial splint
wear and 3 months after splint wear mean maximum shoulder flexion angle was
closer to children without cerebral palsy (M = 74.5°) compared with baseline
measures. At initial splint wear and after 3 months after splint wear, maximum
shoulder flexion was closer to, but did not attain, the desired range of 80° -145° of
shoulder flexion recommended in the Melbourne Assessment task. The hypothesis
that maximum shoulder flexion will increase was not supported for the task hand to
mouth and down. The data supported the hypothesis that total range of shoulder
flexion / extension increases at 3 months of splint wear and immediate splint removal
compared with baseline for the task reach forwards to an elevated position but not for
the tasks reach forwards and hand to mouth and down.
The data supported the hypothesis that maximum shoulder abduction will increase
from baseline to 3 months of splint wear for the task reach sideways to an elevated
position. The data did not support the hypothesis that the total range of shoulder
abduction / adduction will increase in the task reach sideways to an elevated position
at initial lycra® splint application after 3 months of splint wear and on immediate
splint removal compared with baseline.
Lycra® arm splints aim to impact on posture (Second Skin, 2002). The data
supported the hypothesis that maximum thorax flexion will decrease from baseline to
3 months of splint wear for the tasks reach forwards to an elevated position and hand
to mouth and down. A difference was also established for the task reach forwards to
an elevated position with greater thorax flexion at initial splint wear (M = 38.0°)
compared with 3 months after splint wear (M = 32.7°). For the task hand to mouth
and down, at immediate splint removal children used less thorax flexion (M = 32.4°)
compared with baseline (M = 39.0°). The data did not support the hypothesis that
total range of thorax flexion / extension will decrease at initial splint application, 3
months after splint wear and on immediate splint removal compared with baseline for
the tasks reach forwards, reach forwards to an elevated position and hand to mouth
and down.
The data did not support the hypothesis that thorax lateral flexion (range and
maximum) will reduce in the tasks supination / pronation and reach sideways to an
elevated position. The data did not support the hypothesis that maximum thorax
190
rotation will reduce in the tasks supination / pronation, reach forwards to an elevated
position and reach sideways to an elevated position. The hypothesis that the total
range of thorax rotation will decrease from 3 months of splint wear to baseline for the
task reach forwards to an elevated position was supported by the data. No
difference was established for total range of thorax rotation for the tasks reach
sideways to an elevated position and hand to mouth and down.
No long-term (3 month) carry-over effect of the lycra® arm splint on the variables,
maximum elbow extension, maximum elbow supination and maximum shoulder
flexion was established. The data did not support the hypothesis that there would be
no significant difference between maximum elbow extension (reach forwards to an
elevated position and reach sideways to an elevated position) and maximum elbow
supination (pronation/ supination) at 3 months of lycra® splint wear and 3 months
post lycra® splint wear. The lack of long-term carry-over effect of the lycra® arm
splint was further supported by the data as no significant difference was established
between baseline and 3 months post lycra® splint wear for the same variables. The
data supported the hypothesis that there would be no significant difference in
maximum shoulder flexion for the task reach forwards to an elevated position at 3
months of lycra® splint wear and 3 months post lycra® splint wear. For the same
variable and task, no significant difference was established between baseline and 3
months post lycra® splint wear. The data therefore do not support a long-term carry-
over effect of the splint. The hypothesis that there would be no significant difference
in 3 months of splint wear and 3 months post splint wear for thorax flexion was
supported for the task hand to mouth and down. A significant difference between
baseline and 3 months post splint wear was also established. This supports the long
term carry-over effect of the splint on the variable thorax flexion.
Clinically this research has established that lycra® arm splints, when worn for 3
months, have a positive effect on angular kinematics in children with cerebral palsy
during selected functional tasks. These effects are maximised by the incorporation of
goal directed training. Further research is required to investigate if the duration of
wear of lycra® splints impacts on the carry-over effect and the difference between
the effects of elastic tubular bandages and lycra® splints on angular kinematics in
children with cerebral palsy.
191
CHAPTER 8
Synthesis of Results
This research had five separate but integrated themes, each with a specific goal.
The first four goals focussed on measurement tools with the exploration of the validity
of the Melbourne Assessment (Randall et al., 1999) and establishment of upper limb
normative 3D motion analysis data for children with and without cerebral palsy.
These tools along with the WeeFIM (UDSMR, 1998), GAS (Kiersuk et al., 1994) and
joint range of motion, using a goniometer were subsequently employed to achieve
the final goal of the thesis; to provide objective data on the efficacy of lycra® arm
splints at the level of impairment, activity and participation in children with cerebral
palsy.
This is the first upper limb clinical study to employ 3D angular kinematics (thorax,
shoulder and elbow) and sub-movements. The initial goal of this thesis was to
establish normative data for 3D motion analysis, these data were employed in the
final goal to analyse the direction of change of 3D sub-movements and kinematics at
initial splint wear, 3 months after splint wear, initial splint removal and 3 months post
splint wear in children with cerebral palsy. The second goal of the thesis was to
compare the 3D angular kinematics and movement sub-structures in children with
and without cerebral palsy. Significant differences were established in angular
kinematics at the thorax, shoulder, elbow and wrist for some of the movement tasks
between children with and without cerebral palsy. The sub-structures movement
time, directness index, percentage of distance and time in primary movement,
normalised jerk and jerk index were significantly different in children with and without
cerebral palsy. Through comparison of 3D sub-movements and kinematics in
children with and without cerebral palsy unique information was provided about the
quality of upper limb function in children with cerebral palsy. This greater
understanding of how cerebral palsy impacts on upper limb movement may promote
more effective clinical interventions and act as a catalyst for further research.
The third goal of the thesis was to investigate the sensitivity of the Melbourne
Assessment. This investigation indicated that the Melbourne Assessment was not
able to identify small but clinically significant changes in fluency in this population of
children with cerebral palsy, whereas normalised jerk detected the effects of
192
treatment. This suggests that in a research setting the Melbourne Assessment may
not be the most suitable tool to assess the effectiveness of intervention techniques in
a population of children with cerebral palsy due to a lack of sensitivity. This research
is consistent with the findings of other upper limb research (Corn et al., 2003; Wallen
et al., 2004). The data from this thesis will be invaluable information in the review of
the Melbourne Assessment, which is currently being undertaken by the authors (M.
Randall, personal communication, September 28, 2004).
The fourth goal of the thesis was to explore the validity of the Melbourne
Assessment, by examining the operational performance criteria that form the basis of
the scoring of the assessment. To date no research has examined how typically
developing children perform on the Melbourne Assessment. Inconsistencies were
established both in the maximum range of motion of the sample of typically
developing children in the study and the performance outlined in the scoring criteria,
for the five Melbourne Assessment tasks examined. Further research of the
operational performance criteria, especially in the sub-skill range of motion, is
recommended. Modifications of the scoring to more closely reflect upper limb
function of typically developing children will enhance the validity of the Melbourne
Assessment and thus provide further confidence in the data from the assessment
when used in research and clinical practice.
The fifth and primary goal of the thesis was to investigate the efficacy of lycra® arm
splints at all levels of the ICF in children with cerebral palsy. This study is unique in
that it is the only randomised controlled trial to investigate upper limb splinting in
children with cerebral palsy. This provides therapists and doctors with the highest
level of evidence to form their clinical judgements and guide the way they practice.
Cerebral palsy affects individuals at all levels of the International Classification of
Functioning Disability and Health (WHO, 2001a). Employing the ICF as the
overarching framework has enabled a complete and useful understanding of the
effects of lycra® garments at each domain. This study is the first to examine the
outcomes of any type of splinting employing objective measures at all levels of the
ICF. In the domain of impairment the Melbourne Assessment, range of motion and
3D motion analysis (kinematic and sub-structures) were employed. No statistically
significant change in active or passive range of motion and quality of upper limb
function was established between baseline and initial splint wear, 3 months after
splint wear or immediate splint removal.
193
This is the only clinical study to date to employ 3D angular kinematics and movement
sub-structures to examine the effectiveness of intervention. Three dimensional
motion analysis established statistically significant changes in angular kinematics
(thorax, shoulder and elbow) and movement sub-structures (movement time,
percentage of time and distance in primary movement, jerk index, normalised jerk
and percentage of jerk in primary and secondary movements) for some of the tasks
from the Melbourne Assessment. These changes were primarily identified between
baseline and 3 months of splint wear (not between baseline and initial splint wear).
This highlighted the importance of incorporating goal directed training as part of the
lycra® splinting intervention.
At the level of activity no statistically significant changes across any level of the
independent variable were identified on the WeeFIM (UDSMR, 1998). Significant
change after 3 months was established at the level of participation, as measured by
the GAS. Due to the individual nature of the GAS, outcomes that were meaningful
and beneficial to the child wearing the splint were measured. The parental, teacher
and child questionnaire also provided valuable information about the lycra® splint
from the point of view of the consumer.
Change that is determined to the satisfaction of the child and their family and is
meaningful to the child’s involvement in life situations is the ultimate goal of any
intervention. It is this change that is the fundamental determinant of the benefits of
any intervention. Change at the level of impairment (i.e. greater elbow supination) or
activity (i.e. catching a ball) is of limited benefit to the child and family if there is no
change at the level of participation (i.e. being a member of a local basketball team).
This research has demonstrated that lycra® splints when worn for 3 months in
conjunction with goal directed training have a positive effect on the child’s
involvement in life situations.
All assessments were carried out in a contrived context in the laboratory. A limitation
of the study was data were not collected for a typical performance of the child in his /
her daily environments. The GAS provided an understanding of what the child can
do but what the child actually does was not measured. ‘Snap-shots’ of typical
performance were provided by the teacher, child and parents, however, no
quantitative measures were taken. Further research is required to establish if lycra®
splints make a change in what children actually do in their individual environments.
194
In this research children wore the lycra® arm splint for a set period of 3 months.
During this time they participated in a goal directed training program where they
practised using their upper limb during functional activities. The only evidence of the
long term (3 month) carry over effect of the splint was with maintaince of goals set on
the GAS and maximum thorax flexion for the task hand to mouth and down. Further
research is required to establish if length of splint wear and amount of practice
impact on the long term carry over effect of the lycra® splint.
It is proposed that lycra® splints reduce hypertonicity through the properties of
circumferential pressure, neutral warmth and by altering the sensitivity to stretch of
the muscle spindles through maintained stretch of the hypertonic muscle (Copley &
Kuipers, 1999). Circumferential pressure and neutral warmth can be attained
through the application of an accurately measured elastic tubular bandage. These
elastic bandages are available commercially at a reduced cost compared with a
lycra® arm splint (AllegroMedical, 2004). No research has investigated the effects of
these tubular elastic bandages on children with cerebral palsy, even though they
have similar hypertonicity reducing proprieties to lycra® splints. These tubular elastic
bandages may have a positive effect on impairment, activity and participation in
children with cerebral palsy. It was not within the scope of this research to
investigate what properties of the lycra® splint impacted on impairments, activities
and participation, however, this is an area where further research is recommended.
