Adapting the Canadian Occupational Performance Measure for use in a paediatric clinical trial

GRIN: "GRoup versus INdividual physiotherapy following lower limb intra-muscular Botulinum Toxin-A injections for ambulant children with cerebral palsy: an assessor-masked randomised comparison trial": study protocol

BACKGROUND

Cerebral palsy is the most common cause of physical disability in childhood. Spasticity is a significant contributor to the secondary impairments impacting functional performance and participation. The most common lower limb spasticity management is focal intramuscular injections of Botulinum Toxin-Type A accompanied by individually-delivered (one on one) physiotherapy rehabilitation. With increasing emphasis on improving goal-directed functional activity and participation within a family-centred framework, it is timely to explore whether physiotherapy provided in a group could achieve comparable outcomes, encouraging providers to offer flexible models of physiotherapy delivery. This study aims to compare individual to group-based physiotherapy following intramuscular Botulinum Toxin-A injections to the lower limbs for ambulant children with cerebral palsy aged four to fourteen years.

METHODS/DESIGN

An assessor-masked, block randomised comparison trial will be conducted with random allocation to either group-based or individual physiotherapy. A sample size of 30 (15 in each study arm) will be recruited. Both groups will receive six hours of direct therapy following Botulinum Toxin-A injections in either an individual or group format with additional home programme activities (three exercises to be performed three times a week). Study groups will be compared at baseline (T1), then at 10 weeks (T2, efficacy) and 26 weeks (T3, retention) post Botulinum Toxin-A injections. Primary outcomes will be caregiver/s perception of and satisfaction with their child's occupational performance goals (Canadian Occupational Performance Measure) and quality of gait (Edinburgh Visual Gait Score) with a range of secondary outcomes across domains of the International Classification of Disability, Functioning and Health.

DISCUSSION

This paper outlines the study protocol including theoretical basis, study hypotheses and outcome measures for this assessor-masked, randomised comparison trial comparing group versus individual models of physiotherapy following intramuscular injections of Botulinum Toxin-A to the lower limbs for ambulant children with cerebral palsy.

TRIAL REGISTRATION

ACTRN12611000454976.

Arts-based social skills interventions for adolescents with acquired brain injuries: five case reports

OBJECTIVE

Previous research has demonstrated the value of arts-based programs for adolescents with childhood brain disorder to facilitate social skills and participation. The current study extends this work by examining the feasibility and effectiveness of an arts-based intervention for youth with acquired brain injuries (ABI).

METHODS

A case study approach was used with four adolescent participants and one case control. A battery of quantitative measures were administered four and one week pre-intervention, one week post-intervention, as well six to eight month post-intervention.

RESULTS

Improvements in pragmatic communication skills and social and participation goals were observed across intervention participants. Similar improvements were not seen with the case control participant.

CONCLUSION

Results support the use of an arts-based intervention for youth with ABI to facilitate social skills and participation. Findings also highlight the need for more sensitive measures of these skills for these youth. Suggested guidelines for program implementation are provided.

Clinical tools that measure sitting posture, seated postural control or functional abilities in children with motor impairments: a systematic review

OBJECTIVE

To identify and critically appraise clinical measurement tools used to assess sitting posture, seated postural control or functional abilities for children with motor impairment who are candidates for seating interventions.

DATA SOURCES

Searches were run in 15 electronic databases along with hand searching. The search included articles published in English to December 2011.

REVIEW METHODS

Key terms included: posture, sitting, sitting posture, seated posture, seated postural control, sitting position, seating, wheelchair(s), outcome and assess(ment). The PRISMA statement was followed with inclusion criteria set a priori. Two reviewers independently screened titles, reviewed abstracts and identified full-text articles that met criteria. Data extraction included tool description and clinical utility. Two quality-rating scales were used to evaluate conduct of the studies and psychometric properties of the tools.

