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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

i

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.

ii

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.

iii

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.

iv

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

v

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

vi

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

vii

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

viii

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

ix

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:

x

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,

xi

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

xii

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

1

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,

2

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

3

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

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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

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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

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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

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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).

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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 =

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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

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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.

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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.

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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).

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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.

156

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

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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.

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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)

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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

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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

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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

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