This randomised controlled trial supports the current clinical practice of prescription
of lycra® arm splints for some children with cerebral palsy (hypertonicity). The
incorporation of measures at all levels of the ICF has provided a unique and
comprehensive understanding of the effects of lycra® splints in children with cerebral
palsy. In this study 3D upper limb motion analysis (kinematics and movement sub-
structures) were employed for the first time and have shown to be a valuable
measure at the level of impairment to detect the effects of treatment.
195
REFERENCES Aicardi, J., & Bax, M. (1998). Cerebral palsy. In J. Aicardi (Ed.), Diseases of the
nervous system in childhood (2nd ed., pp. 330-374). London: Mac Keith Press.
Allegro Medical. (2004). Tubigrip elastic tubular support. Retrieved 12th April, 2005,
from
http://www.allegromedical.com/wound_care/bandages/convatec/tubigrip_elasti
c_tubular_support_bandage.P191630
Allison, S. C., Abraham, L. D., & Petersen, C. L. (1996). Reliability of the Modified
Ashworth Scale in the assessment of plantarflexor muscle spasticity in
patients with traumatic brain injury. International Journal of Rehabilitation
Research, 19(1), 67-78.
American Society of Hand Therapists (ASHT). (1992). Splint classification system.
Chicago: The Society.
Aminian, A., Vankoski, S. J., Dias, L., & Novak, R. A. (2003). Spastic hemiplegic
cerebral palsy and the femoral derotation osteotomy: effect at the pelvis and
hip in the transverse plane during gait. Journal of Pediatric Orthopaedics,
23(3), 314-320.
An, K. N., Browne, A. O., Korinek, S., Tanaka, S., & Morrey, B. F. (1991). Three-
dimensional kinematics of glenohumeral elevation. Journal of Orthopaedic
Research, 9(1), 143-149.
Anglin, C., & Wyss, U. P. (2000). Review of arm motion analyses. Proceedings of
the Institution of Mechanical Engineers Part H - Journal of Engineering in
Medicine, 214(5), 541-555.
Ashworth, B. (1964). Preliminary trial of carisoprodol in multiple sclerosis.
Practitioner, 192, 540-542.
Attfield, S. F., Pickering, P., & Rennie, D. (1998). Calculation of upper limb
kinematics using bone embedded co-ordinate frames. European Society for
the Movement of Adults & Children. Gait & Posture, 7(4), 73-74.
Australian Institute of Health and Welfare (AIHW). (2000). Integrating indicators:
theory and practice in the disability services field (No. DIS-17). Canberra:
Australian Institute of Health and Welfare.
Australian Institute of Health and Welfare (AIHW). (2003). ICF Australian User
Guide Version 1.0. Canberra: Australian Institute of Health and Welfare.
196
Autti-Ramo, I., Larsen, A., Taimo, A., & von Wendt, L. (2001). Management of the
upper limb with botulinum toxin type A in children with spastic type cerebral
palsy and acquired brain injury: clinical implications. European Journal of
Neurology, 8(Suppl 5), 136-144.
Ballantyne, J., & Colegate, J. (2003). Dynamic Lycra splinting advancements in the
field of paediatric neurology. Paper presented at the 2nd Paediatric
Conference: What works with kids (pp. 32). Brisbane.
Barnes, M. P. (2001). Spasticity: a rehabilitation challenge in the elderly.
Gerontology, 47(6), 295-299.
Bates, B. T., Dufek, J. S., & Davis, H. P. (1992). The effect of trial size on statistical
power. Medicine & Science in Sports & Exercise, 24(9), 1059-1065.
Battaglia, M., Russo, E., Bolla, A., Chiusso, A., Bertelli, S., Pellegri, A., et al. (2004).
International Classification of Functioning, Disability and Health in a cohort of
children with cognitive, motor, and complex disabilities. Developmental
Medicine & Child Neurology., 46(2), 98-106.
Bax, M., & Brown, J. K. (2004). The spectrum of disorders known as cerebral palsy.
In D. Scrutton, D. Damiano & M. Mayston (Eds.), Management of the motor
disorders of children with cerebral palsy (2nd ed., pp. 9-21). London: Mac
Keith Press.
Bax, M. C. (1964). Terminology and classification of cerebral palsy. Developmental
Medicine & Child Neurology, 11, 295-297.
Becher, J. G. (2002). Pediatric rehabilitation in children with cerebral palsy: general
management, classification of motor disorders. JPO: Journal of Prosthetics
and Orthotics, 14(4), 143-149.
Beckung, E., & Hagberg, G. (2002). Neuroimpairments, activity limitations, and
participation restrictions in children with cerebral palsy. Developmental
Medicine & Child Neurology, 44(5), 309-316.
Bennett, K. M., Marchetti, M., Iovine, R., & Castiello, U. (1995). The drinking action
of Parkinson's disease subjects. Brain, 118(Pt 4), 959-970.
Bernhardt, J., Bate, P. J., & Matyas, T. A. (1998). Accuracy of observational
kinematic assessment of upper-limb movements. Physical Therapy, 78(3),
259-270.
Blackburn, M., van Vliet, P., & Mockett, S. P. (2002). Reliability of measurements
obtained with the modified Ashworth scale in the lower extremities of people
with stroke. Physical Therapy, 82(1), 25-34.
197
Blair, E., Ballantyne, J., Horsman, S., & Chauvel, P. (1995). A study of a dynamic
proximal stability splint in the management of children with cerebral palsy.
Developmental Medicine & Child Neurology, 37(6), 544-554.
Blair, E., Ballantyne, J., Horsman, S., & Chauvel, P. (1996). A study of a dynamic
proximal stability splint in the management of children with cerebral palsy
[Comment. Letter]. Developmental Medicine & Child Neurology, 32(2), 182-
183.
Bohannon, R. W., & Smith, M. B. (1987). Interrater reliability of a modified Ashworth
scale of muscle spasticity. Physical Therapy, 67(2), 206-207.
Bosch, J. (1995). The reliability and validity of the Canadian Occupational
Performance Measure. Unpublished Masters, McMaster University, Hamilton,
Ontario.
Bourke-Taylor, H. (2003). Melbourne Assessment of Unilateral Upper Limb
Function: construct validity and correlation with the Pediatric Evaluation of
Disability Inventory. Developmental Medicine & Child Neurology, 45(2), 92-96.
Bower, E., McLellan, D. L., Arney, J., & Campbell, M. J. (1996). A randomised
controlled trial of different intensities of physiotherapy and different goal-
setting procedures in 44 children with cerebral palsy. Developmental Medicine
& Child Neurology, 38(3), 226-237.
Bower, E., Michell, D., Burnett, M., Campbell, M. J., & McLellan, D. L. (2001).
Randomized controlled trial of physiotherapy in 56 children with cerebral palsy
followed for 18 months.[see comment]. Developmental Medicine & Child
Neurology, 43(1), 4-15.
Boyd, R., Bach, T., Morris, M. E., Graham, H. K., Imms, C., Johnson, L., et al.
(2003). A randomized trial of botulinum toxin A and upper limb training in
congenital hemiplegia: outcomes of activity, participation, and societal change.
Developmental Medicine & Child Neurology Supplement, 24, 49.
Boyd, R., Bach, T., Morris, M. E., Imms, C., Johnson, L., Graham, H. K., et al.
(2004). A randomized trial of botulinum toxin A and upper limb training - a
functional MRI study. Paper presented at the 58th Annual meeting of the
American Academy for Cerebral Palsy and Developmental Medicine Sept 29-
Oct 2 (pp. 9 B:6). Los Angeles: The Academy.
Boyd, R., Barwood, S. A., Ballieu, C. E., & Graham, H. K. (1998). Validity of a
clinical measure of spasticity in children with cerebral palsy in a randomized
clinical trial. Developmental Medicine & Child Neurology Supplement, 40(78),
7.
198
Boyd, R. N., & Graham, H. K. (1999). Objective measurement of clinical findings in
the use of botulinum toxin type A for the management of children with cerebral
palsy. European Journal of Neurology, 6 Suppl 4, S23-S35.
Boyd, R. N., & Hays, R. M. (2001). Outcome measurement of effectiveness of
botulinum toxin type A in children with cerebral palsy: an ICIDH-2 approach.
European Journal of Neurology, 8(Suppl 5), 167-177.
Boyd, R. N., Morris, M. E., & Graham, H. K. (2001). Management of upper limb
dysfunction in children with cerebral palsy: a systematic review. European
Journal of Neurology, 8(Suppl 5), 150-166.
Bradley, R. H., & Caldwell, B. M. (1988). Using the home inventory to assess the
family environment. Pediatric Nursing, 14(2), 97-102.
Bradley, R. H., Rock, S. L., Caldwell, B. M., & Brisby, J. A. (1989). Uses of the
HOME inventory for families with handicapped children. American Journal of
Mental Retardation, 94(3), 313-330.
Brashear, A., Zafonte, R., Corcoran, M., Galvez-Jimenez, N., Gracies, J. M.,
Gordon, M. F., et al. (2002). Inter- and intrarater reliability of the Ashworth
Scale and the Disability Assessment Scale in patients with upper-limb
poststroke spasticity. Archives of Physical Medicine & Rehabilitation, 83(10),
1349-1354.
Braun, S. L. (1991). A practical approach to functional assessments in pediatrics.
Occupational Therapy Practice, 2(2), 46-51.
Brown, D. A., Effgen, S. K., & Palisano, R. J. (1998). Performance following ability-
focused physical therapy intervention in individuals with severely limited
physical and cognitive abilities. Physical Therapy, 78(9), 934-947.
Brown, J. K., van Rensburg, F., Walsh, G., Lakie, M., & Wright, G. W. (1987). A
neurological study of hand function of hemiplegic children. Developmental
Medicine & Child Neurology, 29(3), 287-304.
Brown, J. K., & Walsh, E. G. (2000). Neurology of upper limb. In B. Neville & R.
Goodman (Eds.), Congenital hemiplegia (pp. 113-149). London: MacKeith.
Brownlee, F., Eunson, P., Jackson, P., McLeman, A., Szadurski, M., & Young, V.
(2000). Evaluation of lycra-based dynamic splinting in treatment of children
with cerebral plasy. Paper presented at the European Academy of Childhood
Disability 12th Annual Meeting (pp. 11-12). Tubigen, Germany: European
Academy of Childhood Disability.
Butler, C., & Campbell, S. (2000). Evidence of the effects of intrathecal baclofen for
spastic and dystonic cerebral palsy. Developmental Medicine & Child
Neurology, 42(9), 634-645.
199
Caldwell, B., & Bradley, R. (1984). Administration manual: Home Observation for
Measurement of the Environment (Rev ed.). Little Rock, AR.: University of
Arkansas at Little Rock.
Campbell, D. T., & Stanley, J. C. (1963). Experimental and quasi-experimental
designs for research. Boston: Houghton Mifflin.
Canadian Mortgage and Housing Corporation. (1989). Maintaining senior's
independence. Ottawa, Ontario: Canadian Mortgage and Housing
Corporation.
Capability Scotland. (2000). Turning disability into ability: investing lycra splinting.