RESULTS

Of the 497 titles found in the search, 29 full-text articles met the inclusion criteria and 19 tools were identified. Tools represented all components of the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY), with emphasis on body structure and function and activity components. Evidence supporting reliability and validity varied, with small sample sizes influencing quality ratings. Evidence of the tools' reliability was more prevalent than evidence of the tools' validity. Only four tools reported on responsiveness, an important consideration for evaluating change. Little information on clinical utility was provided.

CONCLUSION

Although a number of tools are available, evidence supporting their use for seating interventions is limited, as is the evidence supporting the strength of their measurement properties. Few tools address participation, environmental factors or the child's and family's perspective.

Effectiveness of occupational performance coaching in improving children's and mothers' performance and mothers' self-competence

OBJECTIVE

This study examined the effectiveness of occupational performance coaching in improving children's and mothers' occupational performance and mothers' parenting self-competence.

METHOD

A one-group time-series design was used to evaluate changes in children's (n = 29) and mothers' (n = 8) occupational performance at four time points: (1) pre-wait list, (2) preintervention, (3) postintervention, and (4) follow-up.

RESULTS

Significant improvements in occupational performance occurred postintervention for children, F(1, 78) = 153.72, p < .001, η² = .86, and mothers, F(1, 78) = 153.72, p < .001, η² = .86, that were maintained 6 wk after intervention. Mothers' self-competence in parenting also improved, F(1, 72) = 17.36, p < .001, η² = .42.

CONCLUSION

Findings provide preliminary evidence supporting the effectiveness of occupational performance coaching in improving children's and mothers' occupational performance and mothers' parenting self-competence. Improvements were sustained and appeared to generalize to other areas of performance.

Modeling developmental plasticity after perinatal stroke: defining central therapeutic targets in cerebral palsy

Perinatal stroke is presented as the ideal human model of developmental neuroplasticity. The precise timing, mechanisms, and locations of specific perinatal stroke diseases provide common examples of well defined, focal, perinatal brain injuries. Motor disability (hemiparetic cerebral palsy) constitutes the primary adverse outcome and the focus of models explaining how motor systems develop in health and after early injury. Combining basic science animal work with human applied technology (functional magnetic resonance imaging, diffusion tensor imaging, and transcranial magnetic stimulation), a model of plastic motor development after perinatal stroke is presented. Potential central therapeutic targets are revealed. The means to measure and modulate these targets, including evidence-based rehabilitation therapies and noninvasive brain stimulation, are suggested. Implications for clinical trials and future directions are discussed.

Evaluation of the effects of botulinum toxin A injections when used to improve ease of care and comfort in children with cerebral palsy whom are non-ambulant: a double blind randomized controlled trial

Background

Children with cerebral palsy (CP) whom are non-ambulant are at risk of reduced quality of life and poor health status. Severe spasticity leads to discomfort and pain. Carer burden for families is significant. This study aims to determine whether intramuscular injections of botulinum toxin A (BoNT-A) combined with a regime of standard therapy has a positive effect on care and comfort for children with CP whom are non-ambulant (GMFCS IV/V), compared with standard therapy alone (cycle I), and whether repeated injections with the same regime of adjunctive therapy results in greater benefits compared with a single injecting episode (cycle II). The regime of therapy will include serial casting, splinting and/or provision of orthoses, as indicated, combined with four sessions of goal directed occupational therapy or physiotherapy.

Method/design

This study is a double blind randomized controlled trial. Forty participants will be recruited. In cycle I, participants will be randomized to either a treatment group who will receive BoNT-A injections into selected upper and/or lower limb muscles, or a control group who will undergo sham injections. Both groups will receive occupational therapy and /or physiotherapy following injections. Groups will be assessed at baseline then compared at 4 and 16 weeks following injections or sham control. Parents, treating clinicians and assessors will be masked to group allocation. In cycle II, all participants will undergo intramuscular BoNT-A injections to selected upper and/or lower limb muscles, followed by therapy.

