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An integrative review of assessments used in occupational therapy interventions for children with cerebral palsy

Revisão integrativa de avaliações utilizadas em intervenções de terapia ocupacional para crianças com paralisia cerebral

Abstract

Introduction:

Children with cerebral palsy (CP) experience a wide range of deficits and symptoms. When undergoing occupational therapy (OT) interventions, it is essential that the OT select assessments that can accurately reflect the outcome measures of the targeted domains.

Objective:

To identify the assessment tools most frequently reported in research studies as measures for OT interventions when treating children with CP.

Method:

Pubmed and Ovid databases were systematically searched by using key terms “cerebral palsy,” “assessments,” and “occupational therapy”. Assessment tools were explored and extracted from articles contingent on the following inclusion criteria: (1) children birth to 18 years diagnosed with cerebral palsy; (2) use of assessment(s) as a measure of OT intervention; (3) published in English between 2007 and 2017. In the preliminary search, Pubmed yielded 151 records and Ovid yielded 571. Out of these, only 76 met the inclusion criteria. From the remaining 76 articles, a total of 88 assessment tools were retrieved and included in this literature review.

Results:

Ten assessments were found to be of importance based on frequency of use. The Assisting Hand Assessment (AHA) and Pediatric Evaluation of Disability Inventory (PEDI) were the most commonly used.

Conclusion:

This study helps to determine which assessments are frequently used in OT practice with children with CP. The findings of this study play an important role in addressing the challenge of assessment selection faced by occupational therapists and provide a basis for future research to expand on with regards to treating children with CP.

Keywords:
Cerebral Palsy; Occupational Therapists; Assessments

Resumo

Introdução:

Crianças com Paralisia Cerebral (PC) apresentam uma ampla gama de déficits e sintomas. Quando submetidos a intervenções de terapia ocupacional (OT), é essencial que as avaliações utilizadas reflitam com precisão as medidas de resultados dos domínios visados.

Objetivo:

Identificar os instrumentos de avaliação mais utilizados como medidas para intervenções no TO no tratamento de crianças com PC.

Método:

Bancos de dados Pubmed e Ovid foram sistematicamente pesquisados ​​usando os termos-chave “paralisia cerebral”, “avaliações” e “terapia ocupacional”. Avaliaçoes foram exploradas e extraídas de artigos contingentes aos seguintes critérios de inclusão: (1) crianças de até 18 anos com diagnóstico de paralisia cerebral; (2) uso da(s) avaliação (ões) como medida de intervenção do TO; (3) publicado em inglês entre 2007 e 2017. Na pesquisa preliminar, foram encontrados 151 artigos em Pubmed e 571 em Ovid. Destes, apenas 76 foram inlcuidos devido aos critérios de inclusão. Dos 76 artigos restantes, um total de 89 avaliaçoes foram encontradas e incluídas nesta revisão da literatura.

Resultados:

Dez avaliações foram consideradas importantes com base na frequência de uso. A “Assisting Hand Assessment” (AHA) e o Inventário de Avaliação Pediátrica de Incapacidade (PEDI) foram os mais utilizados.

Conclusão:

Os achados deste estudo desempenham um papel importante no e do desafio de seleção de avaliação enfrentado pelos terapeutas ocupacionais e fornecem uma base para futuras pesquisas para expandir no que diz respeito ao tratamento de crianças com PC.