First Person Retrieved 12 April, 2005, from http://www.capability-
scotland.org.uk/upload%5Cdocuments%5Cnewsletters%5Cissue1.pdf
Capability Scotland. (2004). Lycra Dynamic Splinting. CP Factsheet Retrieved April
10th, 2005, from http://www.capability-
scotland.org.uk/upload%5Cdocuments%5Ccerebralpalsy%5CCP_Lycra_Dyna
mic_Splinting.pdf
Cardillo, J.E., & Smith, A. (1994), Reliability of goal attainment scaling. In T.J.
Kiresuk, A. Smith, & J.E. Cardillo (Eds.) Goal Attainment Scaling :
applications, theory, and measurement. (pp. 213-242). Hillsdale, N.J.: L.
Erlbaum Associates.
Carmick, J. (1997). Use of neuromuscular electrical stimulation and [corrected]
dorsal wrist splint to improve the hand function of a child with spastic
hemiparesis.[erratum appears in Phys Ther 1997 Aug;77(8):859]. Physical
Therapy, 77(6), 661-671.
Casey, C. A., & Kratz, E. J. (1988). Soft splinting with neoprene: the thumb
abduction supinator splint. American Journal of Occupational Therapy, 42(6),
395-398.
Cerebral Palsy Association of Western Australia (CPA). (1999). Using the
opportunity: embedding a child's goals into everyday routines. Coolbinia,
Western Australia: Cerebral Palsy Association of Western Australia.
Cerebral Palsy Association of Western Australia (CPA). (2003). Goal attainment
scaling (GAS): staff manual. Coolbinia, Western Australia: Cerebral Palsy
Association of Western Australia.
Chao, E. Y., An, K. N., Askew, L. J., & Morrey, B. F. (1980). Electrogoniometer for
the measurement of human elbow joint rotation. Journal of Biomechanical
Engineering, 102(4), 301-310.
Charlton, J. L. (1992). Motor control considerations for assessment and
rehabilitation of movement disorders. In J. J. Summers (Ed.), Approaches to
200
the study of motor control and learning (pp. 441-467). Amsterdam, the
Netherlands: Elsevier Science.
Chauvel, P. J., Horsman, S., Ballantyne, J., & Blair, E. (1993). Lycra splinting and
the management of cerebral palsy. Developmental Medicine & Child
Neurology, 35(5), 456-457.
Chieffi, S., Gentilucci, M., Allport, A., Sasso, E., & Rizzolatti, G. (1993). Study of
selective reaching and grasping in a patient with unilateral parietal lesion.
Dissociated effects of residual spatial neglect. Brain, 116(Pt 5), 1119-1137.
Clark, M. S., & Caudrey, D. J. (1983). Evaluation of rehabilitation services: the use
of goal attainment scaling. International Rehabilitation Medicine, 5(1), 41-45.
Clarkson, H. M., & Gilewich, G. B. (1989). Musculoskeletal assessment: joint range
of motion and manual muscle strength. Baltimore: Williams & Wilkins.
Clemson, L. (1997). Home falls hazards: a guide to identifying fall hazards in the
homes of elderly people and an accompaniment to the assessment tool, the
Westmead Home Safety Assessment. West Brunswick, Vic. Australia:
Coordinates.
Cohen, S., Mermelstein, R., Kamarck, T., & Hoberman, H. M. (1985). Measuring the
functional components of social support. In I. G. Sarason & B. R. Sarason
(Eds.), Social support: theory, research, and applications (pp. 21-37). Boston:
Martinus Nijhoff.
Cooper, B., Letts, L., Rigby, P., Stewart, D., & Strong, S. (2001). Measuring
environmental factors. In M. C. Law, C. M. Baum & W. Dunn (Eds.),
Measuring occupational performance : supporting best practice in
occupational therapy (pp. 229-256). Thorofare, NJ: Slack.
Copley, J., & Kuipers, K. (1999). Management of upper limb hypertonicity. San
Antonio, Tex.: Therapy Skill Builders.
Copley, J., Watson-Will, A., & Dent, K. (1996). Upper limb casting for clients with
cerebral palsy: a clinical report. Australian Occupational Therapy Journal,
43(2), 39-50.
Coppard, B. M., & Lynn, P. (2001). Introduction to splinting. In B. M. Coppard, H.
Lohman & K. Shultz-Johnson (Eds.), Introduction to splinting : a critical-
reasoning & problem-solving approach (2nd ed., pp. 1-33). St. Louis: Mosby.
Corn, K., Imms, C., Timewell, G., Carter, C., Collins, L., Dubbeld, S., et al. (2003).
Impact of second skin lycra splinting on the quality of upper limb movement in
children. British Journal of Occupational Therapy, 66(10), 464-472.
Corn, K., & Timewell, G. (2003). The effect of second skin lycra splints on the
quality of upper limb movement for children with a neurological disorder. Paper
201
presented at the OT Australia 22nd National Conference and Exhibition:
Leading change (pp. 94-95). Melbourne, Australia.
Corry, I. S., Cosgrove, A. P., Walsh, E. G., McClean, D., & Graham, H. K. (1997).
Botulinum toxin A in the hemiplegic upper limb: a double-blind trial.
Developmental Medicine & Child Neurology, 39(3), 185-193.
Coster, W. (1998). Occupation-centered assessment of children. American Journal
of Occupational Therapy, 52(5), 337-344.
Coster, W., Deeney, T., Haltiwanger, J., & Haley, S. (1998). School Function
Assessment. San Antonio, TX: The Psychological Corporation.
Crossman, E. R., & Goodeve, P. J. (1983). Feedback control of hand-movement
and Fitts' Law. Quarterly Journal of Experimental Psychology A, 35(Pt 2), 251-
278.
Cytrynbaum, S., Ginath, Y., Birdwell, J., & Brandt, L. (1979). Goal Attainment Scale:
a critical review. Evaluation Quarterly, 3, 5-40.
Daltroy, L. H., Liang, M. H., Fossel, A. H., & Goldberg, M. J. (1998). The POSNA
pediatric musculoskeletal functional health questionnaire: report on reliability,
validity, and sensitivity to change. Pediatric Outcomes Instrument
Development Group. Pediatric Orthopaedic Society of North America. Journal
of Pediatric Orthopaedics, 18(5), 561-571.
Davis, R., & DeLuca, P. (1996). Clinical gait analysis: current methods and future
directions. In G. F. Harris & P. A. Smith (Eds.), Human motion analysis:
current applications and future directions (pp. 17-42). New York: Institute of
Electrical and Electronics Engineers.
De Groot, J. H. (1997). The variability of shoulder motions recorded by means of
palpation. Clinical Biomechanics, 12(7-8), 461-472.
DeMatteo, C., Law, M., Russell, D., Pollock, N., Rosenbaum, P., & Walter, S.
(1992). QUEST: Quality of Upper Extremity Skills Test. Hamilton, Ontario:
McMaster University, Neurodevelopmental Clinical Research Unit.
DeMatteo, C., Law, M., Russell, D., Pollock, N., Rosenbaum, P., & Walter, S.
(1993). The reliability and validity of Quality of Upper Extremity Skills Test.
Physical and Occupational Therapy in Pediatrics, 13(2), 1-18.
Deshaies, L. D. (2002). Upper extremity orthoses. In C. A. Trombly & M. V.
Radomski (Eds.), Occupational therapy for physical dysfunction. (5th ed., pp.
313-350). Baltimore, USA: Lippincott Williams & Wilkins.
Donnelly, C., & Carswell, A. (2002). Individualized outcome measures: a review of
the literature. Canadian Journal of Occupational Therapy, 69(2), 84-94.
202
Duncan, R. M. (1989). Basic principles of splinting the hand. Physical Therapy,
69(12), 1104-1116.
Dunn, W. (2001). Measurement issues and practices. In M. C. Law, C. M. Baum &
W. Dunn (Eds.), Measuring occupational performance : supporting best
practice in occupational therapy (pp. 21-30). Thorofare, NJ: Slack.
Edmonson, J., Fisher, K., & Hanson, C. (1999). How effective are lycra suits in the
management of children with cerebral palsy? Association of Paediatric
Chartered Physiotherapists, 93, 49-57.
Edwards, D., & Baum, C. (2001). Occupational performance: measuring the
perspectives of others. In M. C. Law, C. M. Baum & W. Dunn (Eds.),
Measuring occupational performance : supporting best practice in
occupational therapy (pp. 77-89). Thorofare, NJ: Slack.
Ehara, Y., Fujimoto, H., Miyazaki, S., Mochimaru, M., Tanaka, S., & Yamamoto, S.
(1997). Comparison of the performance of 3D camera systems II. Gait &
Posture, 5(3), 251-255.
Elliott, B., Wallis, R., Sakurai, S., Lloyd, D., & Besier, T. (2002). The measurement
of shoulder alignment in cricket fast bowling. Journal of Sports Sciences,
20(6), 507-510.
Elovic, E. P., Simone, L. K., & Zafonte, R. (2004). Outcome assessment for
spasticity management in the patient with traumatic brain Injury: the state of
the art. The Journal of Head Trauma Rehabilitation, 19(2), 155-177.
Exner, C. E., & Bonder, B. R. (1983). Comparative effects of three hand splints on
bilateral hand use, grasp, and arm-hand posture in hemiplegic children: a pilot
study. The Occupational Therapy Journal of Research, 3(2), 75-92.
Faul, F., & Erdfelder, E. (1992). GPOWER: A priori, post-hoc, and compromise
power analyses for MS-DOS. Bonn, FRG: Bonn University, Dept of
Psychology.
Fehlings, D., Rang, M., Glazier, J., & Steele, C. (2000). An evaluation of botulinum-
A toxin injections to improve upper extremity function in children with
hemiplegic cerebral palsy. Journal of Pediatrics, 137(3), 331-337.
Fehlings, D., Rang, M., Glazier, J., & Steele, C. (2001). Botulinum toxin type A
injections in the spastic upper extremity of children with hemiplegia: child
characteristics that predict a positive outcome. European Journal of
Neurology, 8 Suppl 5, 145-149.
Feldman, A. B., Haley, S. M., & Coryell, J. (1990). Concurrent and construct validity
of the Pediatric Evaluation of Disability Inventory. Physical Therapy, 70(10),
602-610.
203
Feng, C. J., & Mak, A. F. (1997). Three-dimensional motion analysis of the voluntary
elbow movement in subjects with spasticity. IEEE Transactions on
Rehabilitation Engineering, 5(3), 253-262.
Fetters, L., & Kluzik, J. (1996). The effects of neurodevelopmental treatment versus
practice on the reaching of children with spastic cerebral palsy. Physical
Therapy, 76(4), 346-358.
Fetters, L., & Todd, J. (1987). Quantitative assessment of infant reaching
movements. Journal of Motor Behaviour, 19(2), 147-166.
Fisher, A. G. (2001). Assessment of motor and process skills. Fort Collins (CO):
Three Star Press.
Fitts, P. M. (1992). The information capacity of the human motor system in
controlling the amplitude of movement. 1954. Journal of Experimental
Psychology: General, 121(3), 262-269.
Flash, T., & Hogan, N. (1985). The coordination of arm movements: an
experimentally confirmed mathematical model. Journal of Neuroscience, 5(7),
1688-1703.
Flash, T., Inzelberg, R., Schechtman, E., & Korczyn, A. D. (1992). Kinematic
analysis of upper limb trajectories in Parkinson's disease. Experimental
Neurology, 118(2), 215-226.
