Incomplete reporting of components of interventions limits uptake of evidence into clinical practice.
To evaluate the completeness of reporting of research and control interventions in randomised ...trials of upper limb therapies for children with unilateral cerebral palsy.
Sixty randomized trials were included, encompassing 60 research and 68 control interventions. Using the 12-item Template for Intervention Description and Replication (TIDieR) checklist, two reviewers independently rated intervention and control descriptions.
When using 50% of studies as the benchmark, five of the 12 TIDieR items for the research intervention, eight of the 12 items for the control intervention and 11 of 12 items for “usual care” interventions were inadequately reported. Procedures used to deliver the research intervention were adequately reported for 63% of studies. Materials were used in 94% of research interventions, yet only 27% provided details to access/replicate materials. Training materials for interventionists were used in 38% of trials, 10 (17%) had procedure manuals, yet only 3 reported details to access materials. The location where the research intervention was provided was detailed in 65% of studies. Reporting of all items was poorer for the control intervention.
No study adequately reported all elements on the TIDieR checklist. Details crucial for replication of interventions and interpretation of results were missing. Authors, reviewers, and editors all have a responsibility to improve the quality of intervention reporting in published trials. The TIDieR guide is a potential solution, helping to structure accounts of interventions.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Introduction
Neuroplasticity is harnessed through high‐intensity or high‐dose training. Given the costs and time burden for families of children with cerebral palsy (CP), it is important to quantify ...which rehabilitation training approaches and doses confer the largest clinical gain. The main objective of this systematic review was to determine any threshold dose of upper limb training needed for children with CP to achieve clinically significant functional improvements.
Methods
This systematic review included studies if they were as follows: randomised controlled trials; participants had a diagnosis of CP or brain injury; mean age of participants was 0–18 years; and intervention was an active upper limb training intervention. Two raters independently extracted data. Data were pooled and analysed using a receiver operator characteristic (ROC) curve and odds ratios to investigate the dose of practice that led to clinically significant gains.
Results
A total of 74 trials were included in this review. Quantitative analyses included 25 studies (707 participants; age range 18 months to 21 years) for motor function (Assisting Hand Assessment) and 20 studies (491 participants; age range 3 months to 17 years) for individual goal achievement (Canadian Occupational Performance Measure). ROC curve analyses found that approximately 40 hr of practice is needed to improve upper limb motor ability in the unilateral population. For all typographies of CP, individual goals were achieved at a lower dose (14–25 hr) of practice when goal‐directed interventions were provided.
Conclusion
To improve individual goals, children need to practice goals for more than 14–25 hr, combining face‐to‐face therapy with home practice. To improve general upper limb function (based on evidence in the unilateral population), children need to practice for more than 30–40 hr. Interventions that set functional goals and involve actual practice of those goals lead to goal achievement at a lower dose than general upper limb motor training.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK, VSZLJ
This study explored the experience of adolescents with brain injuries and their caregivers who participated in the Program for the Education and Enrichment of Relational Skills (PEERS
®
) in ...Australia.
Twenty-seven adolescents and 31 caregivers, who completed the PEERS
®
intervention as part of an RCT, contributed to focus groups following the 14-week program. Semi-structed interviews guided focus groups. An interpretive description methodology was used to understand participants' experiences in the program and suggestions for improvements.
Thematic analysis led to the development of five themes. "Challenging families and meeting expectations" explored the challenge and worth of participating. "Learnt new skills" highlighted skills and strategies gained and methods used to achieve these. "Connecting, belonging and understanding that's our normal" represented the value placed on the group experience. "Confidence in knowing and doing" reflected the changes in everyday social experiences and "Where to from here?" provided many suggestions for adaptation to improve practice.
After taking part in the PEERS
®
social skills group intervention, most adolescents with brain injury and their caregivers perceived improvement in their social participation and had suggestions for improving the group experience. Some adolescents didn't enjoy the program.
IMPLICATIONS FOR REHABILITATION
Offering adolescents with brain injury and their caregivers the opportunity to participate in a group social skills intervention is an important part of paediatric rehabilitation.
Participants of group social skills interventions are likely to perceive improvements in their everyday social functioning following completion.
Considering strategies to enhance engagement in the group is expected to be important for outcomes.
Participants of group social skills programs may need additional support and adjustments to balance the demands of the intervention with other everyday family and school tasks and requirements.
To determine the efficacy of interventions with active parent implementation for young children with cerebral palsy (CP) to improve child and parent outcomes in low-middle income countries (LMICs).
...Five databases were systematically searched. Randomised or comparison studies evaluating interventions with the training of the parent and/or home practice components to implement with their child with CP (<60 months of age) were included. The modified Downs and Black scale assessed methodological quality. Data were pooled to calculate mean differences and 95% confidence intervals (95% CI).