Palavras-chave:
Paralisia Cerebral; Terapeutas Ocupacionais; Avaliações

1 Introduction

Cerebral palsy (CP) is a non-progressive group of developmental motor disorders that may result in spasticity, paralysis, or abnormal posture (COKER-BOLT; GARCIA; NABER, 2015COKER-BOLT, P. C.; GARCIA, T.; NABER, E. Neuromotor: Cerebral palsy. In: CASE-SMITH, J.; O’BRIEN, J. (Ed.). Occupational therapy for children and adolescents. St. Louis: Elsevier, 2015. p. 793- 811.). CP affects motor skills, movement, and muscle tone and is the most common cause of physical disability in childhood with a consistent prevalence of 3.1 to 3.6 per 1000 births for over the last 20 years (LOWES et al., 2014LOWES, L. P. et al. Pilot study of the efficacy of constraint-induced movement therapy for infants and toddlers with cerebral palsy. Physical & Occupational Therapy in Pediatrics, London, v. 34, n. 1, p. 4-21, 2014.; CHRISTENSEN et al., 2014CHRISTENSEN, D. et al. Prevalence of cerebral palsy, co-occurring autism spectrum disorders, and motor functioning - Autism and Developmental Disabilities Monitoring Network, USA, 2008. Developmental Medicine and Child Neurology, London, v. 56, n. 1, p. 59-65, 2014.). Because CP is a lifelong condition, all aspects of an individual’s development and independence are impacted (STEULTJENS et al., 2004STEULTJENS, E. M. et al. Occupational therapy for children with cerebral palsy: A systematic review. Clinical Rehabilitation, London, v. 18, n. 1, p.1-14, 2004.). Occupational therapy (OT) is one of many disciplines that provides treatment for children with CP with the goal of optimizing functional abilities and increasing independence (STEULTJENS et al., 2004). OT focuses on skill development to perform activities of daily living, addresses cognitive and perceptual deficits, promotes functional independence, and utilizes a wide variety of interventions and approaches during treatment (STEULTJENS et al., 2004). The American Occupational Therapy Association’s centennial vision has caused a rising demand for practitioners to provide evidence-based treatment in order to maximize effectiveness of client care (AMERICAN…, 2017; SALEH et al., 2009SALEH, M. N. et al. Actual vs. best practices for young children with cerebral palsy: A survey of paediatric occupational therapists and physical therapists in Quebec, Canada. Developmental Neurorehabilitation, London, v. 11, n. 1, p. 60-80, 2009.). A major challenge in basing OT interventions on evidence-based practice is choosing the most appropriate assessment for individual clients (SALEH et al., 2009). Specifically, OTs report that standardized assessment, which are essential to OT practice, benefit clients and the OT profession as opposed to non-standardized assessments (PIERNIK-YODER; BECK, 2012PIERNIK-YODER, B.; BECK, A. The use of standardized assessments in occupational therapy in the United States. Occupational Therapy in Health Care, London, v. 26, n. 2-3, p. 97-108, 2012.). Considering the specific and complex deficits and needs of children with CP, it is essential that standardized assessments utilized to measure the unique skills and behaviors of this population accurately align with and reflect targeted outcomes when undergoing OT interventions. According to Wright and Majnemer (2014WRIGHT, F. V.; MAJNEMER, A. The concept of a toolbox of outcome measures for children with cerebral palsy: Why, what, and how to use? Journal of Child Neurology, Littleton, v. 29, n. 8, p. 1055-1065, 2014.), if all clinicians in the rehabilitative community chose assessments from the same toolbox when treating children with CP, then a universal approach of measuring outcomes can be developed. While Wright and Majnemer (2014) discussed concepts that should be considered when choosing assessments to use with children with CP, they only provided examples of possible measures clinicians can utilize.

Other research that has been conducted to review the literature on assessment tools used for children with CP include Wagner and Davids (2012WAGNER, L. V.; DAVIDS, J. R. Assessment tools and classification systems used for the upper extremity in children with cerebral palsy. Clinical Orthopaedics and Related Research, Philadelphia, v. 470, n. 5, p. 1257-1271, 2012.) systematic review study. Using the databases Health and Psychosocial Instruments (HaPI), US National Library of Medicine (PubMed), and Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus) databases, they found twenty-one assessment tools and classification systems used specifically for upper extremity function and performance in children with CP (WAGNER; DAVIDS, 2012WAGNER, L. V.; DAVIDS, J. R. Assessment tools and classification systems used for the upper extremity in children with cerebral palsy. Clinical Orthopaedics and Related Research, Philadelphia, v. 470, n. 5, p. 1257-1271, 2012.). Furthermore, a systematic review that searched MEDLINE, Embase, CINAHL, and PscyhINFO databases found eight assessments that were used to measure only activity limitation for children with CP (HARVEY et al., 2008HARVEY, A. et al. A systematic review of measures of activity limitation for children with cerebral palsy. Developmental Medicine & Child Neurology, London, v. 50, n. 3, p. 190-198, 2008.). Functional motor abilities of children with CP represented another domain used to conduct a systematic literature review of assessment measures (KETELAAR; VERMEER; HELDERS, 1998). The study searched MEDLINE, Sportdisk, and PsychLIT databases and yielded seventeen instruments used in pediatric rehabilitation to evaluate functional motor abilities of children with CP (KETELAAR; VERMEER; HELDERS, 1998).