Folio, M. R., & Fewell, R. R. (1983). Peabody Developmental Motor Scales and
Activity Cards. Allen, TX: DLM Teaching Resources.
Forssberg, H., Eliasson, A. C., Redon-Zouitenn, C., Mercuri, E., & Dubowitz, L.
(1999). Impaired grip-lift synergy in children with unilateral brain lesions. Brain,
122(Pt 6), 1157-1168.
Foster, S., & Ranka, J. (1997). Splinting spasticity: does it make a difference? Paper
presented at the OT Australia 19th National Conference: Making a difference
(pp. 371-376). Perth: Australian Association of Occupational Therapists.
Frackowiak, R. S. (2001). [New functional cerebral cartography: studies of plasticity
of the human brain]. Bulletin de l Academie Nationale de Medecine, 185(4),
707-724; discussion 724-706.
Friedman, A., Diamond, M., Johnston, M. V., & Daffner, C. (2000). Effects of
botulinum toxin A on upper limb spasticity in children with cerebral palsy.
American Journal of Physical Medicine & Rehabilitation, 79(1), 53-59.
Glazier, J. N., Fehlings, D. L., & Steele, C. A. (1997). Test-retest reliability of upper
extremity goniometric measurements of passive range of motion and of
sphygmomanometer measurements of grip strength in children with cerebral
204
palsy and upper extremity spasticity. Developmental Medicine & Child
Neurology Supplement, 75, 33-34.
Gough, M., Eve, L. C., Robinson, R. O., & Shortland, A. P. (2004). Short-term
outcome of multilevel surgical intervention in spastic diplegic cerebral palsy
compared with the natural history. Developmental Medicine & Child
Neurology, 46(2), 91-97.
Gracies, J. M., Fitzpatrick, R., Wilson, L., Burke, D., & Gandevia, S. C. (1997). Lycra
garments designed for patients with upper limb spasticity: mechanical effects
in normal subjects. Archives of Physical Medicine & Rehabilitation, 78(10),
1066-1071.
Gracies, J. M., Marosszeky, J. E., Renton, R., Sandanam, J., Gandevia, S. C., &
Burke, D. (2000). Short-term effects of dynamic lycra splints on upper limb in
hemiplegic patients. Archives of Physical Medicine & Rehabilitation, 81(12),
1547-1555.
Graham, H. K. (2004). Mechanisms of deformity. In D. Scrutton, D. Damiano & M.
Mayston (Eds.), Management of the motor disorders of children with cerebral
palsy (2nd ed., pp. 105-130). London: Mac Keith Press.
Granger, C. V., Hamilton, B. B., Keith, R. A., Zielezny, M., & Sherwin, F. S. (1986).
Advances in functional assessment for medical rehabilitation. In Topics in
geriatric rehabilitation (Vol. 1, pp. 59-79). Aspen, MD: Rockville.
Grea, H., Desmurget, M., & Prablanc, C. (2000). Postural invariance in three-
dimensional reaching and grasping movements. Experimental Brain Research,
134(2), 155-162.
Gregson, J. M., Leathley, M., Moore, A. P., Sharma, A. K., Smith, T. L., & Watkins,
C. L. (1999). Reliability of the Tone Assessment Scale and the modified
Ashworth scale as clinical tools for assessing poststroke spasticity. Archives of
Physical Medicine and Rehabilitation, 80(9), 1013-1016.
Gronley, J. K., Newsam, C. J., Mulroy, S. J., Rao, S. S., Perry, J., & Helm, M.
(2000). Electromyographic and kinematic analysis of the shoulder during four
activities of daily living in men with C6 tetraplegia. Journal of Rehabilitation
Research & Development, 37(4), 423-432.
Hagberg, B., & Hagberg, G. (2000). Antecedents. In B. Neville & R. Goodman
(Eds.), Congenital Hemiplegia (pp. 5-18). London: Cambridge University
Press.
Hagberg, B., Hagberg, G., Beckung, E., & Uvebrant, P. (2001). Changing panorama
of cerebral palsy in Sweden. VIII. Prevalence and origin in the birth year period
1991-94. Acta Paediatrica, 90(3), 271-277.
205
Hagberg, B., Hagberg, G., & Olow, I. (1993). The changing panorama of cerebral
palsy in Sweden. VI. Prevalence and origin during the birth year period 1983-
1986. Acta Paediatrica, 82(4), 387-393.
Haley, S. M., Coster, W. J., Ludlow, L. H., Haltiwanger, J. T., & Andrellos, P. J.
(1992). Pediatric Evaluation of Disability Inventory: Development,
Standardization, and Administration Manual, Version 1.0. Boston, MA:
Trustees of Boston University, Center for Rehabilitation Effectiveness.
Hall, S. J. (1999). Basic biomechanics (3 ed.). Boston, Mass.: WCB/McGraw-Hill,.
Hallam, P., & Weindling, M. (1998). The objective measurement of grip strength in
children with cerebral palsy. Pediatric Research, 44(3), 448.
Hamill, J., & Knutzen, K. (1995). Biomechanical basis of human movement.
Baltimore, Md.: Williams & Wilkins.
Harms, T., Cryer, D., & Clifford, R. M. (1990). Infant/toddler Environment Rating
Scale manual. New York: Teachers College Press.
Harris, S. R. (1996). A study of a dynamic proximal stability splint in the
management of children with cerebral palsy [comment]. Developmental
Medicine & Child Neurology, 38(2), 181-183.
Harris, S. R., Smith, L. H., & Krukowski, L. (1985). Goniometric reliability for a child
with spastic quadriplegia. Journal of Pediatric Orthopedics, 5(3), 348-351.
Henderson, S., Duncan-Jones, P., Byrne, D. G., & Scott, R. (1980). Measuring
social relationships. The Interview Schedule for Social Interaction.
Psychological Medicine, 10(4), 723-734.
Hermsdorfer, J., Laimgruber, K., Kerkhoff, G., Mai, N., & Goldenberg, G. (1999).
Effects of unilateral brain damage on grip selection, coordination, and
kinematics of ipsilesional prehension. Experimental Brain Research, 128(1-2),
41-51.
Hickey, A., & Ziviani, J. (1998). A review of the Quality of Upper Extremities Skills
Test (QUEST) for children with cerebral palsy. Physical and Occupational
Therapy in Pediatrics, 18(3/4), 123-135.
Hill, G. G. (1988). Current trend in upper-extremity splinting. In R. Boehme (Ed.),
Improving Upper Body Control, An Approach to Assessment and Treatment of
Tonal Dysfunction (pp. 131-164). Arizona: Therapy Skill Builders.
Hogan, N., & Flash, T. (1987). Moving gracefully: quantitative theories of motor
coordination. Trends in Neuroscience, 10(4), 170-174.
Humphris, D. (2003). Types of evidence. In S. Hamer & G. Collinson (Eds.),
Achieving evidence based practice: a handbook for practitioners (pp. 13-40).
Edinburgh: Baillière Tindall.
206
Hurvitz, E. A., Conti, G. E., Flansburg, E. L., & Brown, S. H. (2000). Motor control
testing of upper limb function after botulinum toxin injection: a case study.
Archives of Physical Medicine & Rehabilitation, 81(10), 1408-1415.
Hylton, N., & Allen, C. (1997). The development and use of SPIO Lycra
compression bracing in children with neuromotor deficits. Pediatric
Rehabilitation, 1(2), 109-116.
Inzelberg, R., Flash, T. &. Korczyn, A. D. (1990) Kinematic properties of upper-limb
trajectories in Parkinson's disease and idiopathic torsion dystonia. Advances
in Neurology. 53 183-9
Inzelberg, R., Flash, T., Schechtman, E., & Korczyn, A. D. (1995). Kinematic
properties of upper limb trajectories in idiopathic torsion dystonia. Journal of
Neurology, Neurosurgery & Psychiatry, 58(3), 312-319.
Jagacinski, R. J., Repperger, D. W., Moran, M. S., Ward, S. L., & Glass, B. (1980).
Fitt's law and the microstructure of rapid discrete movements. Journal of
Experimental Psychology, Human Perception and Performance, 6, 309-320.
Jarvis, S. N., Holloway, J. S., & Hey, E. N. (1985). Increase in cerebral palsy in
normal birth weight babies. Archives of Disease in Childhood, 60(12), 1113-
1121.
Jeannerod, M. (1984). The timing of natural prehension movements. Journal of
Motor Behaviour, 16(3), 235-254.
Johnson, L. M., Randall, M. J., Reddihough, D. S., Oke, L. E., Byrt, T. A., & Bach, T.
M. (1994). Development of a clinical assessment of quality of movement for
unilateral upper-limb function. Developmental Medicine & Child Neurology,
36(11), 965-973.
Jone, G. (1995, 19th October). It suits me Daddy. Today.
Kadaba, M. P., Ramakrishnan, H. K., Wootten, M. E., Gainey, J., Gorton, G., &
Cochran, G. V. (1989). Repeatability of kinematic, kinetic, and
electromyographic data in normal adult gait. Journal of Orthopaedic Research,
7(6), 849-860.
Kaine, N., & Chapparo, C. (1997). What are the immediate effects of neoprene
orthotic intervention on the hand functioning of children with spastic cerebral
palsy? Paper presented at the OT Australia 19th National Conference: Making
a difference (pp. 395-399). Perth: Australian Association of Occupational
Therapists.
Kandel, E. R., Schwartz, J. H., & Jessell, T. M. (1995). Essentials of neural science
and behaviour. Norwalk, CT: Appleton & Lange.
207
Katz, R. T., Rovai, G. P., Brait, C., & Rymer, W. Z. (1992). Objective quantification
of spastic hypertonia: correlation with clinical findings. Archives of Physical
Medicine & Rehabilitation, 73(4), 339-347.
Kay, R. M., Rethlefsen, S. A., Ryan, J. A., & Wren, T. A. (2004). Outcome of
gastrocnemius recession and tendo-achilles lengthening in ambulatory
children with cerebral palsy. Journal of Pediatric Orthopaedics, Part B, 13(2),
92-98.
Kellor, M., Frost, J., Silberberg, N., Iversen, I., & Cummings, R. (1971). Hand
strength and dexterity. American Journal of Occupational Therapy, 25(2), 77-
83.
Kennedy, S., Peck, F., & Stone, J. (2000). The treatment of interphalangeal joint
flexion contractures with reinforced lycra finger sleeves. Journal of Hand
Therapy, 13(1), 52-55.
Kent, R. M., Gilbertson, L., & Geddes, J. M. L. (2002). Orthotic devices for abnormal
limb posture after stroke or non-progressive cerebral causes of spasticity
(Protocol for a Cochrane Review). Cochrane Library, Issue 3.
Kerem, M., Livanelioglu, A., & Topcu, M. (2001). Effects of Johnstone pressure
splints combined with neurodevelopmental therapy on spasticity and
cutaneous sensory inputs in spastic cerebral palsy. Developmental Medicine &
Child Neurology, 43(5), 307-313.