Searches yielded 189 unique articles. 11 studies from ten papers of moderate to high quality were included. Parent-implemented general developmental interventions had a small negative effect on gross motor function compared to interventionist-implemented therapy. Parent-implemented upper limb training compared to interventionist-implemented neurodevelopmental therapy had a small positive effect on bimanual hand function. Parent-implemented functional feeding training had a large significant effect on chewing function compared to parent-implemented oral motor exercises. Parent-implemented interventions targeting general child development and feeding had mixed effects on parent stress outcomes.
Parent-implemented interventions in LMICs are promising to improve child bimanual hand and chewing function. Further research evaluating the efficacy of parent-implemented interventions to improve parent mental health is needed.
Implications for Rehabilitation:
Intensive motor training-based interventions with active parent implementation were effective to improve child gross motor, bimanual hand, and chewing function in young children with CP compared to passive, generic interventionist-implemented or health education interventions.
Interventions with active parent implementation had mixed results to improve parent mental health, however, this was frequently not assessed. A consistent level of support and training provided to parents may be required to have a positive effect on parent stress.
To further understand the feasibility of early interventions with active parent implementation in LMICs, data on adherence to home practice dose and session attendance and a qualitative understanding of contextual and child factors influencing parent implementation is needed.
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IJS, NUK, UL, UM, UPUK, VSZLJ
Aim: To review definitions and elements of interventions in studies, which used the word "functional" to describe their intervention for children with cerebral palsy (CP), and to determine whether ...definitions and elements are similar to criteria of functional therapy described in the Dutch Guidelines.
Methods: Systematic review of intervention studies, which used the word "functional" to describe interventions for children with CP. We described criteria of functional therapy that were used to describe the intervention, and whether criteria were described similarly to the descriptions used in the Dutch Guidelines.
Results: Of the 27 included studies, criteria "based on the activities/participation level of the ICF-CY", "goal-directed" and "context-specific" were referred to the most (40-59.3%). Descriptions of these criteria were less comparable to the suggested definition (43.8-69.2%). The remaining three criteria ("active involvement", "task-specific", and "focused on functionality instead of normality") were referred to less frequently (18.5-33.3%). The descriptions reported for these criteria were, however, the most comparable with the suggested definitions (80-100%).
Conclusions: The included studies, in general have not used criteria of functional therapy. Future studies have to describe the elements of interventions in detail. Moreover, it is important to reach consensus on the definition and elements of functional therapy.
Children with unilateral cerebral palsy experience difficulties with unimanual and bimanual upper limb function, impacting independence in daily life. Targeted upper limb therapies such as ...constraint-induced movement therapy, bimanual training, and combined approaches have emerged in the last decade. This article reviews the scientific rationale underpinning these treatments and current evidence to improve upper limb outcomes and goal attainment. Intensive models of therapy achieved modest to strong effects to improve upper limb function compared to usual care. Dose-matched comparisons of bimanual and unimanual training demonstrated similar gains in upper limb outcomes. The optimum timing, dose and impact of repeat episodes of intensive upper limb therapies require further investigation. Characteristics of children who achieve clinically meaningful outcomes remain unclear. Key components of intervention include collaborative goal setting with families and intensive repetitive, incrementally challenging, task practice. Choice of treatment approach should be governed by child/family goals and preferences, individual, and contextual factors.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
To determine the efficacy of a participation-focused therapy (ParticiPAte CP) on leisure-time physical activity goal performance and satisfaction and habitual physical activity (HPA) in children with ...CP.
Randomized waitlist-controlled trial.
Home and community.
Children classified at Gross Motor Function Classification System (GMFCS) levels I-III were recruited (n=37; 18 males; mean age ± SD, 10.0±1.4y) from a population-based register.
Participants were randomized to ParticiPAte CP (an 8-wk goal-directed, individualized, participation-focused therapy delivered by a physical therapist) or waitlist usual care.
The primary outcome was Canadian Occupational Performance Measure. Accelerometers were worn for objective measurement of HPA (min/d moderate-to-vigorous physical activity MVPA, sedentary time). Barriers to participation, community participation, and quality-of-life outcomes were also collected. Data were analyzed by intention-to-treat using generalized estimating equations.
ParticiPAte CP led to significant improvements in goal performance (mean difference MD=3.58; 95% confidence interval 95% CI, 2.19-4.97; P<.001), satisfaction (MD=1.87; 95% CI, 0.37-3.36, P=.014), and barriers to participation (MD=26.39; 95% CI, 6.13-46.67; P=.011) compared with usual care at 8 weeks. There were no between-group differences on minutes per day of MVPA at 8 weeks (MD=1.17; 95% CI, -13.27 to 15.61; P=.874). There was a significant difference in response to intervention between participants who were versus were not meeting HPA guidelines at baseline (MD=15.85; 95% CI, 3.80-27.89; P<.0061). After ParticiPAte CP, low active participants had increased average MVPA by 5.98±12.16 minutes per day.