Overall, these studies showed the types of assessments being used to measure specific domains (DIAS et al., 2017DIAS, T. S. et al. As contribuições da gameterapia no desempenho motor de indivíduo com paralisia cerebral. Cadernos Brasileiros de Terapia Ocupacional, São Carlos, v. 25, n. 3, p. 575-584, 2017.). However, there remains a lack of evidence on what assessments are currently being used to measure outcomes specifically for OT interventions for children with CP. In order to develop a toolbox of assessments utilized for children with CP, it is necessary to gain a cohesive understanding of the current assessments in use. The purpose of this study was to perform an integrative review of the literature to identify what assessments are being used to measure outcomes of OT interventions for children with CP.

2 Method

The study aimed to obtain a frequency count of each assessment used with the children with CP as reported the literature. An integrative review was performed and followed Arksey and O’Malley (2005ARKSEY, H.; O’MALLEY, L. Scoping studies: towards amethodological framework. International Journal of Social Research Methodology, London, v. 8, n. 1, p. 19-32, 2005.) stages of methodological framework, which include identifying the research question, identifying relevant studies, selecting studies, charting the data, and summarizing and reporting the results (Figure 1). The research team included three student investigators and a supervising professor. Pubmed and Ovid databases were systematically searched in January 2018 using the key terms “cerebral palsy”, “assessment” and “occupational therapy”. The following inclusion criteria were used: (1) children birth to 18 years old diagnosed with cerebral palsy; (2) use of assessment(s); (3) published in English between 2007 and 2017. Using these criteria, our search yielded a total of 383 articles that were imported to RefWorks. After eliminating duplicate articles, 307 articles remained and were allocated between three student researchers to be further reviewed by abstract and title. Based off the content found, further exclusion criteria were developed post hoc and included (1) articles lacking OT intervention; (2) systematic reviews. Assessments used in systematic reviews were not included in the frequency count to eliminate the possibility of duplicates. With the use of these post hoc criteria 76 articles were included for the analysis in this integrative review.

Figure 1
Flow chart of search process.

3 Results

The search yielded 76 articles that were synthesized and analyzed. In table 1, the list of the 76 articles and the assessments reported in each article are presented. The researchers found that there are 88 different assessments presented in these studies,

Table 1
Assessments Used for Children with CP as Found in Literature.

Of the 88 assessments, the ten most frequently reported in the studies are in descending order, including the Assisting Hand Assessment (AHA), Pediatric Evaluation of Disability Inventory (PEDI), Gross Motor Function Classification Scale (GMFCS), Canadian Occupational Performance Measure (COPM), Goal Attainment Scale (GAS), Manual Ability Classification System (MACS), Melbourne Assessment of Unilateral Upper Limb Function (MUUL), Pediatric Motor Activity Log (PMAL), Quality of Upper Extremity Skills Test (QUEST), and Jebsen-Taylor Hand Function Test (JTHFT). Table 2 lists these ten assessments and their associated properties.

Table 2
Top Ten Assessments and their Frequency of Use, Assessment Type, Purpose, Age Range, Psychometrics, Administration Time, and Price.

Additionally, a prominent trend was observed in which a majority of the articles utilized more than one assessment. Specifically, 66 out of the 76 articles used two or more assessments. Using more than one assessment shows the complexity and need of assessing the unique skills and behaviors of children with CP.

4 Discussion

This integrative review depicted the current trend of assessments used in research involving OT interventions for children with CP. The evidence determined the AHA, PEDI, GMFCS, COPM, GAS, MACS, MUUL, PMAL, QUEST, and JTTHF, to be the most frequently used ten assessments in research in descending order. Additionally, 66 out of 76 articles used a combination of two or more assessments. Since CP is a complex condition affecting several functional domains, using more than one assessment allowed the researchers to address the multiple needs of this population. Additionally, the use of assessments in clinical practice guides OTs not only during interventions, but also to establish therapeutic goals (BREWER; POLLOCK; WRIGHT, 2014WRIGHT, F. V.; MAJNEMER, A. The concept of a toolbox of outcome measures for children with cerebral palsy: Why, what, and how to use? Journal of Child Neurology, Littleton, v. 29, n. 8, p. 1055-1065, 2014.)