Ketelaar, M., Vermeer, A., & Helders, P. J. (1998). Functional motor abilities of
children with cerebral palsy: a systematic literature review of assessment
measures. Clinical Rehabilitation, 12(5), 369-380.
King, G., Tucker, M., Alambets, P., Gritzan, J., McDougall, J., Ogilvie, A., et al.
(1998). The evaluation of functional, school-based therapy services for
children with special needs: A feasibility study. Physical and Occupational
Therapy in Pediatrics, 18(1-27).
King, G. A., McDougall, J., Palisano, R. J., Gritzan, J., & Tucker, M. A. (1999). Goal
attainment scaling: its use in evaluating pediatric therapy programs. Physical
and Occupational Therapy in Pediatrics, 19(2), 31-52.
King, G. A., McDougall, J., Tucker, M. A., Gritzan, J., Malloy-Miller, T., Alambets, P.,
et al. (1999). The evaluation of functional, school-based therapy services for
children with special needs: A feasibility study. Physical and Occupational
Therapy in Pediatrics, 19(2), 5-29.
Kiresuk, T. J., & Lund, S. H. (1978). Goal attainment scaling. In C. C. Attkisson
(Ed.), Evaluation of human service programs (pp. 341-370). New York:
London.
208
Kiresuk, T. J., & Sherman, R. E. (1968). Goal attainment scaling: a general method
for evaluating community mental health programs. Community Mental Health
Journal, 4, 443-453.
Kiresuk, T. J., Smith, A., & Cardillo, J. E. (1994). Goal Attainment Scaling:
applications, theory, and measurement. Hillsdale, N.J.: L. Erlbaum Associates.
Kitazawa, S., Goto, T., & Urushihara, Y. (1993). Quantitative evaluation of reaching
movements in cats with and without cerebellar lesions using normalized
integral of jerk. Paper presented at the Role of the cerebellum and basal
ganglia in voluntary movement: proceedings of the 8th Tokyo Metropolitan
Institute for Neuroscience (TMIN), International Symposium (20th anniversary
of TMIN), Tokyo, 17-19 November 1992 (pp. 11-19). Amsterdam: Excerpta
Medica.
Kluzik, J., Fetters, L., & Coryell, J. (1990). Quantification of control: a preliminary
study of effects of neurodevelopmental treatment on reaching in children with
spastic cerebral palsy. Physical Therapy, 70(2), 65-76.
Knox, V. (2003). The use of Lycra garments in children with cerebral palsy: A report
of a descriptive clinical trial. British Journal of Occupational Therapy, 66(2),
71-77.
Knox, V., & Evans, A. L. (2002). Evaluation of the functional effects of a course of
Bobath therapy in children with cerebral palsy: a preliminary study.
Developmental Medicine & Child Neurology, 44(7), 447-460.
Kolobe, T. H., Palisano, R. J., & Stratford, P. W. (1998). Comparison of two
outcome measures for infants with cerebral palsy and infants with motor
delays. Physical Therapy, 78(10), 1062-1072.
Krylow, A. M., & Rymer, W. Z. (1997). Role of intrinsic muscle properties in
producing smooth movements. IEEE Transactions on Biomedical Engineering,
44(2), 165-176.
Landgraf, J. M., Abetz, L. N., & Ware, J. E. (1996). The CHQ User’s Manual.
Boston, MA: The Health Institute, New England Medical Center.
Langlois, S., MacKinnon, J. R., & Pederson, L. (1989). Hand splints and cerebral
spasticity: a review of the literature. Canadian Journal of Occupational
Therapy, 56(3), 113-119.
Langlois, S., Pederson, L., & MacKinnon, J. R. (1991). The effects of splinting on
the spastic hemiplegic hand: Report of a feasibility study. Canadian Journal of
Occupational Therapy, 58(1), 17-25.
209
Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatojko, H., & Pollock, N.
(1998). The Canadian Occupational Performance Measure (3 ed.). Toronto:
Canadian Association of Occupational Therapists.
Law, M., & Baum, C. (2001). Measurement in occupational therapy. In M. C. Law,
C. M. Baum & W. Dunn (Eds.), Measuring occupational performance:
supporting best practice in occupational therapy (pp. 3-21). Thorofare, NJ:
Slack.
Law, M., Cadman, D., Rosenbaum, P., Walter, S., Russell, D., & DeMatteo, C.
(1991). Neurodevelopmental therapy and upper-extremity inhibitive casting for
children with cerebral palsy. Developmental Medicine & Child Neurology,
33(5), 379-387.
Law, M., Russell, D., Pollock, N., Rosenbaum, P., Walter, S., & King, G. (1997). A
comparison of intensive neurodevelopmental therapy plus casting and a
regular occupational therapy program for children with cerebral palsy.
Developmental Medicine & Child Neurology, 39(10), 664-670.
Lawton, M. P., Moss, M., Fulcomer, M., & Kleban, M. H. (1982). A research and
service oriented multilevel assessment instrument. Journal of Gerontology,
37(1), 91-99.
Letts, L., & Bosch, J. (2001). Measuring occupational performance in basic activities
of daily living. In M. C. Law, C. M. Baum & W. Dunn (Eds.), Measuring
occupational performance: supporting best practice in occupational therapy
(pp. 121-161). Thorofare, NJ: Slack.
Letts, L., Scott, S., Burtney, J., Marshall, L., & McKean, M. (1998). The reliability
and validity of the safety assessment of function and the environment for
rehabilitation (SAFER Tool). British Journal of Occupational Therapy, 61(3),
127-132.
LeVeau, B. F. (1992). Williams & Lissner's biomechanics of human motion (3 ed.).
Philadelphia: W.B. Saunders Co.
Lloyd, D. G., Alderson, J., & Elliott, B. C. (2000). An upper limb kinematic model for
the examination of cricket bowling: a case study of Mutiah Muralitharan.
Journal of Sports Sciences, 18(12), 975-982.
Lohman, M. (2001). Antispasticity splinting. In B. Coppard, H. Lohman & K. Shultz-
Johnson (Eds.), Introduction to splinting : a critical-reasoning and problem-
solving approach (2 ed., pp. 325-349). St. Louis, MO: Mosby Inc.
Love, S. C., Valentine, J. P., Blair, E. M., Price, C. J., Cole, J. H., & Chauvel, P. J.
(2001). The effect of botulinum toxin type A on the functional ability of the child
210
with spastic hemiplegia a randomized controlled trial. European Journal of
Neurology, 8 Suppl 5, 50-58.
Lowe, K., Novak, I., Cusick, A., & McIntosh, A. (2002). Upper limb botulinum toxin
treatment in hemiplegic cerebral palsy: a randomised controlled trial.
Australian Journal of Physiotherapy, 48, 144.
MacGillivray, I., & Campbell, D. M. (1995). The changing pattern of cerebral palsy in
Avon. Paediatric and Perinatal Epidemiology, 9(2), 146-155.
Mackay, S., & Wallen, M. (1996). Re-examining the effects of the soft splint in acute
hypertonicity at the elbow. Australian Occupational Therapy Journal, 43, 51-
59.
Mackey, A. H., Walt, S., Lobb, G., Reynolds, N., & Stott, N. S. (2002). Repeatability
of 3D upper limb kinematic analysis in children with cerebral palsy: a pilot
study. Gait & Posture, 16(Supplement 1 ESMAC 2002), 163-164.
Mackey, A. H., Walt, S. E., Lobb, G., & Stott, N.S. (2004) Intraobserver reliability of
the modified Tardieu scale in the upper limb of children with hemiplegia.
Developmental Medicine & Child Neurology, 46(4). 267-272
Mackey, A. H., Walt, S. E., & Stott, N. S. (2003). Research update from University of
Auckland Gait Laboratory. Australian Academy of Cerebral Palsy and
Developmental Medicine (2), 2-3.
Maloney, F. P., Mirrett, P., Brooks, C., & Johannes, K. (1978). Use of the Goal
Attainment Scale in the treatment and ongoing evaluation of neurologically
handicapped children. American Journal of Occupational Therapy, 32(8), 505-
510.
Mathiowetz, V., Bolding, D. J., & Trombly, C. A. (1983). Immediate effects of
positioning devices on the normal and spastic hand measured by
electromyography. American Journal of Occupational Therapy, 37(4), 247-
254.
Mayston, M. J. (2001). People with cerebral palsy: effects of and perspectives for
therapy. Neural Plasticity, 8(1-2), 51-69.
McAuliffe, C. A., Wenger, R. E., Schneider, J. W., & Gaebler-Spira, D. J. (1998).
Usefulness of the Wee-Functional Independence Measure to detect functional
change in children with cerebral palsy. Pediatric Physical Therapy, 10(1), 23-
28.
McCarthy, M. L., Silberstein, C. E., Atkins, E. A., Harryman, S. E., Sponseller, P. D.,
& Hadley-Miller, N. A. (2002). Comparing reliability and validity of pediatric
instruments for measuring health and well-being of children with spastic
cerebral palsy. Developmental Medicine & Child Neurology, 44(7), 468-476.
211
McColl, M. A. & Friedland, J. (1989) Development of a multidimensional index for
assessing social support in rehabilitation. Occupational Therapy Journal of
Research, 9
McColl, M. A., Paterson, M., Davies, D., Doubt, L., & Law, M. (2000). Validity and
community utility of the Canadian occupational performance measure. The
Canadian Journal of Occupational Therapy, 67(1), 22.
McColl, M. A., & Pollock, N. (2001). Measuring occupational performance using a
client-centred perspective. In M. C. Law, C. M. Baum & W. Dunn (Eds.),
Measuring occupational performance : supporting best practice in
occupational therapy (pp. 65-76). Thorofare, NJ: Slack.
McLaren, C., & Rodger, S. (2003). Goal attainment scaling: Clinical implications for
paediatric occupational therapy practice. Australian Occupational Therapy
Journal, 50(4), 216-224.
McLaughlin, J. F., Bjornson, K. F., Astley, S. J., Graubert, C., Hays, R. M., Roberts,
T. S., et al. (1998). Selective dorsal rhizotomy: efficacy and safety in an
investigator-masked randomized clinical trial.[see comment]. Developmental
Medicine & Child Neurology, 40(4), 220-232.
McPherson, J. J. (1981). Objective evaluation of a splint designed to reduce
hypertonicity. American Journal of Occupational Therapy, 35(3), 189-194.
McPherson, J. J., Becker, A. H., & Franszczak, N. (1985). Dynamic splint to reduce
the passive component of hypertonicity. Archives of Physical Medicine &
Rehabilitation, 66(4), 249-252.
McPherson, J. J., Kreimeyer, D., Aalderks, M., & Gallagher, T. (1982). A
comparison of dorsal and volar resting hand splints in the reduction of
hypertonus. American Journal of Occupational Therapy, 36(10), 664-670.
McPherson, J. J., Schild, R., Spaulding, S. J., Barsamian, P., Transon, C., & White,
S. C. (1991). Analysis of upper extremity movement in four sitting positions: a
comparison of persons with and without cerebral palsy. American Journal of
Occupational Therapy, 45(2), 123-129.
Metaxiotis, D., Wolf, S., & Doederlein, L. (2004). Conversion of biarticular to
monoarticular muscles as a component of multilevel surgery in spastic
diplegia. Journal of Bone & Joint Surgery - British Volume, 86(1), 102-109.