ParticiPAte CP was effective at increasing perceived performance of leisure-time physical activity goals in children with CP GMFCS I-III by reducing modifiable barriers to participation. This did not translate into change in HPA on average; however, low active children may have a clinically meaningful response.
Aim
To examine the relationship between self‐care and bimanual performance in children aged 8 to 12 years with cerebral palsy (CP).
Method
This was a cross‐sectional study of 74 children with CP ...(unilateral n=30, bilateral n=44; 48 males, 26 females; median age 9y 8mo 25th, 75th centiles 9y 1mo, 10y 8mo, Manual Abilities Classification System level I=30, II=28, III=16). Self‐care was measured using the Pediatric Evaluation of Disability Inventory–Computer Adaptive Test (PEDI‐CAT), and bimanual performance using the Assisting Hand Assessment (AHA) and Both Hands Assessment (BoHA). Measures of cognition, behavioural regulation, inattention, and gross motor function were included. Analyses used a directed acyclic graph to select variables for linear regression modelling.
Results
Higher AHA and BoHA scores were associated with higher PEDI‐CAT scores. An increase of 1 AHA unit was associated with an increase of 0.12 PEDI‐CAT scores, and a 1 BoHA unit increase was associated with an increase of 0.17 PEDI‐CAT scores. The BoHA accounted for 57% of variance in PEDI‐CAT scores for children with bilateral CP, while BoHA and cognition accounted for 68% of variance. The AHA accounted for 40% of variance in PEDI‐CAT scores for unilateral CP with no effect of cognition on self‐care.
Interpretation
Self‐care was strongly and positively associated with bimanual performance. Associations between self‐care and bimanual performance differed for those with unilateral and bilateral CP.
What this paper adds
There is a strong positive relationship between self‐care and bimanual performance for unilateral and bilateral cerebral palsy (CP).
Both Hands Assessment (BoHA) scores have a stronger association with self‐care than Assisting Hand Assessment scores.
BoHA scores also account for more variation in self‐care.
There is a strong positive relationship between self‐care and cognition overall.
The effect of cognition on self‐care performance differed for bilateral and unilateral CP.
What this paper adds
There is a strong positive relationship between self‐care and bimanual performance for unilateral and bilateral cerebral palsy (CP).
Both Hands Assessment (BoHA) scores have a stronger association with self‐care than Assisting Hand Assessment scores.
BoHA scores also account for more variation in self‐care.
There is a strong positive relationship between self‐care and cognition overall.
The effect of cognition on self‐care performance differed for bilateral and unilateral CP.
This article is commented on by Konigorski on page 498 of this issue.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
ParticiPAte CP is a participation-focused therapy intervention that is effective to increase perceived performance of physical activity (PA) participation goals in children with cerebral palsy (CP). ...We aimed to characterise the contents of ParticiPAte CP using validated behaviour change frameworks.
Data came from physiotherapist treatment notes and were used to specify: (1) physiotherapist-perceived barriers to behaviour change (using the International Classification of Functioning, Disability and Health Framework ICF and Theoretical Domains Framework), intervention content (Behaviour Change Technique Taxonomy v1), intervention functions (Behaviour Change Wheel) and mechanisms of action (Capability, Opportunity, Motivation - Behaviour model).
Physiotherapist-perceived barriers to participation were identified in all ICF and Theoretical Domains Framework domains. ParticiPAte CP consisted of 32 behaviour change techniques, delivered via six intervention functions of the Behaviour Change Wheel, especially enablement. All six possible mechanisms of action were identified according to the Capability, Opportunity, Motivation - Behaviour model. These were targeted most frequently through Theoretical Domains Framework domains social influences, environmental context and resources, intentions, skills, knowledge, and beliefs about capabilities.
The content of a PA intervention for children with CP can be specified according to behaviour change frameworks. ParticiPAte CP was complex, with multiple targets, constituent behaviour change techniques and mechanisms of action. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615001064594.
Implications for rehabilitation
Providing social support to families through practical actions such as motivating conversation, providing information, linking families to community services and participating in activities with children to support their self-efficacy may be a defining feature of effective participation-focused therapies.
If children with cerebral palsy (CP) and their families nominate goals for increased frequency of attendance or improved involvement in physical activities (PAs), therapists must identify all important barriers to participation, including behavioural barriers that may be thought of less often (e.g. emotions, beliefs, optimism etc.).
Promoting PA participation in children with CP may require a complex or multi-faceted therapy intervention that supports not only physical capability, but also enhances the social and physical opportunity for participation to take place and promotes the psychological capability and motivation for PA of children and families.
Therapists or researchers may consider using the Behaviour Change Wheel to prospectively design their own health behaviour intervention for children with CP.
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IJS, NUK, UL, UM, UPUK, VSZLJ
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