The primary outcome measure will be change in parent ratings in identified areas of concern for their child’s care and comfort, using the Canadian Occupational Performance Measure (COPM). Secondary measures will include the Care and Comfort Hypertonicity Scale (ease of care), the Cerebral Palsy Quality of Life Questionnaire (CP QoL–Child) (quality of life), the Caregiver Priorities and Child Health Index of Life with Disabilities Questionnaire (CPCHILD©) (health status) and the Paediatric Pain Profile (PPP) (pain). Adverse events will be carefully monitored by a clinician masked to group allocation.

Discussion

This paper outlines the theoretical basis, study hypotheses and outcome measures for a trial of BoNT-A injections and therapy for children with non-ambulant CP.

Trial registration

Australia New Zealand Clinical Trials Registry:N12609000360213

Implementation of ICF in goal setting in rehabilitation of children with chronic disabilities at Beitostolen Healthsports Centre

PURPOSE

Develop an International Classification of Functioning, Disability and Health (ICF) Code Set, useful in goal oriented rehabilitation of a study population of children with chronic disabilities.

METHOD

A triangulation of methods, using an interview to identify the main needs and goals of the study population, and a questionnaire to identify the main problems, with a registration of the frequency within each category. After qualitative and quantitative analyses this resulted in two sets of ICF categories. These two sets were then compared and merged into a proposed ICF Code Set for goal setting.

RESULTS

Thirty categories were identified from the interviews and the following linking process. Problems were reported in all suggested categories within the ICF questionnaire, resulting in 49 categories. The comparison of the two sets of categories resulted in a proposed ICF Code Set of 40 categories.

CONCLUSIONS

Through a triangulation of methods, we developed a tailored code set for the goal setting process in rehabilitation for children with a disability, taking into account both individual preferences and the health professionals' perspective. Although the external validity is limited, our methodological procedures may have relevance for the implementation of ICF in other clinical settings and populations.

Valid and reliable instruments for arm-hand assessment at ICF activity level in persons with hemiplegia: a systematic review

BACKGROUND

Loss of arm-hand performance due to a hemiparesis as a result of stroke or cerebral palsy (CP), leads to large problems in daily life of these patients. Assessment of arm-hand performance is important in both clinical practice and research. To gain more insight in e.g. effectiveness of common therapies for different patient populations with similar clinical characteristics, consensus regarding the choice and use of outcome measures is paramount. To guide this choice, an overview of available instruments is necessary. The aim of this systematic review is to identify, evaluate and categorize instruments, reported to be valid and reliable, assessing arm-hand performance at the ICF activity level in patients with stroke or cerebral palsy.

METHODS

A systematic literature search was performed to identify articles containing instruments assessing arm-hand skilled performance in patients with stroke or cerebral palsy. Instruments were identified and divided into the categories capacity, perceived performance and actual performance. A second search was performed to obtain information on their content and psychometrics.

RESULTS

Regarding capacity, perceived performance and actual performance, 18, 9 and 3 instruments were included respectively. Only 3 of all included instruments were used and tested in both patient populations. The content of the instruments differed widely regarding the ICF levels measured, assessment of the amount of use versus the quality of use, the inclusion of unimanual and/or bimanual tasks and the inclusion of basic and/or extended tasks.

CONCLUSIONS

Although many instruments assess capacity and perceived performance, a dearth exists of instruments assessing actual performance. In addition, instruments appropriate for more than one patient population are sparse. For actual performance, new instruments have to be developed, with specific focus on the usability in different patient populations and the assessment of quality of use as well as amount of use. Also, consensus about the choice and use of instruments within and across populations is needed.

Canadian Occupational Performance Measure: Impact of Blinded Parent-Proxy Ratings on Outcome

Background. There is potential for unintended effects on intervention outcome when using the Canadian Occupational Performance Measure (COPM) in intervention studies.

Purpose. To determine the effect of blinded parent-proxy ratings of the COPM on outcomes at later endpoints.