Meyer, D. E., Abrams, R. A., Kornblum, S., Wright, C. E., & Smith, J. E. (1988).
Optimality in human motor performance: ideal control of rapid aimed
movements. Psychological Review, 95(3), 340-370.
212
Michaelsen, S. M., Luta, A., Roby-Brami, A., & Levin, M. F. (2001). Effect of trunk
restraint on the recovery of reaching movements in hemiparetic patients.
Stroke, 32(8), 1875-1883.
Mills, V. M. (1984). Electromyographic results of inhibitory splinting. Physical
Therapy, 64(2), 190-193.
Mitchell, T., & Cusick, A. (1998). Evaluation of a client-centred paediatric
rehabilitation programme using goal attainment scaling. Australian
Occupational Therapy Journal, 45(1), 7-17.
Moos, R. (1986). Work as a human context. In M. S. Pallak & R. O. Perloff (Eds.),
Psychology and work : productivity, change, and employment (pp. 9-52).
Washington, D.C :: American Psychological Association,.
Morrey, B. F., Askew, L. J., & Chao, E. Y. (1981). A biomechanical study of normal
functional elbow motion. Journal of Bone & Joint Surgery - American Volume,
63(6), 872-877.
Msall, M. E., DiGaudio, K., Duffy, L. C., LaForest, S., Braun, S., & Granger, C. V.
(1994). WeeFIM. Normative sample of an instrument for tracking functional
independence in children. Clinical Pediatrics, 33(7), 431-438.
Msall, M. E., DiGaudio, K., Rogers, B. T., LaForest, S., Catanzaro, N. L., Campbell,
J., et al. (1994). The Functional Independence Measure for Children
(WeeFIM). Conceptual basis and pilot use in children with developmental
disabilities. Clinical Pediatrics, 33(7), 421-430.
Msall, M. E., DiGaudio, K. M., & Duffy, L. C. (1993). Use of functional assessment in
children with developmental disabilities. Physical Medicine and Rehabilitation
Clinics of North America, 4(3), 517-527.
Msall, M. E., Ottenbacher, K., Duffy, L., Lyon, N., Heyer, N., Phillips, L., et al.
(1996). Reliability and Validity of the Weefim in Children with
Neurodevelopmental Disabilities. Pediatric Research Program Issue APS SPR
39 (4) 378 Retrieved 11 March, 2005, from
http://gateway.ut.ovid.com/gw2/ovidweb.cgi
Msall, M. E., Rogers, B. T., Ripstein, H., Lyon, N., & Wilczenski, F. (1997).
Measurements of functional outcomes in children with cerebral palsy. Mental
Retardation and Developmental Disabilities Research Reviews, 3, 194-203.
Mullineaux, D. R., Bartlett, R. M., & Bennett, S. (2001). Research design and
statistics in biomechanics and motor control. Journal of Sports Sciences,
19(10), 739-760.
213
Murphy, C. C., Yeargin-Allsopp, M., Decoufle, P., & Drews, C. D. (1993).
Prevalence of cerebral palsy among ten-year-old children in metropolitan
Atlanta, 1985 through 1987. Journal of Pediatrics, 123(5), S13-20.
Murphy, D. (1996). Lycra working splint for the rheumatoid arthritic hand with MCP
ulnar deviation. Australian Journal of Rural Health, 4(4), 217-220.
Mutch, L., Alberman, E., Hagberg, B., Kodama, K., & Perat, M. V. (1992). Cerebral
palsy epidemiology: where are we now and where are we going?
Developmental Medicine & Child Neurology, 34(6), 547-551.
Mutsaarts, M., Steenbergen, B., & Meulenbroek, R. (2004). A detailed analysis of
the planning and execution of prehension movements by three adolescents
with spastic hemiparesis due to cerebral palsy. Experimental Brain Research,
156(3), 293-304.
Naganuma, G., & Billingsley, F. F. (1990). The use of hand splints with the
neurologically involved child. Physical and Rehabilitation Medicine, 2(2), 87-
100.
Nakano, E., Imamizu, H., Osu, R., Uno, Y., Gomi, H., Yoshioka, T., et al. (1999).
Quantitative examinations of internal representations for arm trajectory
planning: minimum commanded torque change model. Journal of
Neurophysiology, 81(5), 2140-2155.
National Health and Medical Research Council (NHMRC). (1999). How to review
the evidence: systematic identification and review of the scientific literature.
CP65 Toolkit 1 Retrieved 3rd April, 2005, from
http://www.nhmrc.gov.au/publications/pdf/cp65.pdf
Neuhaus, B. E., Ascher, E. R., Coullon, B. A., Donohue, M. V., Einbond, A., Glover,
J. M., et al. (1981). A survey of rationales for and against hand splinting in
hemiplegia. American Journal of Occupational Therapy, 35(2), 83-90.
Nicholson, J. H., Morton, R. E., Attfield, S., & Rennie, D. (2001). Assessment of
upper-limb function and movement in children with cerebral palsy wearing
lycra garments. Developmental Medicine & Child Neurology, 43(6), 384-391.
Nordmark, E., Hagglund, G., & Jarnlo, G. B. (1997). Reliability of the gross motor
function measure in cerebral palsy. Scandinavian Journal of Rehabilitation
Medicine, 29(1), 25-28.
Novak, K. E., Miller, L. E., Baker, J. F., & Hourk, J. C. (1996). Optimization criteria
driving adaptation in manipulative hand movements. Society for Neuroscience
Abstracts, 22, 898.
214
Novak, K. E., Miller, L. E., & Houk, J. C. (2000). Kinematic properties of rapid hand
movements in a knob turning task. Experimental Brain Research, 132(4), 419-
433.
O'Flaherty, S., & Waugh, M. C. (2003). Pharmacologic management of the spastic
and dystonic upper limb in children with cerebral palsy. Hand Clinics, 19(4),
585-589.
Ogonowski, J., Kronk, R., Rice, C., & Feldman, H. (2004). Inter-rater reliability in
assigning ICF codes to children with disabilities. Disability & Rehabilitation.,
26(6), 353-361.
Ottenbacher, K. J., & Cusick, A. (1990). Goal attainment scaling as a method of
clinical service evaluation. American Journal of Occupational Therapy, 44(6),
519-525.
Ottenbacher, K. J., & Cusick, A. (1993). Discriminative versus evaluative
assessment: some observations on goal attainment scaling. American Journal
of Occupational Therapy, 47(4), 349-354.
Ottenbacher, K. J., Msall, M. E., Lyon, N., Duffy, L. C., Granger, C. V., & Braun, S.
(1999). Measuring developmental and functional status in children with
disabilities. Developmental Medicine & Child Neurology, 41(3), 186-194.
Ottenbacher, K. J., Msall, M. E., Lyon, N., Duffy, L. C., Ziviani, J., Granger, C. V., et
al. (2000). Functional assessment and care of children with
neurodevelopmental disabilities. American Journal of Physical Medicine &
Rehabilitation, 79(2), 114-123.
Ottenbacher, K. J., Taylor, E. T., Msall, M. E., Braun, S., Lane, S. J., Granger, C. V.,
et al. (1996). The stability and equivalence reliability of the functional
independence measure for children (WeeFIM). Developmental Medicine &
Child Neurology, 38(10), 907-916.
Ounpuu, S., DeLucca, P. A., & Davis, R. (2000). Gait analysis. In B. Neville & R.
Goodman (Eds.), Congenital hemiplegia (pp. 81-97). London: MacKeith.
Paleg, G., Hubbard, S., Breit, E., & O'Donnell, K. (1999). Dynamic trunk splints and
hypotonia: a case study. Accepted for Publication 6/99 in PT Case Reports
Retrieved 12 January, 2005, from
http://www.aacpdm.org/index?service=page/dynamicTrunkSplints
Palisano, R., Haley, S., & Brown, D. (1992). Goal attainment scaling as a measure
of change in infants with motor delays. Physical Therapy, 72, 432-437.
Palisano, R., Rosenbaum, P., Walter, S., Russell, D., Wood, E., & Galuppi, B.
(1997). Development and reliability of a system to classify gross motor
215
function in children with cerebral palsy. Developmental Medicine & Child
Neurology, 39(4), 214-223.
Palisano, R. J. (1993). Validity of goal attainment scaling in infants with motor
delays. Physical Therapy, 73(10), 651-658.
Papadonikolakis, A. S., Vekris, M. D., Korompilias, A. V., Kostas, J. P., Ristanis, S.
E., & Soucacos, P. N. (2003). Botulinum A toxin for treatment of lower limb
spasticity in cerebral palsy: gait analysis in 49 patients. Acta Orthopaedica
Scandinavica, 74(6), 749-755.
Patel, A. T., Haig, A. J., & Cook, M. (2000). Assessment tools for musculoskeletal
impairment rating and disability assessment. In R. D. Rondinelli & R. T. Katz
(Eds.), Impairment rating and disability evaluation (pp. 55-77). Philadelphia:
W.B. Saunders.
Pencharz, J., Young, N. L., Owen, J. L., & Wright, J. G. (2001). Comparison of three
outcomes instruments in children. Journal of Pediatric Orthopedics, 21(4),
425-432.
Pharoah, P. O., Cooke, T., Cooke, R. W., & Rosenbloom, L. (1990). Birthweight
specific trends in cerebral palsy. Archives of Disease in Childhood, 65(6), 602-
606.
Portney, L. G., & Watkins, M. P. (2000). Foundations of clinical research:
applications to practice (2nd ed.). Upper Saddle River, NJ: Prentice Hall.
Rab, G., Petuskey, K., & Bagley, A. (2000). A method for 3D analysis of upper
extremity kinematics applied to a case study of brachial plexus birth palsy.
Pediatric Gait, 2000: A new Millennium in Clinical Care and Motion Analysis
Technology Retrieved 3 April, 2005, from
http://ieeexplore.ieee.org/xpl/tocresult.jsp?isnumber=18637&isYear=2000&cou
nt=31&page=1&ResultStart=25
Rab, G., Petuskey, K., & Bagley, A. (2002). A method for determination of upper
extremity kinematics. Gait & Posture, 15(2), 113-119.
Ramos, E., Latash, M. P., Hurvitz, E. A., & Brown, S. H. (1997). Quantification of
upper extremity function using kinematic analysis. Archives of Physical
Medicine & Rehabilitation, 78(5), 491-496.
Randall, M., Carlin, J. B., Chondros, P., & Reddihough, D. (2001). Reliability of the
Melbourne assessment of unilateral upper limb function. Developmental
Medicine & Child Neurology, 43(11), 761-767.
216
Randall, M., Imms, C., & Carey, L. (2004). Further development of 'The Melbourne
Assessment of Unilateral Upper Limb Function' to include children aged 2 to 4
years. Paper presented at the The Australasian Academy of Cerebral Palsy
and Developmental Medicine Second Conference: Partnerships and
Outcomes: New Dimensions. Melbourne, Vic.: The Australasian Academy of
Cerebral Palsy and Developmental Medicine.
Randall, M. J., Johnson, L. M., & Reddihough, D. S. (1999). The Melbourne
Assessment of Unilateral Upper Limb Function: test administration manual.