The findings of this study have the following implications for OT practice:

Because OT is a field striving towards evidence-based practice, OT practitioners working with children with CP can utilize the evidence from this article to aid their selection of assessments for use in clinical practice.

With this growing focus on evidence-based practice, OT practitioners should conduct research that adds to the development of a universal toolbox to establish a standard approach of measuring OT intervention outcomes for children with CP.

Data from this study helped to establish the most frequently used assessments in research studies. Further investigation is needed to determine what assessments are currently used in clinical OT practices in order to develop a toolbox of assessments for children with CP. For instance, AHA, represents the only standardized tool of spontaneous play that measures bimanual hand use. This is a unique scope of use, which may have contributed to its frequent selection by researchers despite the high cost for the test kit and certification process (HOLMEFUR; KRUMLINDE-SUNDHOLM; ELIASSON, 2007KRUMLINDE-SUNDHOLM, L. et al. The assisting hand assessment: Current evidence of validity, reliability, and responsiveness to change. Developmental Medicine & Child Neurology, London, v. 49, n. 4, p. 259-264, 2007.; KRUMLINDE-SUNDHOLM et al., 2007). The second most frequented cited, the PEDI, allows a wide scope of use by researchers since it can be utilized as an initial, interim, discharge, and evaluation assessment for individual or group interventions, and rehabilitative and therapeutic programs (ASHER, 2007ASHER, I. E. Asher’s occupational therapy assessment tools: An annotated index. Bethesda: American Occupational Therapy Association, 2007.).

Possible factors that may have contributed to the selection of assessments in these research studies include attributes such as scope of use, affordability, feasibility with time, and psychometric properties. All of the top 10 assessments present fair to excellent psychometric properties, they are usually performed on average of 30-40 minutes, and five out of ten assessments (GMFM, COPM, GAS, PMAL, and JTTHF) cost $0 to $40. Measures that are accepted into a toolbox are expected to have demonstrated strong reliability and validity when use with children with cerebral palsy (STRATFORD; RIDDLE, 2005STRATFORD, P.; RIDDLE, D. Assessing sensitivity to change: choosing the appropriate change coefficient. Health Qual Life Outcome, London, v. 3, n. 23, p. 1-7, 2005.). As in these research studies, it is important for clinical OTs to also take into consideration the use of quality assessment measures to implement evidence-based practice. Therefore the use of a toolbox containing OT assessments specific for children with CP will ultimately enable a universal approach to guide clinicians in the rehabilitative community to measure outcomes and gauge effectiveness of their treatment.

5 Conclusion

These research studies showed the complexity of assessing children with CP. The clinical OTs must be aware of these complexities and that more than one assessment may be needed to capture the unique skills and behaviors of the children with CP.

As for study limitations, only two databases (PubMed and OVID) were used to search for articles that contain the targeted keywords. Utilizing more databases can widen the scope of search for studies that contain assessments and strengthen the evidence by increasing the frequency count. Additionally, even though a good portion of the articles originated from countries other than the United States, the reviewing of English-language only articles excluded data that could have provided a more accurate depiction of assessments used for children with CP on a global scale. Future research studies are needed to expand on the current study, to provide additional justifications for assessment use, and contribute to the development of an assessment toolbox for children with CP that is specific to measure outcomes for OT interventions.

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Publication Dates

  • Publication in this collection
    Jan 2019

History

  • Received
    20 Nov 2018
  • Reviewed
    20 Dec 2018
  • Accepted
    10 Jan 2019
Universidade Federal de São Carlos, Departamento de Terapia Ocupacional Rodovia Washington Luis, Km 235, Caixa Postal 676, CEP: , 13565-905, São Carlos, SP - Brasil, Tel.: 55-16-3361-8749 - São Carlos - SP - Brazil
E-mail: cadto@ufscar.br