Methods. Data were drawn from a randomized trial of 50 children with hemiplegic cerebral palsy aged 19 months to seven years. Outcomes were measured at baseline, post-intervention, and six months. Parents of 36 children were randomly allocated to complete six-month COPM proxy ratings blinded or unblinded to previous ratings. A group of 32 parents rated the six-month COPM blinded and then re-rated it after access to previous ratings.

Findings. There was no statistically significant difference in ratings between those completing the COPM blinded compared to unblinded.

Implications. The COPM should continue to be rated blinded at post-intervention endpoints in the absence of further research to the contrary.

Congenital diaphragmatic hernia and occupational therapy: a case report

This case report describes occupational therapy (OT) intervention in an outpatient setting and outcomes for a child diagnosed with congenital diaphragmatic hernia (CDH) from 4 to 28 months of age. There is little information on therapy intervention and outcomes of children who have survived. The patient is a white male, born at 35 weeks gestation with a diagnosis of left CDH that required a patch repair. He also had a Nissen fundoplication, gastrostomy tube and spent the first 100 days of his life in the hospital. He received outpatient OT for 2 years. The process of service provision is described using the "Occupational therapy practice framework: Domain and process, 2nd edition" (American Occupational Therapy Association, 2008 , American Journal of Occupational Therapy, 62(6), 625-683). The focus of intervention, description of the intervention process, and timeline for achievement of skills is provided. Outcomes and assessment tools used included the Canadian Occupational Performance Measure and Peabody Developmental Motor Scales-Second Edition.

Children and youth with myelomeningocele's independence in managing clean intermittent catheterization in familiar settings

AIM

To examine the ability of children and youth with myelomeningocele to independently manage clean intermittent catheterization.

METHODS

There were 50 participants with myelomeningocele (5-18 years); 13 of them had also participated in a previous hospital-based study. Their abilities and interest in completing the toilet activity were examined at home or in school using an interview and the Canadian Occupational Performance Measure (COPM). Actual performance was observed and rated. Background variables were collected from medical records and KatAD+E tests.

RESULTS

In total, 48% were observed to perform the toilet activity independently, in comparison with 74% who self-reported independence. Univariate analyses found KatAD+E could predict who was independent. COPM failed to do so. Ability to remain focused and ambulation were predictors of independence, but age, sex and IQ were not. Multivariable analysis found time to completion to be the strongest predictor of independence. Four children were independent in their familiar environment, but not in the hospital setting, and six of 13 children maintained focus only in their familiar environment.

CONCLUSIONS

Interviews were not sufficiently accurate to assess independence in the toilet activity. Instead, observations including time to completion are recommended. The execution of the toilet activity is influenced by the environmental context.

The effects of problem-solving skills training based on metacognitive principles for children with acquired brain injury attending mainstream schools: a controlled clinical trial

PURPOSE

To investigate the effects of an explicit problem-solving skills training programme based on metacognitive principles for children with acquired brain injury (ABI) who attend mainstream schools.

METHOD

Thirty-two children with moderate to severe ABI studying in mainstream schools were allocated randomly by matched pairs to either an experimental or a comparison group. The participants in the experimental group received problem-solving skills training based on metacognitive principles, while those in the comparison group were on a waiting list to receive the experimental intervention shortly after the intervention in the experimental group had been completed. All participants were measured pre- and post-intervention using measures of abstract reasoning, metacognition, problem-solving functional behaviour in the home environment or social situations and individual goal-directed behaviour.

RESULTS

Significant differences in post-test scores were found for all measurements between children in the experimental group and those in the comparison group, using the baselines of dependent variables, years of schooling and the full IQ scores as the covariates.

CONCLUSION

The results of this study supported the use of explicit problem-solving skills training to improve daily functioning for children with ABI, and the need for a larger-scale, randomised controlled study with long-term follow-up.