Melbourne: Royal Children's Hospital.
Rau, G., Disselhorst-Klug, C., & Schmidt, R. (2000). Movement biomechanics goes
upwards: from the leg to the arm. Journal of Biomechanics, 33(10), 1207-
1216.
Reddihough, D., & Ong, K. (2000). Cerebral palsy: An information guide for parents.
Melbourne: Royal Children’s Hospital.
Reddihough, D. S., & Collins, K. J. (2003). The epidemiology and causes of cerebral
palsy. Australian Journal of Physiotherapy, 49(1), 7-12.
Reid, D. T. (1992a). A survey of Canadian occupational therapists' use of hand
splints for children with neuromuscular dysfunction. Canadian Journal of
Occupational Therapy, 59(1), 16-27.
Reid, D. T. (1992b). An instrumentation approach for assessing the effects of a
hand positioning device on reaching motion of children with cerebral palsy.
Occupational Therapy Journal of Research, 12(5), 278-295.
Reid, D. T., & Sochaniwskyj, A. (1992). Influences of a hand positioning device on
upper-extremity control of children with cerebral palsy. International Journal of
Rehabilitation Research, 15(1), 15-29.
Reid, S., Elliott, C., Alderson, J., Hamer, P., & Lloyd, D. (2004). Reliability of a 3D
upper limb kinematic model. Paper presented at the The Australasian
Academy of Cerebral Palsy and Developmental Medicine Second Conference:
Partnerships and Outcomes: New Dimensions (pp. Melbourne, Vic.: The
Australasian Academy of Cerebral Palsy and Developmental Medicine.
Rennie, D. J., Attfield, S. F., Morton, R. E., Polak, F. J., & Nicholson, J. (2000). An
evaluation of lycra garments in the lower limb using 3-D gait analysis and
functional assessment (PEDI). Gait & Posture, 12(1), 1-6.
Richards, J. G. (1999). The measurement of human motion: a comparison of
commercially available systems. Human Movement Science, 18(5), 589-602.
217
Riikonen, R., Raumavirta, S., Sinivuori, E., & Seppala, T. (1989). Changing pattern
of cerebral palsy in the southwest region of Finland. Acta Paediatrica
Scandinavica, 78(4), 581-587.
Romilly, D. P., Anglin, C., Gosine, R. G., Herschler, C., & Raschke, S. U. (1994). A
functional task analysis and motion simulation for the development of a
powered upper-limb orthosis. IEEE Transactions on Rehabilitation
Engineering, 2(3), 119-129.
Rondinelli, R., Murphy, J., Esler, A., Marciano, T., & Cholmakjian, C. (1992).
Estimation of normal lumbar flexion with surface inclinometry. A comparison of
three methods. American Journal of Physical Medicine & Rehabilitation, 71(4),
219-224.
Rondinelli, R. D., & Duncan, P. W. (2000). The concepts of impairment and
disability. In R. D. Rondinelli & R. T. Katz (Eds.), Impairment rating and
disability evaluation (pp. 17-24). Philadelphia: W.B. Saunders.
Rose, V., & Shah, S. (1987). A comparative study on the immediate effects of hand
orthoses on reduction of hypertonus. Australian Occupational Therapy
Journal, 34(2), 59-64.
Rothstein, J. M., Miller, P. J., & Roettger, R. F. (1983). Goniometric reliability in a
clinical setting. Elbow and knee measurements. Physical Therapy, 63(10),
1611-1615.
Russell, D., & Law, M. (1995). Casting\Splinting\Orthoses. Retrieved 11 April, 2005,
from http://bluewirecs.tzo.com/canchild/kc/KC1995-2.html
Russell, D. J., Avery, L. M., Rosenbaum, P. L., Raina, P. S., Walter, S. D., &
Palisano, R. J. (2000). Improved scaling of the gross motor function measure
for children with cerebral palsy: evidence of reliability and validity. Physical
Therapy, 80(9), 873-885.
Russell, D. J., Rosenbaum, P. L., Avery, L. M., & Lane, M. (2002). Gross Motor
Function Measure (GMFM-66 & GMFM-88) user's manual. London: Mac Keith
Press.
Russell, D. J., Rosenbaum, P. L., Cadman, D. T., Gowland, C., Hardy, S., & Jarvis,
S. (1989). The gross motor function measure: a means to evaluate the effects
of physical therapy. Developmental Medicine & Child Neurology, 31(3), 341-
352.
218
Rymer, W. Z., & Beer, R. (2000). Mechanisms for disturbed motor coordination in
stroke: an analysis of voluntary movement trajectories. Pediatric Gait, 2000: A
new Millennium in Clinical Care and Motion Analysis Technology Retrieved 3
April, 2005, from
http://ieeexplore.ieee.org/xpl/tocresult.jsp?isnumber=18637&isYear=2000&cou
nt=31&page=1&ResultStart=25
Sakzewski, L., Ziviani, J., & Van Eldik, N. (2001). Test/retest reliability and inter-
rater agreement of the Quality of Upper Extremities Skills Test (QUEST) for
older children with acquired brain injuries. Physical & Occupational Therapy in
Pediatrics, 21(2-3), 59-67.
Sand, P. L., Taylor, N., Hill, M., Kosky, N., & Rawlings, M. (1974). Hand function in
children with myelomeningocele. American Journal of Occupational Therapy,
28(2), 87-90.
Sand, P. L., Taylor, N., & Sakuma, K. (1973). Hand function measurement with
educable mental retardates. American Journal of Occupational Therapy, 27(3),
138-140.
Sarioglu, B., Serdaroglu, G., Tutuncuoglu, S., & Ozer, E. A. (2003). The use of
botulinum toxin type A treatment in children with spasticity. Pediatric
Neurology, 29(4), 299-301.
Schellekens, J. M., Scholten, C. A., & Kalverboer, A. F. (1983). Visually guided
hand movements in children with minor neurological dysfunction: response
time and movement organization. Journal of Child Psychology & Psychiatry &
Allied Disciplines, 24(1), 89-102.
Schmidt, R., Disselhorst-Klug, C., Silny, J., & Rau, G. (1999). A marker-based
measurement procedure for unconstrained wrist and elbow motions. Journal of
Biomechanics, 32(6), 615-621.
Schneider, J. W., & Gaebler-Spira, D. J. (2002). The effect of botulinum toxin A on
functional sitting and standing in children with cerebral palsy. Developmental
Medicine & Child Neurology Supplement, 44(91), 7.
Scope. (2001). The UPSuit. Retrieved 5th April, 2005, from
http://www.scope.org.uk/cgi-bin/eatsoup.cgi?id=6002
Scope. (2003). Lycra dynamic splinting. Factsheet Retrieved 13th April, 2005, from
http://www.scope.org.uk/downloads/factsheets/word/lycra.doc
Scott-Tatum, L. (1999). What is dynamic lycra splinting and does it work? HemiHelp
Newsletter, Spring, 23-24.
Scott-Tatum, L. (2003). Lycra-based splinting: can it really help? London: Scope.
219
Scrutton, D. (2000). Physical assessment and aims of treatment. In B. Neville & R.
Goodman (Eds.), Congenital hemiplegia (pp. 65-80). London: Mac Keith
Press.
Second Skin. (2000). Second skin dynamic lycra splints in the management of post
CVA hemiplegia. Perth, Western Australia: Second Skin.
Second Skin. (2002). Pronation-flexion arm splint. Retrieved 15 September, 2003,
from http://www.secondskin.com.au/2ND/pron_arm_splint.html
Shepherd, C. (1997). Help where it is needed: a second skin offers support for
Singaporeans. Asiaweek Retrieved 15 January, 2005, from
http://www.asiaweek.com/asiaweek/97/0124/feat2.html
Siebes, R. C., Wijnroks, L., & Vermeer, A. (2002). Qualitative analysis of therapeutic
motor intervention programmes for children with cerebral palsy: an update.
Developmental Medicine & Child Neurology, 44(9), 593-603.
Simoneau, G., Hambrook, G., Bachschmidt, R., & Harris, G. (2000). Quantifying
upper extremity efforts when using a walking frame. Pediatric Gait, 2000: A
new Millennium in Clinical Care and Motion Analysis Technology Retrieved 3
April, 2005, from
http://ieeexplore.ieee.org/xpl/tocresult.jsp?isnumber=18637&isYear=2000&cou
nt=31&page=1&ResultStart=25
Sloan, R. L., Sinclair, E., Thompson, J., Taylor, S., & Pentland, B. (1992). Interrater
reliability of the modified Ashworth Scale for spasticity in hemiplegic patients.
International Journal of Rehabilitation Research, 15, 158-161.
Smith, A. W., Jamshidi, M., & Lo, S. K. (2002). Clinical measurement of muscle tone
using a velocity-corrected modified Ashworth scale. American Journal of
Physical Medicine & Rehabilitation, 81(3), 202-206.
Snook, J. H. (1979). Spasticity reduction splint. American Journal of Occupational
Therapy, 33(10), 648-651.
Sommerfeld, D., Fraser, B. A., Hensinger, R. N., & Beresford, C. V. (1981).
Evaluation of physical therapy service for severely mentally impaired students
with cerebral palsy. Physical Therapy, 61(3), 338-344.
Soto-Faraco, S., Kingstone, A., & Spence, C. (2003). Multisensory contributions to
the perception of motion. Neuropsychologia, 41(13), 1847-1862.
Spence, C., Nicholls, M. E., & Driver, J. (2001). The cost of expecting events in the
wrong sensory modality. Perception & Psychophysics, 63(2), 330-336.
220
Sperle, P. A., Ottenbacher, K. J., Braun, S. L., Lane, S. J., & Nochajski, S. (1997).
Equivalence reliability of the functional independence measure for children
(WeeFIM) administration methods. American Journal of Occupational
Therapy, 51(1), 35-41.
Stanley, F. J., & Blair, E. (1991). Why have we failed to reduce the frequency of
cerebral palsy?[erratum appears in Med J Aust 1991 Jun 3;154(11):740].
Medical Journal of Australia, 154(9), 623-626.
Stanley, F. J., Blair, E., & Alberman, E. D. (2000). Cerebral palsies : epidemiology
and causal pathways. London: Mac Keith.
Stanley, F. J., & Watson, L. (1992). Trends in perinatal mortality and cerebral palsy
in Western Australia, 1967 to 1985. BMJ: British Medical Journal, 304(6843),
1658-1663.
Steenbergen, B., & van der Kamp, J. (2004). Control of prehension in hemiparetic
cerebral palsy: similarities and differences between the ipsi- and contra-
lesional sides of the body. Developmental Medicine & Child Neurology, 46(5),
325-332.
Stein, F., & Cutler, S. K. (2000). Clinical research in occupational therapy (4th ed.).
San Diego Calif.: Singular Thomson Learning.
Steinwender, G., Saraph, V., Scheiber, S., Zwick, E. B., Uitz, C., & Hackl, K. (2000).
Intrasubject repeatability of gait analysis data in normal and spastic children.
Clinical Biomechanics, 15(2), 134-139.
Stelmach, G. E., & Thomas, J. R. (1997). What's different in speed/accuracy trade-
off in young and elderly subjects. Behavioural and Brain Sciences, 20(2), 321-
322.