LEARN 2 MOVE 2-3: a randomized controlled trial on the efficacy of child-focused intervention and context-focused intervention in preschool children with cerebral palsy

Background

Little is known about the efficacy and the working mechanisms of physical and occupational therapy interventions for children with cerebral palsy (CP). In recent years a shift from a child-focused intervention approach to a more context-focused intervention approach can be recognized. Until now the evidence on the efficacy and the working mechanisms of these interventions for children with CP is inconclusive. This study aims to evaluate the efficacy and working mechanisms of two intervention approaches compared to regular care intervention in improving mobility and self-care skills of children (2-3 years) with CP and their families: a child-focused intervention approach and a context-focused intervention approach.

Methods/Design

A multi-centre, randomized controlled trial research design will be used. Ninety-four children with CP (Gross Motor Function Classification System (GMFCS) level I-IV; age 2 to 3 years), their parents, and service providers (physical and occupational therapists) will be included. During a period of six months children will receive child-focused, context-focused or regular care intervention. Therapists will be randomly assigned to deliver either a child-focused intervention approach, a context-focused intervention approach or regular care intervention. Children follow their therapist into the allocated intervention arm. After the six months study-intervention period, all participants return to regular care intervention. Outcomes will be evaluated at baseline, after six months and at a three months follow-up period. Primary outcome is the capability of functional skills in self-care and mobility, using the Functional Skills Scale of the Pediatric Evaluation of Disability Inventory (PEDI). Other outcomes will be quality of life and the domains of the International Classification of Functioning, Disability and Health - for Children and Youth (ICF-CY), including body function and structure, activities (gross motor capacity and performance of daily activities), social participation, environmental variables (family functioning, parental empowerment).

Discussion

This paper presents the background information, design, description of interventions and protocol for this study on the efficacy and working mechanisms of child-focused intervention approach and context-focused intervention approach compared to regular care intervention in mobility and self-care skills of children (2-3 years) with CP.

Trial registration

This study is registered in the Dutch Trial Register as NTR1900

Family priorities for activity and participation of children and youth with cerebral palsy

BACKGROUND

Understanding family priorities for children and youth with cerebral palsy is essential for family-centered service.

OBJECTIVE

The purposes of this study were: (1) to identify family priorities for activity and participation in children and youth with cerebral palsy and (2) to determine differences based on age and Gross Motor Functional Classification System (GMFCS) level.

DESIGN

Five hundred eighty-five children and youth with cerebral palsy and their caregivers participated at regional children's hospitals. The children and youth were 2 to 21 years of age; 56% were male, and 44% were female. Their caregivers, predominantly mothers (80%), had a mean age of 40.3 years (SD=9.3). The Canadian Occupational Performance Measure was administered to caregivers to identify their priorities for their children. The priorities were coded into 3 categories (daily activities, productivity, and leisure) and 13 subcategories. The GMFCS levels were determined by assessors who met the criterion for reliability. Friedman and Kruskal-Wallis one-way analyses of variance were used to examine differences in priorities.

RESULTS

Parents of children in all age groups and GMFCS levels II to V identified more priorities for daily activities. Parents of school-aged children and youth had more priorities for productivity than parents of younger children. For parents of children in all age groups and motor function levels, self-care was the most frequent priority subcategory. Sixty-one percent of parents identified at least one priority related to mobility.

LIMITATIONS

The study did not include qualitative analysis of priorities of parents.

CONCLUSIONS

Parents' priorities for their children and youth with cerebral palsy differed depending on age and gross motor function level; however, the most frequent priority for all age groups was daily activities. Interviews with families are recommended for identifying outcomes for activity and participation and developing an intervention plan.

Goal-setting in paediatric rehabilitation: perceptions of parents and professional

BACKGROUND

In paediatric rehabilitation, there is a belief in goal-setting as a fundamental component of decision-making that encourages collaboration and motivation, and improves outcomes. This study aimed to explore parents' and professionals' perceptions of setting and implementing goals within a family centred rehabilitation programme for preschoolers with cerebral palsy (CP).

METHODS

Parents and service providers of 13 preschoolers with CP, classified in Gross Motor Function Classification System level I-III, participated in two-step focus group interviews.

RESULTS

Three major themes emerged, each with two subthemes: (1) 'Goals enhance competence' with the subthemes 'parents as drivers', and 'awareness through observation'; (2) 'Goals direct attention' with the subthemes 'goals as valuable means' and 'collaboration through participation', and (3) 'Goals enter everyday life' with the subthemes 'goals as activities' and 'training vs. everyday practise'. A fourth theme 'child perspective' with the subthemes 'follow-up initiative', 'capture mastery', and 'create learning opportunities' was both an exclusive theme and integrated in the other three main themes.

CONCLUSIONS

Active involvement of parents throughout the process of setting and implementing goals seemed to increase their feeling of competency and partnership with professionals. Concrete goals based on families' preferences and concerns, participatory observation, and discussions with professionals, came out as valuable means for practice of functional tasks within home environments.

The combined effect of Dynamic splinting and Neuromuscular electrical stimulation in reducing wrist and elbow contractures in six children with Cerebral palsy

The aim of this pilot study was to investigate the feasibility of applying the combination of Dynamic splinting (DS) and Neuromuscular electrical stimulation (NMES) in order to improve wrist and elbow function, and range of motion, in children with upper limb contractures due to Cerebral palsy (CP). Six children aged seven to 16, with contractures at the wrist or elbow, were recruited. Following a 12-week baseline period all participants underwent a 12-week treatment period where DS was used for one hour per day and combined with NMES for the second half of the 1-h treatment. A 12-week follow-up period then ensued. Upper limb function was assessed with the Melbourne assessment, physical disability with the Paediatric Evaluation of Disability Index and the Activity Scale for Kids, and quality of life with the Pediatric Quality of Life Scale. Passive and active range of motion at the wrist and elbow were measured using manual and electrical goniometers. The technique of using combined NMES and DS was demonstrated to be feasible and compliance with the intervention was good. There was an increase in passive elbow extension in two participants treated for elbow contractures, although no accompanying change in upper limb function was demonstrated. Wrist range of movement improved in one participant treated for wrist contracture.

Repeat botulinum toxin-A injections in the upper limb of children with hemiplegia: a randomized controlled trial

AIM

To test the effectiveness of repeat botulinum toxin A (BoNT-A) injections in the affected arm of 22 children with hemiplegic cerebral palsy (19 males, three females), aged 1 year 10 months to 4 years 10 months (mean 3y 8mo, SD 9mo) in a randomized controlled trial.

METHOD

Children received either three series of BoNT-A injections plus twice-weekly occupational therapy (OT) or OT alone in 16-week cycles. Muscles targeted at each injection cycle in the 11 children receiving BoNT-A+OT were the adductor pollicis (n=9), flexor pollicis longus (n=5), flexor digitorum superficialis (n=8), flexor digitorum profundus (n=8), flexor carpi radialis (n=2), flexor carpi ulnaris (n=6), pronator teres (n=10), and biceps brachii (n=11). Parental perception of treatment efficacy was assessed using the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scale (GAS), quality of movement using the Quality of Upper Extremity Skills Test (QUEST), fine motor skills using the Peabody Developmental Motor Scale - Fine Motor (PDMS-FM), and spasticity using the Modified Tardieu Scale (MTS). Between-group differences at 12 months were analysed using independent-sample t-tests.

RESULTS

All children were at Gross Motor Function Classification System levels I (BoNT-A+OT n=6; OT n=8) or II (n=5 and n=3 respectively) and were too young to be classified using the Manual Ability Classification System. The BoNT-A+OT group had higher COPM performance scores (mean difference -0.8, 95% confidence interval [CI] -1.5-0.0) and higher GAS T scores (mean difference -6.9, 95% CI -13.8 to -0.1]). No significant difference was found for the COPM satisfaction, PDMS-FM, or QUEST scores. The BoNT-A+OT group showed progressive reduction in spasticity compared with the OT group. At study completion MTS mean difference was 50.0 degrees (95% CI 22.4-77.6) for pronators and 20.9 degrees (95% CI 2.4-39.4) for wrist flexors.