Stephens, J. L., Pratt, N., & Michlovitz, S. (1996). The reliability and validity of the
Tekdyne hand dynamometer: Part II. Journal of Hand Therapy, 9(1), 18-26.
Stephens, J. L., Pratt, N., & Parks, B. (1996). The reliability and validity of the
Tekdyne hand dynamometer: Part I. Journal of Hand Therapy, 9(1), 10-17.
Stephens, T. E., & Haley, S. M. (1991). Comparison of two methods for determining
change in motorically handicapped children. Physical & Occupational Therapy
in Pediatrics, 11(1), 1-17.
Stern, E. B., Callinan, N., Hank, M., Lewis, E. J., Schousboe, J. T., & Ytterberg, S.
R. (1998). Neoprene splinting: dermatological issues. American Journal of
Occupational Therapy, 52(7), 573-578.
Stern, G. R. (1980). Thumb abduction splint. Physiotherapy, 66(10), 352.
221
Stocker, B., & Stuecker, R. (2002). Calcaneal lengthening for equinovalgus foot
deformity in spastic cerebral palsy. Developmental Medicine & Child
Neurology Supplement, 44(91), 17.
Taylor, N., Sand, P. L., & Jebsen, R. H. (1973). Evaluation of hand function in
children. Archives of Physical Medicine & Rehabilitation, 54(3), 129-135.
Teng, C. A., & Kamm, K. (2002). Effects of support conditions on posture and
reaching in children with cerebral palsy: a single case study. Paper presented
at the 13th World Congress of Occupational Therapists (pp. Stockholm,
Sweden.
Teplicky, R. (2002). The effectiveness of casts, orthoses and splints for children with
neurological disorders. Infants and Young Children, 15(1), 42-51.
Teulings, H. L., Contreras-Vidal, J. L., Stelmach, G. E., & Adler, C. H. (1997).
Parkinsonism reduces coordination of fingers, wrist, and arm in fine motor
control. Experimental Neurology, 146(1), 159-170.
Thelen, E., Corbetta, D., & Spencer, J. P. (1996). Development of reaching during
the first year: role of movement speed. Journal of Experimental Psychology:
Human Perception & Performance, 22(5), 1059-1076.
Thomas, J. R., Nelson, J. K., & Thomas, K., T. (1999). A generalized rank-order
method for nonparametric analysis of data from exercise science: a tutorial.
Research Quarterly for Exercise and Sport, 70(1), 11-20.
Thomas, J. R., Yan, J. H., & Stelmach, G. E. (2000). Movement substructures
change as a function of practice in children and adults. Journal of
Experimental Child Psychology, 75(3), 228-244.
Tobell, J., & Burns, J. (1997a). Goal attainment scaling for people with a learning
disability: trainer's handbook. Bicester, Oxon: Winslow.
Tobell, J., & Burns, J. (1997b). Goal attainment scaling for people with a learning
disability: workbook. Bicester, Oxon.: Winslow.
Trombly, C. A. (1989). Occupational therapy for physical dysfunction (3rd ed.).
Baltimore: Williams & Wilkins.
Trombly, C. A. (1992). Deficits of reaching in subjects with left hemiparesis: a pilot
study. American Journal of Occupational Therapy, 46(10), 887-897.
Trombly, C. A., & Podolski, C. R. (2002). Assessing abilities and capabilities: range
of motion, strength and endurance. In C. A. Trombly & M. V. Radomski (Eds.),
Occupational therapy for physical dysfunction. (5th ed., pp. 47-136). Baltimore,
USA: Lippincott Williams & Wilkins.
Uniform Data System for Medical Rehabilitation (UDSMR). (1998). WeeFIM System
Clinical Guide Version 5.0. Buffalo, NY: University at Buffalo.
222
Unsworth, C. (2000). Measuring the outcome of occupational therapy: Tools and
resources. Australian Occupational Therapy Journal, 47(4), 147-158.
van der Helm, F. C., & Pronk, G. M. (1995). Three-dimensional recording and
description of motions of the shoulder mechanism. Journal of Biomechanical
Engineering, 117(1), 27-40.
van der Linden, M. L., Aitchison, A. M., Hazlewood, M. E., Hillman, S. J., & Robb, J.
E. (2003). Effects of surgical lengthening of the hamstrings without a
concomitant distal rectus femoris transfer in ambulant patients with cerebral
palsy. Journal of Pediatric Orthopaedics, 23(3), 308-313.
Van Thiel, E., Meulenbroek, R. G. J., Smeets, J. B. J., & Hulstijn, W. (2002). Fast
adjustments of ongoing movements in hemiparetic cerebral palsy.
Neuropsychologia, 40(1), 16-27.
von Hofsten, C., & Ronnqvist, L. (1988). Preparation for grasping an object: a
developmental study. Journal of Experimental Psychology: Human Perception
& Performance, 14(4), 610-621.
Wallace, S. A., & Newell, K. M. (1983). Visual control of discrete aiming movements.
Quarterly Journal of Experimental Psychology A, 35 Pt 2, 311-321.
Wallen, M., & Mackay, S. (1995). An evaluation of the soft splint in the acute
management of elbow hypertonicity. Occupational Therapy Journal of
Research, 15(1), 3-16.
Wallen, M., & O'Flaherty, S. (1991). The use of the soft splint in the management of
spasticity of the upper limb. Australian Occupational Therapy Journal, 38(1),
227-231.
Wallen, M. A., O'Flaherty, S. J., & Waugh, M. A. (2004). Functional outcomes of
intramuscular botulinum toxin type A in the upper limbs of children with
cerebral palsy: a phase II trial. Archives of Physical Medicine and
Rehabilitation, 85(2), 192-200.
Walsh, E. G. (1992). Muscles, masses, and motion: the physiology of normality,
hypotonicity, spasticity, and rigidity. London Mac Keith Press: New York.
Wechsler, D. (1991). The Wechsler Intelligence Scale (WISC-III) (3rd ed.). San
Antonio, Tx: The Psychological Corp.
Westwell-O'Connor, M., DeLuca, P., & Ounpuu, S. (2002). Comparison of
percutaneous tendo-Archilles lengthenings with gastrocnemius lengthening to
treat equinus in children with cerebral palsy. Developmental Medicine & Child
Neurology Supplement, 44(91), 15.
223
Williams, F., Knapp, D., & Wallen, M. (1998). Comparison of the characteristics and
features of pressure garments used in the management of burn scars. Burns,
24(4), 329-335.
Wilton, J. (2003). Casting, splinting, and physical and occupational therapy of hand
deformity and dysfunction in cerebral palsy.[erratum appears in Hand Clin.
2004 May;20(2):227]. Hand Clinics, 19(4), 573-584.
Wilton, J. C. (1984). Prescription of functional orthosis for the spastic hand in
cerebral palsy: an assessment profile. American Journal of Occupational
Therapy, 30(4), 137-147.
Wilton, J. C., & Dival, T. A. (1997). Hand splinting: principles of design and
fabrication. London: W.B. Saunders.
Wilwerding-Peck, J. (2001). Mobilization splints. In B. M. Coppard, H. Lohman & K.
Shultz-Johnson (Eds.), Introduction to splinting : a critical-reasoning &
problem-solving approach (2nd ed., pp. 252-253). St. Louis: Mosby.
Winter, D. A. (1990). Biomechanics and motor control of human movement. New
York: Wiley.
Wong, A. M., Chen, C. L., Chen, C. P., Chou, S. W., Chung, C. Y., & Chen, M. J.
(2004). Clinical effects of botulinum toxin A and phenol block on gait in
children with cerebral palsy. American Journal of Physical Medicine &
Rehabilitation, 83(4), 284-291.
Wong, V., Ng, A., & Sit, P. (2002). Open-label study of botulinum toxin for upper
limb spasticity in cerebral palsy. Journal of Child Neurology, 17(2), 138-142.
Woodworth, R. S. (1899). The accuracy of voluntary movement. Psychological
Review Monographs 3 (Suppl.2).
World Health Organization (WHO). (2000). International Classification of
Functioning, Disability and Health: Literature review on environmental factors.
Retrieved 17 January, 2005, from
http://www3.who.int/icf/icftemplate.cfm?mytitle=Literature%20review%20on%2
0environmental%20factors&myurl=litreview.html
World Health Organization (WHO). (2001a). ICF : International classification of
functioning, disability and health. Geneva: World Health Organization,.
World Health Organization (WHO). (2001b). ICF Checklist Version 2.1a, Clinician
Form for International Classification of Functioning, Disability and Health.
Retrieved 5th April, 2005, from http://www3.who.int/icf/checklist/icf-
checklist.pdf
224
World Health Organization (WHO). (2001c). International Classification of
Functioning, Disability and Health: Introduction. Retrieved 17 January, 2005,
from
http://www3.who.int/icf/icftemplate.cfm?myurl=introduction.html%20&mytitle=I
ntroduction
Wu, C., Trombly, C. A., Lin, K., & Tickle-Degnen, L. (1998). Effects of object
affordances on reaching performance in persons with and without
cerebrovascular accident. American Journal of Occupational Therapy, 52(6),
447-456.
Wu, G., & Cavanagh, P. R. (1995). ISB recommendations for standardization in the
reporting of kinematic data. Journal of Biomechanics, 28(10), 1257-1261.
Yan, J. H., Hinrichs, R. N., Payne, V. G., & Thomas, J. R. (2000). Normalized jerk: A
measure to capture developmental characteristics of young girls' overarm
throwing. Journal of Applied Biomechanics, 16(2), 196-203.
Yan, J. H., Thomas, J. R., Stelmach, G. E., & Thomas, K. T. (2000). Developmental
features of rapid aiming arm movements across the lifespan. Journal of Motor
Behaviour, 32(2), 121-140.
Yang, N., Zhang, M., Huang, C., & Jin, D. (2002a). Motion quality evaluation of
upper limb target-reaching movements. Medical Engineering & Physics, 24(2),
115-120.
Yang, N., Zhang, M., Huang, C., & Jin, D. (2002b). Synergic analysis of upper limb
target-reaching movements. Journal of Biomechanics, 35(6), 739-746.
Yang, T. F., Fu, C. P., Kao, N. T., Chan, R. C., & Chen, S. J. (2003). Effect of
botulinum toxin type A on cerebral palsy with upper limb spasticity. American
Journal of Physical Medicine & Rehabilitation, 82(4), 284-289.
Ziviani, J., Ottenbacher, K. J., Shephard, K., Foreman, S., Astbury, W., & Ireland, P.
(2001). Concurrent validity of the Functional Independence Measure for
Children (WeeFIM) and the Pediatric Evaluation of Disabilities Inventory in
children with developmental disabilities and acquired brain injuries. Physical &
Occupational Therapy in Pediatrics, 21(2-3), 91-101.
Zuckerman, J. D., & Matsen, F. A. (1989). Biomechanics of the elbow. In M. Nordin,
V. H. Frankel & s. Basic biomechanics of the skeletal (Eds.), Basic
biomechanics of the musculoskeletal system (2nd ed., pp. 249-260).
Philadelphia: Lea & Febiger.
225
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