INTERPRETATION

Repeat BoNT-A injections in the upper limb combined with OT resulted in progressively reduced spasticity and improved parental perception of performance.

Goal-oriented rehabilitation of preschoolers with cerebral palsy--a multi-case study of combined use of the Canadian Occupational Performance Measure (COPM) and the Goal Attainment Scaling (GAS)

PURPOSE

To explore setting and implementing goals as an ongoing process, using the COPM and the GAS in combination.

METHODS

Multi-case study of a goal-setting approach, involving parents and service providers of 13 children (aged 23-50 months) with mild-to-moderate CP enrolled in a 9-month rehabilitation programme consisting of two blocks of setting and implementing goals. The children's COPM reports and GAS goals and information from a questionnaire about implementation were analysed.

RESULTS

In the initial assessment, most problems prioritized by the parents in the COPM were phrased in terms of activities. The priorities for intervention changed during the process of setting and implementing goals. GAS goals were frequently integrated in everyday activities both at home and in kindergarten based on decisions on how to implement the goals. Changes in the children's performance were recognized by a high proportion of goal attainment and a small, but clear change in the parents' perception of performance. Parents and service providers reported many gains working towards concrete and measurable goals, but also some challenges.

CONCLUSION

By using the COPM and GAS in combination, a dynamic and interactive process of setting and implementing goals in the context of everyday activities emerged.

Paediatric Application of Individualised Client-Centred Outcome Measures: A Literature Review

A literature review was conducted to identify and compare the clinical utility of client-centred, individualised outcome measures for paediatric rehabilitation. Five measures were identified: the Canadian Occupational Performance Measure (COPM) (28 studies); Goal Attainment Scaling (GAS) (34 studies); Perceived Efficacy and Goal Setting System (PEGS) (2 studies); Target Complaints (TC) (1 study); and the Paediatric Activity Card Sort (PACS) (instruction manual only). The COPM and GAS have been used with children across a wide age range and variety of clinical settings. The PEGS and PACS provided young children direct involvement in the goal-setting process. Little evidence supports the use of TC in paediatrics.

Clinicians need to use individualised measures in a way that facilitates the maximal participation of children and families in goal setting and outcome evaluation. Clinicians should document their own role in goal setting. The use of individualised and client-centred measures can motivate children and families and focus their attention on therapy goals.

Repeat injection of botulinum toxin A is safe and effective for upper limb movement and function in children with cerebral palsy

The efficacy of repeated botulinum toxin A (BTX-A) injections in two and three dose regimes, together with occupational therapy, on upper limb movement and function, was studied using an evaluator blinded, randomized, controlled two-group trial. Forty-two children (31 males, 11 females; range 2-8 y, mean 4 y [SD 1 y 7 mo]) with hemiplegic cerebral palsy (Gross Motor Function Classification System Level I) longitudinally participated for 30 months, with the first 6 months reported earlier (Lowe et al. 2006). The BTX-A group (n=21) received three injections (0, 6, and 18 mo), while the delayed group had two (6 and 18 mo; dose 0.5-2.1 units/kg, mean 1.5 [SD 0.18]; dilution 100 units/0.5 ml). At 30 months, no difference existed between groups on any standardized measures. First and second injections showed significant treatment effect sizes, on Quality of Upper Extremity Skills Test (5.5 p=0.01: 4.5 p=0.03); parent Goal Attainment Scaling (GAS; 3.5 p=0.02: 3.9 p=0.01; therapist GAS 7.8 p=0.00: 4.0 p=0.03); Canadian Occupational Performance Measure (performance 0.4 p=0.05: 0.4 p=0.02; satisfaction 0.4 p=0.05: 0.37 p=0.08); and Pediatric Evaluation of Disability Inventory functional skills (1.8 p=0.00: 2.3 p=0.04). BTX-A was not linked to adverse events, suggesting repeated upper limb injections in children with hemiplegia receiving occupational therapy were safe and effective for improvement of movement and function.